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Lépine A, Treibich C, Ndour CT, Gueye K, Vickerman P. HIV infection risk and condom use among sex workers in Senegal: evidence from the list experiment method. Health Policy Plan 2020; 35:408-415. [PMID: 32040183 DOI: 10.1093/heapol/czz155] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2019] [Indexed: 11/13/2022] Open
Abstract
Social desirability bias, which is the tendency to under-report socially undesirable health behaviours, significantly distorts information on sensitive behaviours that is gained from self-reports. As a result, self-reported condom use among high-risk populations is thought to be systematically over-reported, and it is impossible to identify the determinants of condom use. The main objective of the article is to elicit unbiased information on condom use among female sex workers (FSWs) using the double list experiment method to analyse the role of HIV infection and exposure to HIV prevention methods in condom use. More specifically, the difference in levels of condom use between HIV-positive and HIV-negative FSWs is estimated. In addition, the role of FSWs' registration and participation in a pre-exposure prophylaxis (PrEP) demonstration project in condom use is considered. A list experiment was designed to elicit condom use information from 786 FSWs in Senegal who were surveyed in 2015 and 2017. Using the list experiment method, participants were randomly assigned to one of two groups (treatment or control) and were asked to report the number of statements they agreed with. Respondents assigned to the control group were presented with three non-sensitive items, whereas those allocated to the treatment group were presented with the same three statements plus the sensitive item (e.g. 'I used a condom during my last intercourse with a client'). Comparing the average number of sentences that were agreed with in both groups provides an estimation of the condom use rate in the treatment group and estimating such prevalence for several sub-groups allows the role of HIV infection risk in condom use to be identified. The percentage of FSWs using condoms in their last sexual intercourse with a client was 80% in 2015 and 78% in 2017, which was significantly lower than the 97% obtained in the face-to-face surveys in both waves. When estimating condom use among sub-groups with the list experiment method, we found that condom use among HIV-positive FSWs was only 34%, which was 47 percentage points lower than condom use among HIV-negative FSWs. We also found that registered FSWs are more likely to use condoms than clandestine FSWs. However, we did not find any difference in condom use between FSWs who were enrolled in the PrEP demonstration project and those who were not enrolled. Health policies should therefore aim to increase condom use among HIV-positive FSWs.
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Affiliation(s)
- Aurélia Lépine
- Institute for Global Health, University College London, 30 Guilford Street, London WC1N 1EH, UK
| | - Carole Treibich
- Univ. Grenoble Alpes, CNRS, INRAE, Grenoble INP, GAEL, 38000 Grenoble, France
| | - Cheikh Tidiane Ndour
- Division de Lutte contre le Sida et les IST/ nstitut d'hygiène Sociale, Avenue Blaise Diagne X Malick SY - BP 7381 Médina Dakar, Sénégal
| | - Khady Gueye
- Division de Lutte contre le Sida et les IST/ nstitut d'hygiène Sociale, Avenue Blaise Diagne X Malick SY - BP 7381 Médina Dakar, Sénégal
| | - Peter Vickerman
- Population Health Sciences, University of Bristol, Oakfield House, Oakfield Grove, Clifton BS8 2BN, UK
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Gutin SA, Harper GW, Moshashane N, Ramontshonyana K, Mompe A, Fleming PJ, Harries J, Ramogola-Masire D, Morroni C. "I did not know about all these": Perceptions regarding safer conception methods by women living with HIV in Gaborone, Botswana. PLoS One 2020; 15:e0242992. [PMID: 33259505 PMCID: PMC7707558 DOI: 10.1371/journal.pone.0242992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 11/12/2020] [Indexed: 11/19/2022] Open
Abstract
Various safer conception methods to limit HIV transmission risks can be offered in resource-constrained settings. However, implementation of safer conception services remains limited in many countries, including Botswana. Understanding perceptions about safer conception methods and the benefits and challenges to use can help with the development of policies, interventions, and service delivery models. Forty-five women living with HIV in the greater Gaborone, Botswana area participated in focus group discussions. Themes were analyzed using interpretive phenomenology. Despite low knowledge of specific safer conception methods that can be used to prevent transmission of HIV when trying to achieve pregnancy, there was noted interest in pre-exposure prophylaxis and vaginal insemination. Challenges to greater uptake were noted including a lack of knowledge about a range of SC methods, limited partner support and communication, provider stigma, health systems barriers, current policies, and the cultural acceptability of methods. Interventions will need to address these challenges and be responsive to the needs and reflect the realities of WLHIV who desire pregnancy in order for safer conception uptake to become a common practice.
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Affiliation(s)
- Sarah A. Gutin
- Dept. of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan, United States of America
- Women’s Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Division of Prevention Science, Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, California, United States of America
| | - Gary W. Harper
- Dept. of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Neo Moshashane
- Botswana—University of Pennsylvania Partnership, University of Botswana Main Campus, Gaborone, Botswana
| | - Kehumile Ramontshonyana
- Botswana—University of Pennsylvania Partnership, University of Botswana Main Campus, Gaborone, Botswana
| | - Atlang Mompe
- Botswana—University of Pennsylvania Partnership, University of Botswana Main Campus, Gaborone, Botswana
| | - Paul J. Fleming
- Dept. of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Jane Harries
- Women’s Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Chelsea Morroni
- Women’s Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Botswana—University of Pennsylvania Partnership, University of Botswana Main Campus, Gaborone, Botswana
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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53
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Ngure K, Ongolly F, Dolla A, Awour M, Mugwanya KK, Irungu E, Mugo N, Bukusi EA, Morton J, Odoyo J, Wamoni E, Barnabee G, Peebles K, O'Malley G, Baeten JM. "I just believe there is a risk" understanding of undetectable equals untransmissible (U = U) among health providers and HIV-negative partners in serodiscordant relationships in Kenya. J Int AIDS Soc 2020; 23:e25466. [PMID: 32144888 PMCID: PMC7060133 DOI: 10.1002/jia2.25466] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 02/05/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction Sustained HIV viral suppression resulting from antiretroviral therapy (ART) eliminates the risk of HIV transmission, a concept popularly framed as Undetectable = Untransmittable (U = U). We explored knowledge and acceptance of information around the elimination of HIV transmission risk with ART (U = U) in Kenya. Methods Our qualitative study was conducted within a project evaluating the use of pre‐exposure prophylaxis (PrEP) integrated into ART care for HIV serodiscordant couples in public clinics in Kenya (the Partners Scale Up Project). From February 2017 to April 2019, we conducted semi‐structured key informant interviews with 83 health providers and in‐depth interviews with 61 HIV‐negative people in serodiscordant relationships receiving PrEP services. Transcripts were coded using thematic analysis. Results Health providers reported being aware of reduced risk of HIV transmission as a result of consistent ART use and used words such as “very low,” “minimal” and “like zero” to describe HIV transmission risk after viral suppression. Providers reported finding viral load results helpful when counselling clients about the risk of HIV transmission. Many lacked confidence in U = U and counselled on consistent condom use even after viral suppression while some expressed concerns that communicating this message to people living with HIV (PLHIV) would lead them to engage in multiple sexual relationships. Other providers reported that they did not counsel about the reduced risk of HIV transmission after viral suppression for fear of being blamed if HIV transmission occurred. HIV‐negative partners reported being informed about U = U by providers but they did not believe nor trust the message. Even after their partners achieved viral suppression, some HIV‐negative partners were unwilling to stop PrEP, while others indicated that they would use condoms if they stopped PrEP to be sure that they were protected from HIV. Conclusions Despite awareness that effective ART use eliminates HIV transmission risk, there is both a lack of in‐depth knowledge and conviction about the strategy among health providers and HIV‐negative partners in serodiscordant relationships. New strategies that go beyond communicating the science of U = U to consider the local social and clinical environments could maximize the effectiveness of U = U.
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Affiliation(s)
- Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Fernandos Ongolly
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Annabell Dolla
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Merceline Awour
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Elizabeth Irungu
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Nelly Mugo
- Department of Global Health, University of Washington, Seattle, WA, USA.,Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth A Bukusi
- Department of Global Health, University of Washington, Seattle, WA, USA.,Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jennifer Morton
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Josephine Odoyo
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth Wamoni
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Gena Barnabee
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kathryn Peebles
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | | | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
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Kalinjuma AV, Glass TR, Weisser M, Myeya SJ, Kasuga B, Kisung'a Y, Sikalengo G, Katende A, Battegay M, Vanobberghen F. Prospective assessment of loss to follow-up: incidence and associated factors in a cohort of HIV-positive adults in rural Tanzania. J Int AIDS Soc 2020; 23:e25460. [PMID: 32128998 PMCID: PMC7054631 DOI: 10.1002/jia2.25460] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 01/09/2020] [Accepted: 01/22/2020] [Indexed: 12/23/2022] Open
Abstract
Introduction Lifelong antiretroviral therapy (ART) improves health outcomes for HIV‐positive individuals, but is jeopardized by irregular clinic attendance and hence poor adherence. Loss to follow‐up (LTFU) is typically defined retrospectively but this may lead to biased inferences. We assessed incidence of and factors associated with LTFU, prospectively and accounting for recurrent LTFU episodes, in the Kilombero and Ulanga Antiretroviral Cohort (KIULARCO) of HIV‐positive persons in rural Tanzania. Methods We included adults (≥15 years) enrolled in 2005 to 2016, regardless of ART status, with follow‐up through April 2017. LTFU was defined as >60 days late for a scheduled appointment. Participants could experience multiple LTFU episodes. We performed analyses based on the first (prospective) and last (retrospective) events observed during follow‐up, and accounting for recurrent LTFU episodes. Time to LTFU was estimated using cumulative incidence functions. We assessed factors associated with LTFU using cause‐specific proportional hazards, marginal means/rates, and Prentice, Williams and Peterson models. Results Among 8087 participants (65% female, 60% aged ≥35 years, 42% WHO stage 3/4, and 47% CD4 count <200 cells/mm3), there were 8140 LTFU episodes, after which there were 2483 (31%) returns to care. One‐year LTFU probabilities were 0.41 (95% confidence interval 0.40, 0.42) and 0.21 (0.20, 0.22) considering the first and last events respectively. Factors associated with LTFU were broadly consistent across different models: being male, younger age, never married, living far from the clinic, not having an HIV‐positive partner, lower BMI, advanced WHO stage, not having tuberculosis, and shorter time since ART initiation. Associations between LTFU and pregnancy, CD4 count, and enrolment year depended on the analysis approach. Conclusions LTFU episodes were common and prompt tracing efforts are urgently needed. We identified socio‐demographic and clinical characteristics associated with LTFU that can be used to target tracing efforts and to help inform the design of appropriate interventions. Incidence of and risk factors for LTFU differed based on the LTFU definition applied, highlighting the importance of appropriately accounting for recurrent LTFU episodes. We recommend using a prospective definition of LTFU combined with recurrent event analyses in cohorts where repeated interruptions in care are common.
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Affiliation(s)
| | - Tracy R Glass
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Maja Weisser
- Ifakara Health Institute, Ifakara, Tanzania.,Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Department of Infectious Diseases and Hospital Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | | | | | | | | | | | - Manuel Battegay
- University of Basel, Basel, Switzerland.,Department of Infectious Diseases and Hospital Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Fiona Vanobberghen
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
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Arikawa S, Dumazert P, Messou E, Burgos-Soto J, Tiendrebeogo T, Zahui A, Horo A, Minga A, Becquet R. Childbearing desire and reproductive behaviors among women living with HIV: A cross-sectional study in Abidjan, Côte d'Ivoire. PLoS One 2020; 15:e0239859. [PMID: 33085671 PMCID: PMC7577483 DOI: 10.1371/journal.pone.0239859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 09/14/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction Evidence on childbearing desire and reproductive behaviors in women living with HIV on antiretroviral therapy (ART) is scarce, particularly in West Africa. We investigated the prevalence and associated factors of childbearing desire in HIV-infected women in care in Abidjan, Côte d’Ivoire and explored whether such desires were translated into behaviors related to contraceptive use and communication with health personnel. Methods A cross-sectional survey was conducted in two HIV-care facilities in Abidjan, Côte d’Ivoire in 2015. Eligible women were non-pregnant, non-menopausal, aged 18–49 years and diagnosed as HIV-infected. The outcomes were childbearing desire, prevalence of modern contraceptive use, unmet needs for family planning and intention of the last pregnancy since HIV diagnosis. Women wishing to conceive immediately were asked whether they had discussed their desire with HIV healthcare workers. Logistic regression models were used to assess the associations between the outcomes and women’s characteristics. Results Of 1,631 women, 80% declared having childbearing desire. No association was found between women’s childbearing desire and ART status or its duration. In multivariate models, younger age, being in a stable relationship and having no or only one child were significantly associated with increased childbearing desire. Of the women wishing to conceive immediately (n = 713), only 43% reported having had fertility-related dialogue with healthcare provider. Among sexually active women wanting to avoid or delay pregnancy (n = 650), unmet needs for family planning was 40%. Regarding the last pregnancy since HIV diagnosis, one in three women reported not having wanted a baby at that time. Conclusions Pregnancy desire in women living with HIV in Abidjan was extremely high. Integration of safe conception strategies as well as improvement of contraceptive uptake among women in need of family planning are of utmost importance to ensure optimal conception and to avoid transmission of HIV to the male partner or to the forthcoming child.
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Affiliation(s)
- Shino Arikawa
- Inserm, UMR 1219, Bordeaux Population Health Research Center, Team IDLIC, French National Research Institute for Sustainable Development (IRD), University of Bordeaux, Bordeaux, France
- * E-mail:
| | - Patricia Dumazert
- Inserm, UMR 1219, Bordeaux Population Health Research Center, Team IDLIC, French National Research Institute for Sustainable Development (IRD), University of Bordeaux, Bordeaux, France
- Programme PAC-CI, ANRS site in Côte d’Ivoire, Centre Hospitalier Universitaire de Treichville, Abidjan, Côte d'Ivoire
| | - Eugène Messou
- Programme PAC-CI, ANRS site in Côte d’Ivoire, Centre Hospitalier Universitaire de Treichville, Abidjan, Côte d'Ivoire
- Centre de Prise en charge de Recherche et de Formation (CePReF-Aconda-VS), Abidjan, Côte d'Ivoire
| | - Juan Burgos-Soto
- Inserm, UMR 1219, Bordeaux Population Health Research Center, Team IDLIC, French National Research Institute for Sustainable Development (IRD), University of Bordeaux, Bordeaux, France
- Programme PAC-CI, ANRS site in Côte d’Ivoire, Centre Hospitalier Universitaire de Treichville, Abidjan, Côte d'Ivoire
| | - Thierry Tiendrebeogo
- Inserm, UMR 1219, Bordeaux Population Health Research Center, Team IDLIC, French National Research Institute for Sustainable Development (IRD), University of Bordeaux, Bordeaux, France
| | - Angèle Zahui
- Programme PAC-CI, ANRS site in Côte d’Ivoire, Centre Hospitalier Universitaire de Treichville, Abidjan, Côte d'Ivoire
| | - Apollinaire Horo
- Service de gynécologie obstétrique, Centre Hospitalier Universitaire de Yopougon, Abidjan, Côte d’Ivoire
| | - Albert Minga
- Programme PAC-CI, ANRS site in Côte d’Ivoire, Centre Hospitalier Universitaire de Treichville, Abidjan, Côte d'Ivoire
- Centre Médical de Suivi de Donneurs de Sang (CMSDS), Abidjan, Côte d’Ivoire
| | - Renaud Becquet
- Inserm, UMR 1219, Bordeaux Population Health Research Center, Team IDLIC, French National Research Institute for Sustainable Development (IRD), University of Bordeaux, Bordeaux, France
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Geleta RH, Tiruneh MA. Condom Utilization and Affecting Factors Among People Living with HIV/AIDS Attending ART Clinics in Addis Ababa, Ethiopia. HIV AIDS (Auckl) 2020; 12:583-590. [PMID: 33116920 PMCID: PMC7585278 DOI: 10.2147/hiv.s276802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 09/25/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Human immune deficiency virus or acquired immune deficiency syndrome (HIV/AIDS) has been a major public health problem globally as well as in Africa including Ethiopia. To prevent HIV effectively, condoms must be used regularly and consistently. When HIV positive individuals have sex without condom, they can easily transmit the vuirus to a seronegative partner. Condom utilization may be affected by various factors. Therefore, the findings from this study will give an opportunity to understand condom utilization and the barriers to condom use. OBJECTIVE To assess condom utilization and associated factors among people living with HIV/AIDS attending anti-retro viral treatment (ART) clinics in Addis Ababa, Ethiopia. MATERIALS AND METHODS An institution-based cross-sectional study was conducted among 677 people living with HIV/AIDS attending ART clinics in Addis Ababa from February 1, 2019 to March 30, 2019. The sampling technique was three-stage sampling and finally, the study participants were selected using a systematic random sampling technique. Data were coded, cleaned and entered in to EPIData version 3.4, and analyzed using SPSS version 23.0. The association between the dependent variable and independent variables was analyzed using binary logistic regression analysis at 5% level of significance. RESULTS About 677 HIV/AIDS patients receiving ART at health centers participated in the study. From the total participants, 306 (45.2%) utilized a condom in the last six months. Sex (adjusted odds ratio (AOR)=2.02; 95%CI=1.34-3.05), marital status (AOR=0.39; 95%CI=0.19-0.77 and (AOR=0.48; 95%CI=0.24-0.94), employment status (AOR=0.27; 95%CI=0.12-0.59), type of partner (AOR=0.15; 95%CI=0.05-0.48 and AOR=0.46; 95%CI=0.27-0.79), condom access (AOR=3.97; 95%CI=2.04-7.75), disclosure of HIV status (AOR=0.21; 95%CI=0.14-0.33) and attitude towards condoms (AOR=3.76; 95%CI=2.49-5.65) had significant association with condom utilization. CONCLUSION Condom utilization was found to be low among people living with HIV/AIDS attending ART clinics in Addis Ababa. This finding indicates that high concern shall be given to minimize the gap. Sex, marital status, employment status, disclosure of HIV status, condom access, type of partner and attitude towards condoms were significantly associated with condom utilization. Hence, continuous condom provision, promotion, demonstration, and awareness creation are vital.
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Barnabas RV, Szpiro AA, van Rooyen H, Asiimwe S, Pillay D, Ware NC, Schaafsma TT, Krows ML, van Heerden A, Joseph P, Shahmanesh M, Wyatt MA, Sausi K, Turyamureeba B, Sithole N, Morrison S, Shapiro AE, Roberts DA, Thomas KK, Koole O, Bershteyn A, Ehrenkranz P, Baeten JM, Celum C. Community-based antiretroviral therapy versus standard clinic-based services for HIV in South Africa and Uganda (DO ART): a randomised trial. Lancet Glob Health 2020; 8:e1305-e1315. [PMID: 32971053 PMCID: PMC7527697 DOI: 10.1016/s2214-109x(20)30313-2] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/22/2020] [Accepted: 06/25/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Community-based delivery of antiretroviral therapy (ART) for HIV, including ART initiation, clinical and laboratory monitoring, and refills, could reduce barriers to treatment and improve viral suppression, reducing the gap in access to care for individuals who have detectable HIV viral load, including men who are less likely than women to be virally suppressed. We aimed to test the effect of community-based ART delivery on viral suppression among people living with HIV not on ART. METHODS We did a household-randomised, unblinded trial (DO ART) of delivery of ART in the community compared with the clinic in rural and peri-urban settings in KwaZulu-Natal, South Africa and the Sheema District, Uganda. After community-based HIV testing, people living with HIV were randomly assigned (1:1:1) with mobile phone software to community-based ART initiation with quarterly monitoring and ART refills through mobile vans; ART initiation at the clinic followed by mobile van monitoring and refills (hybrid approach); or standard clinic ART initiation and refills. The primary outcome was HIV viral suppression at 12 months. If the difference in viral suppression was not superior between study groups, an a-priori test for non-inferiority was done to test for a relative risk (RR) of more than 0·95. The cost per person virally suppressed was a co-primary outcome of the study. This study is registered with ClinicalTrials.gov, NCT02929992. FINDINGS Between May 26, 2016, and March 28, 2019, of 2479 assessed for eligibility, 1315 people living with HIV and not on ART with detectable viral load at baseline were randomly assigned; 666 (51%) were men. Retention at the month 12 visit was 95% (n=1253). At 12 months, community-based ART increased viral suppression compared with the clinic group (306 [74%] vs 269 [63%], RR 1·18, 95% CI 1·07-1·29; psuperiority=0·0005) and the hybrid approach was non-inferior (282 [68%] vs 269 [63%], RR 1·08, 0·98-1·19; pnon-inferiority=0·0049). Community-based ART increased viral suppression among men (73%, RR 1·34, 95% CI 1·16-1·55; psuperiority<0·0001) as did the hybrid approach (66%, RR 1·19, 1·02-1·40; psuperiority=0·026), compared with clinic-based ART (54%). Viral suppression was similar for men (n=156 [73%]) and women (n=150 [75%]) in the community-based ART group. With efficient scale-up, community-based ART could cost US$275-452 per person reaching viral suppression. Community-based ART was considered safe, with few adverse events. INTERPRETATION In high and medium HIV prevalence settings in South Africa and Uganda, community-based delivery of ART significantly increased viral suppression compared with clinic-based ART, particularly among men, eliminating disparities in viral suppression by gender. Community-based ART should be implemented and evaluated in different contexts for people with detectable viral load. FUNDING The Bill & Melinda Gates Foundation; the University of Washington and Fred Hutch Center for AIDS Research; the Wellcome Trust; the University of Washington Royalty Research Fund; and the University of Washington King K Holmes Endowed Professorship in STDs and AIDS.
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Affiliation(s)
- Ruanne V Barnabas
- Department of Global Health, University of Washington, Seattle, WA, USA; Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
| | - Adam A Szpiro
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Heidi van Rooyen
- Human Sciences Research Council, Sweetwaters, KwaZulu-Natal, South Africa; MRC/Wits Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Deenan Pillay
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | | | - Torin T Schaafsma
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Meighan L Krows
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Alastair van Heerden
- Human Sciences Research Council, Sweetwaters, KwaZulu-Natal, South Africa; MRC/Wits Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Philip Joseph
- Human Sciences Research Council, Sweetwaters, KwaZulu-Natal, South Africa
| | | | | | - Kombi Sausi
- Human Sciences Research Council, Sweetwaters, KwaZulu-Natal, South Africa
| | | | - Nsika Sithole
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Susan Morrison
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Adrienne E Shapiro
- Department of Global Health, University of Washington, Seattle, WA, USA; Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - D Allen Roberts
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | | | - Olivier Koole
- London School of Hygiene & Tropical Medicine, London, UK
| | - Anna Bershteyn
- New York University School of Medicine, New York, NY, USA
| | | | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA; Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, WA, USA; Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA
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Wulandari LPL, Guy R, Kaldor J. The burden of HIV infection among men who purchase sex in low- and middle-income countries - a systematic review and meta-analysis. PLoS One 2020; 15:e0238639. [PMID: 32886695 PMCID: PMC7473528 DOI: 10.1371/journal.pone.0238639] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/20/2020] [Indexed: 12/03/2022] Open
Abstract
Background Since the start of the HIV epidemic, transactional sexual relationships have been considered to present a high risk of HIV transmission to both the client and the person offering the sexual service. However, prevention research and programs have focused predominantly on sex workers rather than on their clients, who are generally men. To support effective and targeted interventions, we undertook a systematic review and meta-analysis of the evidence of the prevalence of HIV infection among men who purchase sex (MWPS) in low- and middle-income countries (LMICs), and the association between HIV infection and purchase of sex. Methods We included articles that reported from LMICs on the prevalence of HIV in MWPS and those that reported on HIV prevalence among both MWPS and non-MWPS in the same study, or any information which allowed calculation of the prevalence. We defined MWPS as heterosexual males (not men who purchase sex or individuals of other sexual orientation) who purchased sex mostly from women (and not men), or who have had sexual contact with female sex workers (FSWs). We searched Medline, Global Health, Scopus, Embase and Cinahl for articles published up until 1 March 2020. Meta-analysis was conducted using a random effects model to estimate the pooled HIV prevalence and the relative risk (RR) of HIV infection associated with purchasing sex. Results Of 34862 studies screened, we included 44 studies (59515 men, 47753 MWPS) from 21 countries. The pooled HIV prevalence among MWPS was 5% (95%CI: 4%-6%; I2 = 95.9%, p < 0.001). The pooled HIV prevalence calculated from studies that reported data collected pre-2001 was highest, i.e. 10% (95% CI: 6%-14%; I2 = 91.2%, p < 0.001), compared to studies whose data was collected between 2001–2010, i.e. 4% (95%CI: 2%-6%; I2 = 96.6%, p < 0.001), and from 2011 and beyond, i.e. 3% (95% CI: 2%-5%; I2 = 94.3%, p < 0.001). For studies which included comparisons of HIV infection among MWPS and non-MWPS, the relative risk of HIV infection was consistently higher among MWPS than among non-MWPS within the same study, with the overall pooled relative risk of 1.95 (95%CI: 1.56–2.44; I2 = 84.3%, p < 0.001), and 2.85 (95%CI: 1.04–7.76; I2 = 86.5%, p < 0.001) for more recent studies. Conclusions This review represents the first comprehensive assessment of the burden of HIV among MWPS in LMICs. We found that HIV prevalence was elevated compared to the population as a whole, and that there was a strong association between purchasing sex and HIV prevalence. Despite a reduction over time in prevalence, these data highlight that MWPS need better access to HIV preventive interventions.
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Affiliation(s)
- Luh Putu Lila Wulandari
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
- Department of Public Health and Preventive Medicine, Faculty of Medicine, Udayana University, Bali, Indonesia
- * E-mail: ,
| | - Rebecca Guy
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - John Kaldor
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
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Wamuti B, Contesse MG, Maingi P, Macharia P, Abuna F, Sambai B, Ng'ang'a A, Spiegel H, Richardson B, Cherutich P, Bukusi D, Farquhar C. Factors Associated With Poor Linkage to Human Immunodeficiency Virus Care Among Index Clients and Sex Partners Receiving Human Immunodeficiency Virus Assisted Partner Services in Kenya. Sex Transm Dis 2020; 47:610-616. [PMID: 32815902 PMCID: PMC7447121 DOI: 10.1097/olq.0000000000001222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/07/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Human immunodeficiency virus (HIV) assisted partner services (aPS) has been recommended as a strategy to increase HIV case finding. We evaluated factors associated with poor linkage to HIV care among newly diagnosed HIV-positive individuals (index clients) and their partners after receiving aPS in Kenya. METHODS In a cluster randomized trial conducted between 2013 and 2015, 9 facilities were randomized to immediate aPS (intervention). Linkage to care-defined as HIV clinic registration, and antiretroviral therapy (ART) initiation were self-reported. Antiretroviral therapy was only offered to those with CD4 less than 500 during this period. We estimated linkage to care and ART initiation separately for index clients and their partners using log-binomial generalized estimating equation models with exchangeable correlation structure and robust standard errors. RESULTS Overall, 550 index clients and 621 sex partners enrolled, of whom 46% (284 of 621) were HIV-positive. Of the 284, 264 (93%) sex partners returned at 6 weeks: 120 newly diagnosed and 144 whom had known HIV-positive status. Among the 120 newly diagnosed, only 69% (83) linked to care at 6 weeks, whereas among the 18 known HIV-positive sex partners not already in care at baseline, 61% (11) linked. Newly diagnosed HIV-positive sex partners who were younger and single were less likely to link to care (P < 0.05 for all). CONCLUSION Only two thirds of newly diagnosed, and known HIV-positive sex partners not in care linked to care after receiving aPS. The HIV aPS programs should optimize HIV care for newly diagnosed HIV-positive sex partners, especially those who are younger and single.
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Affiliation(s)
- Beatrice Wamuti
- From the Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | | | - Peter Maingi
- Voluntary Counseling and Testing (VCT) and HIV Prevention Unit, Kenyatta National Hospital
| | | | - Felix Abuna
- From the Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Betsy Sambai
- From the Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | | | - Hans Spiegel
- Kelly Government Solutions, Contractor to Division of AIDS, PMPRB/Prevention Sciences Program, Division of AIDS, NIAID, NIH, Rockville, MD
| | | | | | - David Bukusi
- Voluntary Counseling and Testing (VCT) and HIV Prevention Unit, Kenyatta National Hospital
| | - Carey Farquhar
- Department of Epidemiology, University of Washington, Seattle, WA
- Global Health
- Medicine, University of Washington, Seattle, WA
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60
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van de Vijver DAMC, Richter AK, Boucher CAB, Gunsenheimer-Bartmeyer B, Kollan C, Nichols BE, Spinner CD, Wasem J, Schewe K, Neumann A. Cost-effectiveness and budget effect of pre-exposure prophylaxis for HIV-1 prevention in Germany from 2018 to 2058. ACTA ACUST UNITED AC 2020; 24. [PMID: 30782266 PMCID: PMC6381659 DOI: 10.2807/1560-7917.es.2019.24.7.1800398] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BackgroundPre-exposure prophylaxis (PrEP) is a highly effective HIV prevention strategy for men-who-have-sex-with-men (MSM). The high cost of PrEP has until recently been a primary barrier to its use. In 2017, generic PrEP became available, reducing the costs by 90%.AimOur objective was to assess cost-effectiveness and costs of introducing PrEP in Germany.MethodsWe calibrated a deterministic mathematical model to the human immunodeficiency virus (HIV) epidemic among MSM in Germany. PrEP was targeted to 30% of high-risk MSM. It was assumed that PrEP reduces the risk of HIV infection by 85%. Costs were calculated from a healthcare payer perspective using a 40-year time horizon starting in 2018.ResultsPrEP can avert 21,000 infections (interquartile range (IQR): 16,000-27,000) in the short run (after 2 years scale-up and 10 years full implementation). HIV care is predicted to cost EUR 36.2 billion (IQR: 32.4-40.4 billion) over the coming 40 years. PrEP can increase costs by at most EUR 150 million within the first decade after introduction. Ten years after introduction, PrEP can become cost-saving, accumulating to savings of HIV-related costs of EUR 5.1 billion (IQR: 3.5-6.9 billion) after 40 years. In a sensitivity analysis, PrEP remained cost-saving even at a 70% price reduction of antiretroviral drug treatment and a lower effectiveness of PrEP.ConclusionIntroduction of PrEP in Germany is predicted to result in substantial health benefits because of reductions in HIV infections. Short-term financial investments in providing PrEP will result in substantial cost-savings in the long term.
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Affiliation(s)
| | - Ann-Kathrin Richter
- Institute for Health Care Management and Research, University of Duisburg-Essen, Essen, Germany
| | | | | | - Christian Kollan
- Department for Infectious Disease epidemiology, Robert Koch Institute, Berlin, Germany
| | - Brooke E Nichols
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University, Boston, United States.,Viroscience department, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Christoph D Spinner
- dagnä (Deutsche Arbeitsgemeinschaft niedergelassener Ärzte in der Versorgung HIV-Infizierter), Berlin, Germany.,Department of Medicine II, University Hospital Klinikum rechts der Isar, Munich, Germany
| | - Jürgen Wasem
- Institute for Health Care Management and Research, University of Duisburg-Essen, Essen, Germany
| | - Knud Schewe
- dagnä (Deutsche Arbeitsgemeinschaft niedergelassener Ärzte in der Versorgung HIV-Infizierter), Berlin, Germany
| | - Anja Neumann
- Institute for Health Care Management and Research, University of Duisburg-Essen, Essen, Germany
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Etoori D, Renju J, Reniers G, Ndhlovu V, Ndubane S, Makhubela P, Maritze M, Gomez-Olive FX, Wringe A. 'If the results are negative, they motivate us'. Experiences of early infant diagnosis of HIV and engagement in Option B. Glob Public Health 2020; 16:186-200. [PMID: 32673142 DOI: 10.1080/17441692.2020.1795220] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Few studies have explored the relationship between early infant diagnosis (EID) of HIV and mothers' engagement in care under Option B+. We conducted in-depth interviews with 20 women who initiated antiretroviral therapy (ART) under Option B+ in rural South Africa to explore the interactions between EID and maternal care engagement. Drawing on practice theory, we identified themes relating to Option B+ care engagement and EID. Women's practice of engagement with HIV care shaped their decision-making around EID. Mothers who disengaged from care during pregnancy were less inclined to utilise EID as they lacked information about its availability and benefits. For some mothers, tensions between wanting to breastfeed and perceptions that it could facilitate transmission led to repeated utilisation of EID as reassurance that the child remained negative. Some mothers used their child's negative result as a proxy for their status, subsequently disengaging from care. For some participants, an HIV diagnosis of their infant and the subsequent double burden of treatment visits for themselves and their infant, contributed to their disengagement. Women's care-seeking practices for themselves and their infants work in a symbiotic ecosystem and should be viewed interdependently to tailor interventions to improve EID uptake and Option B+ care engagement.
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Affiliation(s)
- David Etoori
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jenny Renju
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Georges Reniers
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.,MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Violet Ndhlovu
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sherly Ndubane
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Princess Makhubela
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Meriam Maritze
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Francesc Xavier Gomez-Olive
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Comprehensive HIV risk reduction interventions for 2020 and beyond: product choices and effective service-delivery platforms for individual needs and population-level impact. Curr Opin HIV AIDS 2020; 14:423-432. [PMID: 31261158 DOI: 10.1097/coh.0000000000000567] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW This review summarizes key HIV prevention strategies in the 2020 toolkit and discusses opportunities to maximize the public health impact of these prevention interventions at a population level. RECENT FINDINGS HIV prevention has relied on counseling, HIV testing, and condom distribution for the past three decades. Recent exciting work has provided evidence on effective HIV prevention interventions, including antiretroviral therapy for HIV prevention, expanding preexposure prophylaxis modalities, and voluntary medical male circumcision which all reduce individual-level HIV risk. Efficient service-delivery approaches are necessary to deliver these products at scale while addressing population-specific needs. These approaches include: making it easier to get individuals HIV tested and linked to prevention services; de-medicalization to increase access to prevention products; creating welcoming clinic service-delivery environments; and integrating HIV prevention products into existing clinical platforms to support ongoing care engagement. SUMMARY The 2020 HIV prevention toolkit includes powerful HIV prevention options, and product choice will be increasingly imperative. Meeting ambitious global HIV reduction targets in the next decade will require improved service-delivery platforms to get prevention choices to persons at risk while layering prevention coverage to achieve population-level impact.
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Graham SM, Micheni M, Chirro O, Nzioka J, Secor AM, Mugo PM, Kombo B, van der Elst EM, Operario D, Amico KR, Sanders EJ, Simoni JM. A Randomized Controlled Trial of the Shikamana Intervention to Promote Antiretroviral Therapy Adherence Among Gay, Bisexual, and Other Men Who Have Sex with Men in Kenya: Feasibility, Acceptability, Safety and Initial Effect Size. AIDS Behav 2020; 24:2206-2219. [PMID: 31965432 DOI: 10.1007/s10461-020-02786-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Gay, bisexual, and other men who have sex with men (GBMSM) living with HIV in rights-constrained settings need support for antiretroviral therapy (ART) adherence due to barriers including stigma. The Shikamana intervention combined modified Next Step Counseling by providers with support from trained peers to improve adherence among GBMSM living with HIV in Kenya. A randomized controlled trial with 6-month follow-up was used to determine feasibility, acceptability, safety, and initial intervention effects. Generalized estimating equations examined differences in self-reported adherence and virologic suppression. Sixty men enrolled, with 27 randomly assigned to the intervention and 33 to standard care. Retention did not differ by arm, and no adverse events occurred. Feedback on feasibility and acceptability was positive based on exit interviews. After adjustment for baseline viral suppression and confounding, the intervention group had a sixfold increased odds of viral suppression during follow-up. A larger trial of a scaled-up intervention is needed.
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Affiliation(s)
- Susan M Graham
- Departments of Medicine, Global Health, and Epidemiology, University of Washington, 325 Ninth Avenue, Box 359909, Seattle, WA, 98104, USA.
- Clinical Research, Kenya Medical Research Institute - Wellcome Trust Programme, Kilifi, Kenya.
| | - Murugi Micheni
- Clinical Research, Kenya Medical Research Institute - Wellcome Trust Programme, Kilifi, Kenya
| | - Oscar Chirro
- Clinical Research, Kenya Medical Research Institute - Wellcome Trust Programme, Kilifi, Kenya
| | - Joseph Nzioka
- Clinical Research, Kenya Medical Research Institute - Wellcome Trust Programme, Kilifi, Kenya
| | - Andrew M Secor
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Peter M Mugo
- Clinical Research, Kenya Medical Research Institute - Wellcome Trust Programme, Kilifi, Kenya
| | | | - Elise M van der Elst
- Clinical Research, Kenya Medical Research Institute - Wellcome Trust Programme, Kilifi, Kenya
| | - Don Operario
- Department of Behavioral and Social Sciences, Brown University, Providence, RI, USA
| | - K Rivet Amico
- Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA
| | - Eduard J Sanders
- Clinical Research, Kenya Medical Research Institute - Wellcome Trust Programme, Kilifi, Kenya
- Nuffield Department of Medicine, University of Oxford, Headington, Oxford, OX3 7BN, UK
| | - Jane M Simoni
- Departments of Psychology; Global Health; and Gender, Women, and Sexuality Studies, University of Washington, Seattle, WA, USA
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Wirth KE, Gaolathe T, Pretorius Holme M, Mmalane M, Kadima E, Chakalisa U, Manyake K, Matildah Mbikiwa A, Simon SV, Letlhogile R, Mukokomani K, van Widenfelt E, Moyo S, Bennett K, Leidner J, Powis KM, Lebelonyane R, Alwano MG, Jarvis J, Dryden-Peterson SL, Kgathi C, Moore J, Bachanas P, Raizes E, Abrams W, Block L, Sento B, Novitsky V, El-Halabi S, Marukutira T, Mills LA, Sexton C, Pals S, Shapiro RL, Wang R, Lei Q, DeGruttola V, Makhema J, Essex M, Lockman S, Tchetgen Tchetgen EJ. Population uptake of HIV testing, treatment, viral suppression, and male circumcision following a community-based intervention in Botswana (Ya Tsie/BCPP): a cluster-randomised trial. Lancet HIV 2020; 7:e422-e433. [PMID: 32504575 PMCID: PMC7864245 DOI: 10.1016/s2352-3018(20)30103-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 03/20/2020] [Accepted: 03/20/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND In settings with high HIV prevalence and treatment coverage, such as Botswana, it is unknown whether uptake of HIV prevention and treatment interventions can be increased further. We sought to determine whether a community-based intervention to identify and rapidly treat people living with HIV, and support male circumcision could increase population levels of HIV diagnosis, treatment, viral suppression, and male circumcision in Botswana. METHODS The Ya Tsie Botswana Combination Prevention Project study was a pair-matched cluster-randomised trial done in 30 communities across Botswana done from Oct 30, 2013, to June 30, 2018. 15 communities were randomly assigned to receive HIV prevention and treatment interventions, including enhanced HIV testing, earlier antiretroviral therapy (ART), and strengthened male circumcision services, and 15 received standard of care. The first primary endpoint of HIV incidence has already been reported. In this Article, we report findings for the second primary endpoint of population uptake of HIV prevention services, as measured by proportion of people known to be HIV-positive or tested HIV-negative in the preceding 12 months; proportion of people living with HIV diagnosed and on ART; proportion of people living with HIV on ART with viral suppression; and proportion of HIV-negative men circumcised. A longitudinal cohort of residents aged 16-64 years from a random, approximately 20% sample of households across the 15 communities was enrolled to assess baseline uptake of study outcomes; we also administered an end-of-study survey to all residents not previously enrolled in the longitudinal cohort to provide study end coverage estimates. Differences in intervention uptake over time by randomisation group were tested via paired Student's t test. The study has been completed and is registered with ClinicalTrials.gov (NCT01965470). FINDINGS In the six communities participating in the end-of-study survey, 2625 residents (n=1304 from standard-of-care communities, n=1321 from intervention communities) were enrolled into the 20% longitudinal cohort at baseline from Oct 30, 2013, to Nov 24, 2015. In the same communities, 10 791 (86%) of 12 489 eligible enumerated residents not previously enrolled in the longitudinal cohort participated in the end-of-study survey from March 30, 2017, to Feb 25, 2018 (5896 in intervention and 4895 in standard-of-care communities). At study end, in intervention communities, 1228 people living with HIV (91% of 1353) were on ART; 1166 people living with HIV (88% of 1321 with available viral load) were virally suppressed, and 673 HIV-negative men (40% of 1673) were circumcised in intervention communities. After accounting for baseline differences, at study end the proportion of people living with HIV who were diagnosed was significantly higher in intervention communities (absolute increase of 9% to 93%) compared with standard-of-care communities (absolute increase of 2% to 88%; prevalence ratio [PR] 1·08 [95% CI 1·02-1·14], p=0·032). Population levels of ART, viral suppression, and male circumcision increased from baseline in both groups, with greater increases in intervention communities (ART PR 1·12 [95% CI 1·07-1·17], p=0·018; viral suppression 1·13 [1·09-1·17], p=0·017; male circumcision 1·26 [1·17-1·35], p=0·029). INTERPRETATION It is possible to achieve very high population levels of HIV testing and treatment in a high-prevalence setting. Maintaining these coverage levels over the next decade could substantially reduce HIV transmission and potentially eliminate the epidemic in these areas. FUNDING US President's Emergency Plan for AIDS Relief through the Centers for Disease Control and Prevention.
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Affiliation(s)
- Kathleen E Wirth
- Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA.
| | | | - Molly Pretorius Holme
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Mompati Mmalane
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Etienne Kadima
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Unoda Chakalisa
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Kutlo Manyake
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | | | - Rona Letlhogile
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | | | - Sikhulile Moyo
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Kara Bennett
- Bennett Statistical Consulting, Ballston Lake, NY, USA
| | - Jean Leidner
- Goodtables Data Consulting, Norman, Oklahoma, USA
| | - Kathleen M Powis
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | | | - Mary Grace Alwano
- Centers for Disease Control and Prevention-Botswana, Gaborone, Botswana
| | - Joseph Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; Centers for Disease Control and Prevention-Botswana, Gaborone, Botswana
| | - Scott L Dryden-Peterson
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Coulson Kgathi
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Janet Moore
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Pam Bachanas
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Elliot Raizes
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - William Abrams
- Centers for Disease Control and Prevention-Botswana, Gaborone, Botswana
| | - Lisa Block
- Centers for Disease Control and Prevention, Atlanta, GA, USA; Intellectual Concepts, Atlanta, GA, USA
| | - Baraedi Sento
- Tebelopele Voluntary Counseling and Testing Center, Gaborone, Botswana
| | - Vlad Novitsky
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA
| | | | | | - Lisa A Mills
- Centers for Disease Control and Prevention-Botswana, Gaborone, Botswana
| | - Connie Sexton
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sherri Pals
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Roger L Shapiro
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Rui Wang
- Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA; Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Quanhong Lei
- Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Victor DeGruttola
- Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Joseph Makhema
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Myron Essex
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Shahin Lockman
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Eric J Tchetgen Tchetgen
- Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Statistics, The Wharton School at the University of Pennsylvania, Philadelphia, PA, USA
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Uptake and acceptability of assisted and unassisted HIV self-testing among men who purchase sex in brothels in Indonesia: a pilot intervention study. BMC Public Health 2020; 20:730. [PMID: 32429950 PMCID: PMC7238614 DOI: 10.1186/s12889-020-08812-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 04/29/2020] [Indexed: 02/08/2023] Open
Abstract
Background Along with sexual partners of other high-risk groups, men who purchase sex (MWPS) represented 18% of new HIV diagnoses worldwide in 2018. They are therefore an important population for HIV prevention globally. Despite very low HIV testing coverage among MWPS in many countries, the role of HIV self-testing to increase testing coverage has not been explored. We, therefore, conducted a pilot intervention study to evaluate the uptake and acceptability of assisted and unassisted HIV self-testing among MWPS in Indonesia. Methods MWPS attending seven brothels in Bali between December 2017 and January 2018 were recruited by lay health providers to participate in a brief health survey, and then invited to have a HIV self-test (assisted or unassisted) with an OraQuick® ADVANCE Rapid HIV-1/2 Antibody Test and complete a post-test acceptability survey. Results A total of 292 men completed the health survey (response rate: 70%) and 188 (64.6%) accepted HIV self-testing. Of these men, 13.3% had ever tested for HIV and 58.9% reported condom use at their last sexual encounter with a brothel-based female sex worker. Nearly all men (98.9%) who accepted a HIV self-test preferred assisted HIV self-testing – of whom 83.9% preferred to be fully assisted and 16.1% opted to be partially assisted and read their results privately. Of the men who accepted the test and showed the result to the lay health providers, 4 (2.1%) received reactive results. Linkage following HIV self-test is a concern, as none of the four men with a reactive result attended HIV testing at the recommended referral HIV testing clinic over a two-month follow-up period. Conclusions This study is the first to investigate the acceptance of HIV self-testing when offered to MWPS in brothels by lay health providers. The high uptake of HIV self-testing suggests that this testing model is acceptable and could increase the very low HIV testing coverage among MWPS. The strong preference for fully assisted HIV self-testing highlights the importance of involving lay health providers in future testing programs. When scaling up HIV self-testing programmatically, strategies to improve linkage-to-care should be considered and evaluated.
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Card KG, Lachowsky NJ, Althoff KN, Schafer K, Hogg RS, Montaner JSG. A systematic review of the geospatial barriers to antiretroviral initiation, adherence and viral suppression among people living with HIV. Sex Health 2020; 16:1-17. [PMID: 30409243 DOI: 10.1071/sh18104] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 07/04/2018] [Indexed: 11/23/2022]
Abstract
Background With the emergence of antiretroviral therapy (ART), Treatment as Prevention (TasP) has become the cornerstone of both HIV clinical care and HIV prevention. However, despite the efficacy of treatment-based programs and policies, structural barriers to ART initiation, adherence and viral suppression have the potential to reduce TasP effectiveness. These barriers have been studied using Geographic Information Systems (GIS). While previous reviews have examined the use of GIS for HIV testing - an essential antecedent to clinical care - to date, no reviews have summarised the research with respect to other ART-related outcomes. METHODS Therefore, the present review leveraged the PubMed database to identify studies that leveraged GIS to examine the barriers to ART initiation, adherence and viral suppression, with the overall goal of understanding how GIS has been used (and might continue to be used) to better study TasP outcomes. Joanna Briggs Institute criteria were used for the critical appraisal of included studies. RESULTS In total, 33 relevant studies were identified, excluding those not utilising explicit GIS methodology or not examining TasP-related outcomes. CONCLUSIONS Findings highlight geospatial variation in ART success and inequitable distribution of HIV care in racially segregated, economically disadvantaged, and, by some accounts, increasingly rural areas - particularly in the United States. Furthermore, this review highlights the utility and current limitations of using GIS to monitor health outcomes related to ART and the need for careful planning of resources with respect to the geospatial movement and location of people living with HIV (PLWH).
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Affiliation(s)
- Kiffer G Card
- Faculty of Health Science, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Nathan J Lachowsky
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Keri N Althoff
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Katherine Schafer
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Robert S Hogg
- Faculty of Health Science, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Julio S G Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
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Abstract
OBJECTIVES Improving immune status of people living with HIV through antiretroviral therapy (ART) may also reduce shedding of other viruses in semen. We characterized the seminal fluid virome of men with HIV and tested potential associations between viruses present and CD4 T-cell count, HIV viremia, and antiretroviral therapy (ART) status. DESIGN AND METHODS Metagenomics was used to enrich and sequence viral nucleic acids from the seminal fluid of 55 semen samples from 42 men living with HIV from San Francisco with a median age of 33 (IQR, 28.7-45) and median CD4 T-cell counts of 837 cells/μl (IQR, 258-1571 cells/μl). All samples were collected between 2005 and 2015, and ART status was ascertained from medical records. RESULTS Anelloviruses, cytomegalovirus (CMV), and multiple genotypes of human papillomaviruses were detected. Participants shed from 0 to 4 distinct human viruses. Longitudinally collected seminal fluid samples showed changes in the viruses shed. Viruses were more frequently shed by individuals with detectable HIV viremia (43.7 vs. 15.4%, P = 0.042). A trend was seen for increased shedding by individuals who were not on ART (42.8 vs. 17.8%, P = 0.082) or with CD4 T-cell count less than 350 cells/μl (35.3 vs. 20%, P = 0.27). CONCLUSION Seminal fluid from men with HIV from San Francisco contains nucleic acids from three different DNA viral families. A greater number of viruses, particularly CMV, were shed by participants with detectable HIV viremia (18.9 vs. 0%, P = 0.022). Control of viremia through ART may lower shedding of other viruses in semen in addition to HIV.
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Etoori D, Wringe A, Kabudula CW, Renju J, Rice B, Gomez-Olive FX, Reniers G. Misreporting of Patient Outcomes in the South African National HIV Treatment Database: Consequences for Programme Planning, Monitoring, and Evaluation. Front Public Health 2020; 8:100. [PMID: 32318534 PMCID: PMC7154050 DOI: 10.3389/fpubh.2020.00100] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 03/12/2020] [Indexed: 01/20/2023] Open
Abstract
Background: Monitoring progress toward global treatment targets using HIV programme data in sub-Saharan Africa has proved challenging. Constraints in routine data collection and reporting can lead to biased estimates of treatment outcomes. In 2010, South Africa introduced an electronic patient monitoring system for HIV patient visits, TIER.Net. We compare treatment status and outcomes recorded in TIER.Net to outcomes ascertained through detailed record review and tracing in order to assess discrepancies and biases in retention and mortality rates. Methods: The Agincourt Health and Demographic Surveillance System (HDSS) in north-eastern South Africa is served by eight public primary healthcare facilities. Since 2014, HIV patient visits are logged electronically at these clinics, with patient records individually linked to their HDSS record. These data were used to generate a list of patients >90 days late for their last scheduled clinic visit and deemed lost to follow-up (LTFU). Patient outcomes were ascertained through a review of the TIER.Net database, physical patient files, registers kept by two non-government organizations that assist with patient tracing, cross-referencing with the HDSS records and supplementary physical tracing. Descriptive statistics were used to compare patient outcomes reported in TIER.Net to their outcome ascertained in the study. Results: Of 1,074 patients that were eligible for this analysis, TIER.Net classified 533 (49.6%) as LTFU, 80 (7.4%) as deceased, and 186 (17.3%) as transferred out. TIER.Net misclassified 36% of patient outcomes, overestimating LTFU and underestimating mortality and transfers out. TIER.Net missed 40% of deaths and 43% of transfers out. Patients categorized as LTFU in TIER.Net were more likely to be misclassified than patients classified as deceased or transferred out. Discussion: Misclassification of patient outcomes in TIER.Net has consequences for programme forecasting, monitoring and evaluation. Undocumented transfers accounted for the majority of misclassification, suggesting that the transfer process between clinics should be improved for more accurate reporting of patient outcomes. Processes that lead to correct classification of patient status including patient tracing should be strengthened. Clinics could cross-check all available data sources before classifying patients as LTFU. Programme evaluators and modelers could consider using correction factors to improve estimates of outcomes from TIER.Net.
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Affiliation(s)
- David Etoori
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Chodziwadziwa Whiteson Kabudula
- MRC/WITS Rural Public Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Jenny Renju
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Brian Rice
- MeSH Consortium, Department of Public Health Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - F. Xavier Gomez-Olive
- MRC/WITS Rural Public Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Georges Reniers
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC/WITS Rural Public Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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Ortblad KF, Chanda MM, Mwale M, Haberer JE, McConnell M, Oldenburg CE, Bärnighausen T. Perceived Knowledge of HIV-Negative Status Increases Condom Use Among Female Sex Workers in Zambian Transit Towns. AIDS Patient Care STDS 2020; 34:184-192. [PMID: 32324483 PMCID: PMC7194317 DOI: 10.1089/apc.2019.0266] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Knowledge of HIV status is a necessary pre-condition for most HIV interventions, including treatment as well as biomedical and behavioral prevention interventions. We used data from a female sex worker (FSW) cohort in three Zambian transit towns to understand the effect that knowledge of HIV status has on FSWs' HIV risk-related sexual behaviors with clients. The cohort was formed from an HIV self-testing trial that followed participants for 4 months. Participants completed three rounds of data collection at baseline, 1 month, and 4 months where they reported their perceived knowledge of HIV status, number of clients on an average working night, and consistent condom use with clients. We measured the effect of knowledge of HIV status on participants' sexual behaviors by using linear regression models with individual fixed effects. The majority of the 965 participants tested for HIV at least once during the observation period (96%) and changed their knowledge of HIV status (79%). Knowledge of HIV status did not affect participants' number of clients, but it did affect their consistency of condom use. Compared with unknown HIV status, knowledge of HIV-negative status significantly increased participants' consistent condom use by 8.1% points [95% confidence interval (CI): 2.7–13.4, p = 0.003] and knowledge of HIV-positive status increased participants' consistent condom use by 6.1% points (95% CI: −0.1 to 12.9, p = 0.08); however, this latter effect was not statistically significant. FSWs in Zambia engaged in safer sex with clients when they learned their HIV status. The expansion of HIV testing programs may serve as a behavioral HIV prevention measure among FSWs.
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Affiliation(s)
- Katrina F. Ortblad
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | | | | | - Jessica E. Haberer
- Department of General Internal Medicine, Massachusetts General Hospital Global Health, Boston, Massachusetts, USA
| | - Margaret McConnell
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Catherine E. Oldenburg
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California, USA
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Africa Health Research Institute (AHRI), Somkhele and Durban, South Africa
- Heidelberg Institute of Public Health (HIGH), University of Heidelberg, Heidelberg, Germany
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Xia Q, Wertheim JO, Braunstein SL, Misra K, Udeagu CC, Torian LV. Use of molecular HIV surveillance data and predictive modeling to prioritize persons for transmission-reduction interventions. AIDS 2020; 34:459-467. [PMID: 31794522 PMCID: PMC8580888 DOI: 10.1097/qad.0000000000002452] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To develop a predictive model to prioritize persons with a transmissible HIV viral load for transmission-reduction interventions. METHODS New York City (NYC) HIV molecular surveillance data from 2010 to 2013 were used to build a model to predict the probability that the partial pol gene of the virus of a person with a transmissible HIV viral load (>1500 copies/ml) would be genetically similar to that of a person with a new HIV infection (diagnosis at stage 0 or 1 according to the revised Centers for Disease Control and Prevention classification system). Data from 2013 to 2016 were then used to validate the model and compare it with five other selection strategies that can be used to prioritize persons for transmission-reduction interventions. RESULTS A total of 10 609 persons living with HIV (PLWH) were included in the development dataset, and 8257 were included in the validation dataset. Among the six selection strategies, the predictive model had the highest area under the receiver operating characteristic curve (AUC) [0.86, 95% confidence interval (CI) 0.84--0.88], followed by the 'Young MSM' (0.79, 95% CI 0.77--0.82), 'MSM with high viral loads' (0.74, 95% CI 0.72--0.76), 'Random sample of MSM' (0.73, 95% CI 0.71--0.76), 'Persons with high viral loads' (0.56, 95% CI 0.54--0.59), and 'Random sample' (0.50, 95% CI 0.48--0.53) strategies. CONCLUSIONS Jurisdictions should consider applying predictive modeling to prioritize persons with a transmissible viral load for transmission-reduction interventions and to evaluate its feasibility and effectiveness.
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Affiliation(s)
- Qiang Xia
- HIV Epidemiology and Field Services Program, Bureau of HIV Prevention and Control, New York City Department of Health and Mental Hygiene, Queens, NY
| | - Joel O. Wertheim
- Department of Medicine, University of California San Diego, San Diego, CA
| | - Sarah L. Braunstein
- HIV Epidemiology and Field Services Program, Bureau of HIV Prevention and Control, New York City Department of Health and Mental Hygiene, Queens, NY
| | - Kavita Misra
- HIV Epidemiology and Field Services Program, Bureau of HIV Prevention and Control, New York City Department of Health and Mental Hygiene, Queens, NY
| | - Chi-Chi Udeagu
- HIV Epidemiology and Field Services Program, Bureau of HIV Prevention and Control, New York City Department of Health and Mental Hygiene, Queens, NY
| | - Lucia V. Torian
- HIV Epidemiology and Field Services Program, Bureau of HIV Prevention and Control, New York City Department of Health and Mental Hygiene, Queens, NY
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Changes in Characteristics and Behavior Among African American Men Who Have Sex with Men and Women in the Context of Reductions in HIV Diagnoses Among Women. AIDS Behav 2020; 24:960-966. [PMID: 31073947 DOI: 10.1007/s10461-019-02528-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Men who have sex with men and women (MSMW) connect lower prevalence populations of women to higher prevalence populations of men who have sex with men only. We hypothesize that HIV testing and treatment among MSMW have increased in recent years, and this increase can help explain the declining rates of new HIV diagnoses among African American women. We analyzed data from 2008, 2011, and 2014 of the National HIV Behavioral Surveillance system. African American men who have sex with men (MSM) were surveyed from 19 United States cities using venue-based sampling and tested for HIV infection. We used generalized estimating equations, using year of survey as an independent variable, adjusting for age, to determine differences for selected outcomes regarding healthcare and risk behaviors over time. Among the 1299 African American MSMW interviewed, significant increases were observed in the percent of men who had an HIV test in the previous 12 months (2008: 54%, 2011: 69%, and 2014: 68%, p-value < 0.001). Among HIV-positive men, the percentage of men who were aware of their infection at the time of the interview increased significantly over time (26, 35, and 48%, p-value = 0.002). Among those men, the percentage who reported currently being on antiretroviral therapy also increased significantly over time (46, 69, and 72%, p-value = 0.050). The percentage of men reporting high-risk sexual risk behaviors increased or remained stable. Our findings support the hypothesis that HIV testing and treatment has increased among African American MSM from 2008 to 2014. Additional research is needed to fully explore the population-level impact it has on HIV transmission among women.
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Akullian A, Morrison M, Garnett GP, Mnisi Z, Lukhele N, Bridenbecker D, Bershteyn A. The effect of 90-90-90 on HIV-1 incidence and mortality in eSwatini: a mathematical modelling study. Lancet HIV 2020; 7:e348-e358. [PMID: 32061317 PMCID: PMC7221345 DOI: 10.1016/s2352-3018(19)30436-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 12/12/2019] [Accepted: 12/20/2019] [Indexed: 12/26/2022]
Abstract
Background The rapid scale-up of antiretroviral therapy (ART) towards the UNAIDS 90-90-90 goals over the last decade has sparked considerable debate as to whether universal test and treat can end the HIV-1 epidemic in sub-Saharan Africa. We aimed to develop a network transmission model, calibrated to capture age-specific and sex-specific gaps in the scale-up of ART, to estimate the historical and future effect of attaining and surpassing the UNAIDS 90-90-90 treatment targets on HIV-1 incidence and mortality, and to assess whether these interventions will be enough to achieve epidemic control (incidence of 1 infection per 1000 person-years) by 2030. Methods We used eSwatini (formerly Swaziland) as a case study to develop our model. We used data on HIV prevalence by 5-year age bins, sex, and year from the 2007 Swaziland Demographic Health Survey (SDHS), the 2011 Swaziland HIV Incidence Measurement Survey, and the 2016 Swaziland Population Health Impact Assessment (PHIA) survey. We estimated the point prevalence of ART coverage among all HIV-infected individuals by age, sex, and year. Age-specific data on the prevalence of male circumcision from the SDHS and PHIA surveys were used as model inputs for traditional male circumcision and scale-up of voluntary medical male circumcision (VMMC). We calibrated our model using publicly available data on demographics; HIV prevalence by 5-year age bins, sex, and year; and ART coverage by age, sex, and year. We modelled the effects of five scenarios (historical scale-up of ART and VMMC [status quo], no ART or VMMC, no ART, age-targeted 90-90-90, and 100% ART initiation) to quantify the contribution of ART scale-up to declines in HIV incidence and mortality in individuals aged 15–49 by 2016, 2030, and 2050. Findings Between 2010 and 2016, status-quo ART scale-up among adults (aged 15–49 years) in eSwatini (from 34·0% in 2010 to 74·1% in 2016) reduced HIV incidence by 43·57% (95% credible interval 39·71 to 46·36) and HIV mortality by 56·17% (54·06 to 58·92) among individuals aged 15–49 years, with larger reductions in incidence among men and mortality among women. Holding 2016 ART coverage levels by age and sex into the future, by 2030 adult HIV incidence would fall to 1·09 (0·87 to 1·29) per 100 person-years, 1·42 (1·13 to 1·71) per 100 person-years among women and 0·79 (0·63 to 0·94) per 100 person-years among men. Achieving the 90-90-90 targets evenly by age and sex would further reduce incidence beyond status-quo ART, primarily among individuals aged 15–24 years (an additional 17·37% [7·33 to 26·12] reduction between 2016 and 2030), with only modest additional incidence reductions in adults aged 35–49 years (1·99% [–5·09 to 7·74]). Achieving 100% ART initiation among all people living with HIV within an average of 6 months from infection—an upper bound of plausible treatment effect—would reduce adult HIV incidence to 0·73 infections (0·55 to 0·92) per 100 person-years by 2030 and 0·46 (0·33 to 0·59) per 100 person-years by 2050. Interpretation Scale-up of ART over the last decade has already contributed to substantial reductions in HIV-1 incidence and mortality in eSwatini. Focused ART targeting would further reduce incidence, especially in younger individuals, but even the most aggressive treatment campaigns would be insufficient to end the epidemic in high-burden settings without a renewed focus on expanding preventive measures. Funding Global Good Fund and the Bill & Melinda Gates Foundation.
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Affiliation(s)
- Adam Akullian
- Institute for Disease Modeling, Bellevue, WA, USA; Department of Global Health, University of Washington, Seattle, WA, USA.
| | | | | | - Zandile Mnisi
- Ministry of Health, Kingdom of eSwatini, Mbabane, eSwatini
| | | | | | - Anna Bershteyn
- Institute for Disease Modeling, Bellevue, WA, USA; Department of Population Health, New York University School of Medicine, New York, NY, USA
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Havlir D, Lockman S, Ayles H, Larmarange J, Chamie G, Gaolathe T, Iwuji C, Fidler S, Kamya M, Floyd S, Moore J, Hayes R, Petersen M, Dabis F. What do the Universal Test and Treat trials tell us about the path to HIV epidemic control? J Int AIDS Soc 2020; 23:e25455. [PMID: 32091179 PMCID: PMC7038879 DOI: 10.1002/jia2.25455] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/14/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Achieving HIV epidemic control globally will require new strategies to accelerate reductions in HIV incidence and mortality. Universal test and treat (UTT) was evaluated in four randomized population-based trials (BCPP/Ya Tsie, HPTN 071/PopART, SEARCH, ANRS 12249/TasP) conducted in sub-Saharan Africa (SSA) during expanded antiretroviral treatment (ART) eligibility by World Health Organization guidelines and the UNAIDS 90-90-90 campaign. DISCUSSION These three-year studies were conducted in Botswana, Zambia, Uganda, Kenya and South Africa in settings with baseline HIV prevalence from 4% to 30%. Key observations across studies were: (1) Universal testing (implemented via a variety of home and community-based testing approaches) achieved >90% coverage in all studies. (2) When coupled with robust linkage to HIV care, rapid ART start and patient-centred care, UTT achieved among the highest reported population levels of viral suppression in SSA. Significant gains in population-level viral suppression were made in regions with both low and high baseline population viral load; however, viral suppression gains were not uniform across all sub-populations and were lower among youth. (3) UTT resulted in marked reductions in community HIV incidence when universal testing and robust linkage were present. However, HIV elimination targets were not reached. In BCPP and HPTN 071, annualized HIV incidence was approximately 20% to 30% lower in the intervention (which included universal testing) compared to control arms (no universal testing). In SEARCH (where both arms had universal testing), incidence declined 32% over three years. (4) UTT reduced HIV associated mortality by 23% in the intervention versus control communities in SEARCH, a study in which mortality was comprehensively measured. CONCLUSIONS These trials provide strong evidence that UTT inclusive of universal testing increases population-level viral suppression and decreases HIV incidence and mortality faster than the status quo in SSA and should be adapted at a sub-country level as a public health strategy. However, more is needed, including integration of new prevention interventions into UTT, in order to reach UNAIDS HIV elimination targets.
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Affiliation(s)
- Diane Havlir
- Department of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Shahin Lockman
- Brigham and Women's HospitalBostonMAUSA
- Harvard School T.H. Chan School of Public HealthBostonMAUSA
- Botswana Harvard AIDS Institute PartnershipGaboroneBotswana
| | - Helen Ayles
- Clinical Research DepartmentLondon School of Hygiene & Tropical MedicineLondonUnited Kingdom
- ZambartLusakaZambia
| | - Joseph Larmarange
- Centre Population et DéveloppementInstitut de Recherche pour le DéveloppementUniversité Paris DescartesInsermParisFrance
- Africa Health Research InstituteSomkheleSouth Africa
| | - Gabriel Chamie
- Department of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Tendani Gaolathe
- Botswana Harvard AIDS Institute PartnershipGaboroneBotswana
- University of BotswanaGaboroneBotswana
| | - Collins Iwuji
- Department of Global Health & InfectionBrighton and Sussex Medical SchoolBrightonUnited Kingdom
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Research Department of Infection and Population HealthUniversity College LondonLondonUnited Kingdom
| | - Sarah Fidler
- Imperial CollegeNational Institute for Health Research Biomedical Research CenterLondonUnited Kingdom
- Department of Infectious DiseaseImperial College LondonLondonUnited Kingdom
| | - Moses Kamya
- Department of MedicineMakerere UniversityKampalaUganda
- Infectious Diseases Research Collaboration (IDRC)KampalaUganda
| | - Sian Floyd
- Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Janet Moore
- Division of Global HIV/AIDS and TBCenters for Disease Control and PreventionAtlantaGAUSA
| | - Richard Hayes
- Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Maya Petersen
- School of Public HealthUniversity of California BerkeleyBerkeleyCAUSA
| | - Francois Dabis
- ISPED & Inserm Bordeaux Population Health UMR 1219Univ BordeauxBordeauxFrance
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Schutte C, Forsythe S, Mdala JF, Zieman B, Linder R, Vu L. The short-term effects of the implementation of the "Treat All" guidelines on ART service delivery costs in Namibia. PLoS One 2020; 15:e0228135. [PMID: 31986182 PMCID: PMC6984719 DOI: 10.1371/journal.pone.0228135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 01/08/2020] [Indexed: 11/19/2022] Open
Abstract
The introduction of "Treat All" (TA) has been promoted to increase the effectiveness of HIV/AIDS treatment by having patients initiate antiretroviral therapy at an earlier stage of their illness. The impact of introducing TA on the unit cost of treatment has been less clear. The following study evaluated how costs changed after Namibia's introduction of TA in April 2017. A two-year analysis assessed the costs of antiretroviral therapy (ART) during the 12 months before TA (Phase I-April 1, 2016 to March 31, 2017) and the 12 months following (Phase II-April 1, 2017 to March 31, 2018). The analysis involved interviewing staff at ten facilities throughout Namibia, collecting data on resources utilized in the treatment of ART patients and analyzing how costs changed before and after the introduction of TA. An analysis of treatment costs indicated that the unit cost of treatment declined from USD360 per patient per year in Phase I to USD301 per patient per year in Phase II, a reduction of 16%. This decline in unit costs was driven by 3 factors: 1) shifts in antiretroviral (ARV) regimens that resulted in lower costs for drugs and consumables, 2) negotiated reductions in the cost of viral load tests and 3) declines in personnel costs. It is unlikely that the first two of these factors were significantly influenced by the introduction of TA. It is unclear if TA might have had an influence on personnel costs. The reduction in personnel costs may have either represented a positive development (fewer personnel costs associated with increased numbers of healthier patients and fewer visits required) or alternatively may reflect constraints in Namibia's staffing. Prior to this study, it was expected that the introduction of TA would lead to a significant increase in the number of ART patients. However, there was less than a 4% increase in the number of adult patients at the 10 studied facilities. From a financial point of view, TA did not significantly increase the resources required in the ten sampled facilities, either by raising unit costs or significantly increasing the number of ART patients.
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Affiliation(s)
| | - Steven Forsythe
- Avenir Health, Glastonbury, Fountain Hills, AZ, United States of America
| | | | - Brady Zieman
- Population Council, Washington, DC, United States of America
| | - Rachael Linder
- Avenir Health, Glastonbury, Fountain Hills, AZ, United States of America
| | - Lung Vu
- Population Council, Washington, DC, United States of America
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Jiang Y, Su S, Borné Y. A meta-analysis of the efficacy of HAART on HIV transmission and its impact on sexual risk behaviours among men who have sex with men. Sci Rep 2020; 10:1075. [PMID: 31974510 PMCID: PMC6978405 DOI: 10.1038/s41598-019-56530-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Accepted: 11/04/2019] [Indexed: 11/23/2022] Open
Abstract
Evidence showed preventive impacts of the highly active antiretroviral therapy (HAART) on the Human Immunodeficiency Virus (HIV) transmission amomg heterosexual population, however, that is of deficit among men who have sex with men (MSM). The aim was to systematically examine the efficacy of HAART on HIV transmission and the association between the HAART initiation and unprotected anal intercourse (UAI) in MSM population. Three electronic databases were fully searched for articles published in peer-reviewed journals between 1996 and 2017. Of 1616 identified articles, fifteen articles were eligible for meta-analyses. The summary incidence rate (IR) of HIV was 6.63/100 person-year (95%CI 2.06–11.20/100 person-year)(p = 0.004). The pooled per-contact rate (PCR) of HIV was 0.42% (95% CI 0.21–0.63%)(p < 0.05). The HAART initiation (vs non-HAART) was not associated with engaging in UAI, with odds ratio (OR) 1.09 (95% CI 0.90–1.34)(p > 0.05). In the stratified analysis, participants with no less than 6 months recall period was slightly more likely to engage in UAI (OR 1.32; 95% CI 1.01–1.74)(p < 0.05). It indicated that HAART has potential efficacy on reducing infectivity of HIV positive individuals in anal intercourses. The relationship between the HAART initiation and UAI was not significant and may be influenced by some social-demographic factors. Consistent condom use and education on safe sex among MSM are crucial.
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Affiliation(s)
- Ying Jiang
- Department of Clinical Sciences in Malmö, Faculty of Medicine, Lund University, Lund, Sweden.
| | - Shu Su
- School of public health and preventive medicine, Monash University, Melbourne, Australia
| | - Yan Borné
- Department of Clinical Sciences in Malmö, Faculty of Medicine, Lund University, Lund, Sweden
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Ssekalembe G, Isfandiari MA, Suprianto H. Current Status Towards 90-90-90 UNAIDS Target and Factors Associated with HIV Viral Load Suppression in Kediri City, Indonesia. HIV AIDS (Auckl) 2020; 12:47-57. [PMID: 32021486 PMCID: PMC6970622 DOI: 10.2147/hiv.s231173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 01/02/2020] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION In 2016, UN Member States committed to reduce new HIV infections to fewer than 500,000 annually by 2020, a 75% reduction compared with 2010, reduce AIDS-related deaths to fewer than 500,000 globally as a means of ending AIDS by 2030. The UNAIDS 2020 target is to have 90% of the people living with HIV know their status, 90% of the people living with HIV (who know their HIV status as positive) are already on ART treatment, 90% of people on treatment are virally suppressed. The objective of this study is to determine the current status towards the 2020 90-9-90 UNAIDS target and the factors associated with HIV viral load suppression in Kediri city. METHODS The study was a cross-sectional study in Kediri city. The researcher collected secondary data, carried in-depth interviews, then determined the percentage of HIV-positive patients that did a HIV test and received their results as Positive, the percentage of HIV-positive patients that started ART treatment, the percentage of HIV-positive patients that have viral load suppression from the viral load tests done. A simple bivariate logistic and multivariate logistic regression was used to determine the significant factors that determine viral suppression. RESULTS The progress towards the 90-90-90 UNAIDS target was at 6.4%, 74.9%, 9.9%. The time taken by the HIV-positive patient to start ART treatment from the time of confirmation of HIV positive (AOR= 83.191, CI: 1.617-4280.115) and decrease in body weight of the patient (AOR=29.636, CI: 1.193-736.167) were found to significantly influence viral load suppression. CONCLUSION There is a need to scale up HIV case-detection capacity through creating awareness about HIV, HIV testing and counselling and expand the ART services so as to achieve the 90-0-90 UNAIDS target. Early initiation to ART treatment (Test and Treat) and encouraging body gaining behaviors are needed to achieve viral load suppression.
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Dieckhaus KD, Ha TH, Schensul SL, Sarna A. Modeling HIV Transmission from Sexually Active Alcohol-Consuming Men in ART Programs to Seronegative Wives. J Int Assoc Provid AIDS Care 2020; 19:2325958220952287. [PMID: 32851898 PMCID: PMC7457687 DOI: 10.1177/2325958220952287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The rollout of antiviral therapy in Low and Middle Income Countries (LMICs) has reduced HIV transmission rates at the potential risk of resistant HIV transmission. We sought to predict the risk of wild type and antiviral resistance transmissions in these settings. METHODS A predictive model utilizing viral load, ART adherence, genital ulcer disease, condom use, and sexual event histories was developed to predict risks of HIV transmission to wives of 233 HIV+ men in 4 antiretroviral treatment centers in Maharashtra, India. RESULTS ARV Therapy predicted a 5.71-fold reduction in transmissions compared to a model of using condoms alone, with 79.9%, of remaining transmissions resulting in primary ART-resistance. CONCLUSIONS ART programs reduce transmission of HIV to susceptible partners at a substantial increased risk for transmission of resistant virus. Enhanced vigilance in monitoring adherence, use of barrier protections, and viral load may reduce risks of resistant HIV transmissions in LMIC settings.
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Affiliation(s)
- Kevin D. Dieckhaus
- University of Connecticut Division of Infectious Diseases,
Farmington, CT, USA
| | - Toan H. Ha
- University of Pittsburgh Graduate School of Public Health,
Pittsburgh, PA, USA
| | - Stephen L. Schensul
- University of Connecticut Department of Community Medicine and
Healthcare, Farmington, CT, USA
| | - Avina Sarna
- Population Council, India Habitat Centre, New Delhi, India
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Hogben M, Leichliter J, Aral SO. An Overview of Social and Behavioral Determinants of STI. Sex Transm Infect 2020. [DOI: 10.1007/978-3-030-02200-6_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Abstract
Background: Antiretroviral treatment (ART) reduces HIV infectiousness but the effect of early ART on sexual behaviour is unclear. Methods: We assessed, within the START randomized trial that enrolled HIV-positive adults with CD4+ cell count greater than 500 cells/μl, the effect of early (immediate) versus deferred ART on: condomless sex with HIV-serodifferent partners (CLS-D); all condomless sex (CLS); HIV transmission-risk sex (CLS-D-HIV risk, defined as CLS-D and: not on ART or started ART <6 months ago or viral load greater than 200 copies/ml or no viral load in past 6 months), during 2-year follow-up. Month-12 CLS-D (2010–2014) was the primary outcome. Results: Among 2562 MSM, there was no difference between immediate and deferred arms in CLS-D at month 12 [12.6 versus 13.1%; difference (95% CI): −0.4% (−3.1 to 2.2%), P = 0.75] or month 24, or in CLS. Among 2010 heterosexual men and women, CLS-D at month 12 tended to be higher in the immediate versus deferred arm [10.8 versus 8.3%; difference:2.5% (−0.1 to 5.2%), P = 0.062]; the difference was greater at month 24 [9.3 versus 5.6%; difference: 3.7% (1.0 to 6.4%), P = 0.007], at which time CLS was higher in the immediate arm (20.7 versus 15.7%, P = 0.013). CLS-D-HIV risk at month 12 was substantially lower in the immediate versus deferred arm for MSM [0.2 versus 11%; difference: −10.7% (−12.5 to −8.9%), P < 0.001] and heterosexuals [0.6% versus 7.7%; difference: −7.0% (−8.8 to −5.3%), P < 0.001], because of viral suppression on ART. Conclusion: A strategy of early ART had no effect on condomless sex with HIV-serodifferent partners among MSM, but resulted in modestly higher prevalence among heterosexuals. However, among MSM and heterosexuals, early ART resulted in a substantial reduction in HIV-transmission-risk sex, to a very low absolute level.
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Gray RT, Watson J, Cogle AJ, Smith DE, Hoy JF, Bastian LA, Finlayson R, Drummond FM, Whittaker B, Law MG, Petoumenos K. Funding antiretroviral treatment for HIV-positive temporary residents in Australia prevents transmission and is inexpensive. Sex Health 2019; 15:13-19. [PMID: 28874236 DOI: 10.1071/sh16237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 06/14/2017] [Indexed: 01/20/2023]
Abstract
Background The aim of this study is to estimate the reduction in new HIV infections and resultant cost outcomes of providing antiretroviral treatment (ART) through Australia's 'universal access' health scheme to all temporary residents with HIV infection living legally in Australia, but currently deemed ineligible to access subsidised ART via this scheme. METHODS A mathematical model to estimate the number of new HIV infections averted and the associated lifetime costs over 5 years if all HIV-positive temporary residents in Australia had access to ART and subsidised medical care was developed. Input data came from a cohort of 180 HIV-positive temporary residents living in Australia who are receiving free ART donated by pharmaceutical companies for up to 4 years. RESULTS Expanding ART access to an estimated total 450 HIV+ temporary residents in Australia for 5 years could avert 80 new infections. The model estimated the total median discounted (5%) cost for ART and associated care to be A$36million, while the total savings in lifetime-discounted costs for the new infections averted was A$22million. CONCLUSIONS It is estimated that expanded access to ART for all HIV-positive temporary residents in Australia will substantially reduce HIV transmission to their sexual partners at little additional cost. In the context of Australia's National HIV strategy and Australia's endorsement of global goals to provide universal access to ART for all people with HIV, this is an important measure to remove inequities in the provision of HIV-related treatment and care.
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Affiliation(s)
- Richard T Gray
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia
| | - Jo Watson
- National Association of People with HIV Australia (NAPWHA), Sydney, NSW 2042, Australia
| | - Aaron J Cogle
- National Association of People with HIV Australia (NAPWHA), Sydney, NSW 2042, Australia
| | | | - Jennifer F Hoy
- Department of Infectious Diseases, The Alfred Hospital and Monash University, Melbourne Vic. 3181, Australia
| | - Lisa A Bastian
- Western Australian Department of Health, Perth, WA 6004, Australia
| | - Robert Finlayson
- Taylor Square Private Clinic, Taylor Square, Sydney, NSW 2010, Australia
| | | | - Bill Whittaker
- National Association of People with HIV Australia (NAPWHA), Sydney, NSW 2042, Australia
| | - Matthew G Law
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia
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Kharsany ABM, Cawood C, Lewis L, Yende-Zuma N, Khanyile D, Puren A, Madurai S, Baxter C, George G, Govender K, Beckett S, Samsunder N, Toledo C, Ayalew KA, Diallo K, Glenshaw M, Herman-Roloff A, Wilkinson E, de Oliveira T, Abdool Karim SS, Abdool Karim Q. Trends in HIV Prevention, Treatment, and Incidence in a Hyperendemic Area of KwaZulu-Natal, South Africa. JAMA Netw Open 2019; 2:e1914378. [PMID: 31675082 PMCID: PMC6826647 DOI: 10.1001/jamanetworkopen.2019.14378] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE In Africa, the persistently high HIV incidence rate among young women is the major obstacle to achieving the goal of epidemic control. OBJECTIVE To determine trends in coverage of HIV prevention and treatment programs and HIV incidence. DESIGN, SETTING, AND PARTICIPANTS This cohort study consisted of 2 sequential, community-based longitudinal studies performed in the Vulindlela and Greater Edendale area in KwaZulu-Natal, South Africa. Participants enrolled from June 11, 2014, to June 22, 2015 (2014 survey), with a single follow-up visit from June 24, 2016, to April 3, 2017 (2016 cohort), or enrolled from July 8, 2015, to June 7, 2016 (2015 survey), with a single follow-up visit from November 7, 2016, to August 30, 2017 (2017 cohort). Men and women aged 15 to 49 years were enrolled in the 2014 and 2015 surveys, and HIV-seronegative participants aged 15 to 35 years were followed up in the 2016 and 2017 cohorts. Analysis was conducted from January 1 through December 31, 2018. EXPOSURES HIV prevention and treatment programs in a real-world, nontrial setting. MAIN OUTCOMES AND MEASURES Trends in sex- and age-specific HIV incidence rates, condom use, voluntary medical male circumcision, knowledge of HIV-seropositive status, uptake of antiretroviral therapy, and viral suppression. RESULTS A total of 9812 participants (6265 women [63.9%]; median age, 27 years [interquartile range, 20-36 years]) from 11 289 households were enrolled in the 2014 survey, and 10 236 participants (6341 women [61.9%]; median age, 27 years [interquartile range, 20-36 years]) from 12 247 households were enrolled in the 2015 survey. Of these, 3536 of 4539 (annual retention rate of 86.7%) completed follow-up in the 2016 cohort, and 3907 of 5307 (annual retention rate of 81.4%) completed follow-up in the 2017 cohort. From 2014 to 2015, condom use with last sex partner decreased by 10% from 24.0% (n = 644 of 3547) to 21.6% (n = 728 of 3895; P = .12) in men and by 17% from 19.6% (n = 1039 of 6265) to 16.2% (n = 871 of 6341; P = .002) in women. Voluntary medical male circumcision increased by 13% from 31.9% (1102 of 3547) to 36.1% (n = 1472 of 3895); P = .007) in men, and the proportion of women reporting that their partner was circumcised increased by 35% from 35.7% (n = 1695 of 4766) to 48.2% (n = 2519 of 5207; P < .001). Knowledge of HIV-seropositive status increased by 21% from 51.8% (n = 504 of 3547) to 62.9% (n = 570 of 3895; P < .001) in men and by 14% from 64.6% (n = 1833 of 6265) to 73.4% (n = 2182 of 6341; P < .001) in women. Use of antiretroviral therapy increased by 32% from 36.7% (n = 341 of 3547) to 48.6% (n = 432 of 3895; P < .001) in men and by 29% from 45.6% (n = 1251 of 6265) to 58.8% (n = 1743 of 6341; P < .001) in women; HIV viral suppression increased by 20% from 41.9% (n = 401 of 3547) to 50.3% (n = 456 of 3895; P = .005) in men and by 13% from 54.8% (n = 1547 of 6265) to 61.9% (n = 1828 of 6341; P < .001) in women. Incidence of HIV declined in women aged 15 to 19 years from 4.63 (95% CI, 3.29-6.52) to 2.74 (95% CI, 1.84-4.09) per 100 person-years (P = .04) but declined marginally or remained unchanged among men and women in other age groups. CONCLUSIONS AND RELEVANCE This study showed a significant decline in HIV incidence in young women; however, to further reduce HIV incidence, HIV prevention and treatment program coverage must be intensified and scaled up.
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Affiliation(s)
- Ayesha B. M. Kharsany
- Centre for the AIDS Programme of Research in South Africa, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Cherie Cawood
- Epicentre AIDs Risk Management, Cape Town, South Africa
| | - Lara Lewis
- Centre for the AIDS Programme of Research in South Africa, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Nonhlanhla Yende-Zuma
- Centre for the AIDS Programme of Research in South Africa, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | | | - Adrian Puren
- Centre for HIV and STIs, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | | | - Cheryl Baxter
- Centre for the AIDS Programme of Research in South Africa, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Gavin George
- Health Economics and HIV/AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
| | - Kaymarlin Govender
- Health Economics and HIV/AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
| | - Sean Beckett
- Health Economics and HIV/AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
| | - Natasha Samsunder
- Centre for the AIDS Programme of Research in South Africa, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Carlos Toledo
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Karidia Diallo
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mary Glenshaw
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Eduan Wilkinson
- KwaZulu-Natal Research Innovation and Sequencing Platform, University of KwaZulu-Natal, Durban, South Africa
| | - Tulio de Oliveira
- Centre for the AIDS Programme of Research in South Africa, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- KwaZulu-Natal Research Innovation and Sequencing Platform, University of KwaZulu-Natal, Durban, South Africa
| | - Salim S. Abdool Karim
- Centre for the AIDS Programme of Research in South Africa, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Quarraisha Abdool Karim
- Centre for the AIDS Programme of Research in South Africa, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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Mulhall BP, Wright S, Allen D, Brown K, Dickson B, Grotowski M, Jackson E, Petoumenos K, Read P, Read T, Russell D, Smith DJ, Templeton DJ, Fairley CK, Law MG. High rates of sexually transmissible infections in HIV-positive patients in the Australian HIV Observational Database: a prospective cohort study. Sex Health 2019; 11:291-7. [PMID: 25109880 DOI: 10.1071/sh13074] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Accepted: 05/19/2014] [Indexed: 01/24/2023]
Abstract
UNLABELLED Background In HIV-positive people, sexually transmissible infections (STIs) probably increase the infectiousness of HIV. METHODS In 2010, we established a cohort of individuals (n=554) from clinics in the Australian HIV Observational Database (AHOD). We calculated retrospective rates for four STIs for 2005-10 and prospective incidence rates for 2010-11. RESULTS At baseline (2010), patient characteristics were similar to the rest of AHOD. Overall incidence was 12.5 per 100 person-years. Chlamydial infections increased from 3.4 per 100 person-years (95% confidence interval (CI): 1.9-5.7) in 2005 to 6.7 per 100 person-years (95% CI: 4.5-9.5) in 2011, peaking in 2010 (8.1 per 100 person-years; 95% CI: 5.6-11.2). Cases were distributed among rectal (61.9%), urethral (34%) and pharyngeal (6.3%) sites. Gonococcal infections increased, peaking in 2010 (4.7 per 100 person-years; 95% CI: 5.6-11.2; Ptrend=0.0099), distributed among rectal (63.9%), urethral (27.9%) and pharyngeal (14.8%) sites. Syphilis showed several peaks, the largest in 2008 (5.3 per 100 person-years; 95% CI: 3.3-8.0); the overall trend was not significant (P=0.113). Genital warts declined from 7.5 per 100 person-years (95% CI: 4.8-11.3) in 2005 to 2.4 per 100 person-years (95% CI: 1.1-4.5) in 2011 (Ptrend=0.0016). CONCLUSIONS For chlamydial and gonococcal infections, incidence was higher than previous Australian estimates among HIV-infected men who have sex with men, increasing during 2005-2011. Rectal infections outnumbered infections at other sites. Syphilis incidence remained high but did not increase; that of genital warts was lower and decreased.
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Affiliation(s)
- Brian P Mulhall
- The Kirby Institute for Infection and Immunity in Society, Wallace Wurth Building, University of New South Wales, Sydney, NSW 2052, Australia
| | - Stephen Wright
- The Kirby Institute for Infection and Immunity in Society, Wallace Wurth Building, University of New South Wales, Sydney, NSW 2052, Australia
| | - Debbie Allen
- Holden Street Sexual Health Clinic, PO Box 361, Gosford, NSW 2250, Australia
| | | | | | - Miriam Grotowski
- Clinic 468, Tamworth Sexual Health, Hunter New England Area Health Service, NSW 2340, Australia
| | - Eva Jackson
- Nepean/Blue Mountains Sexual Health, Nepean Hospital, Kingswood NSW 2747, Australia
| | - Kathy Petoumenos
- The Kirby Institute for Infection and Immunity in Society, Wallace Wurth Building, University of New South Wales, Sydney, NSW 2052, Australia
| | - Phillip Read
- The Kirby Institute for Infection and Immunity in Society, Wallace Wurth Building, University of New South Wales, Sydney, NSW 2052, Australia
| | - Timothy Read
- Melbourne Sexual Health Centre, Alfred Hospital, Prahran, Vic. 3181, Australia
| | - Darren Russell
- Cairns Sexual Health Service, PO Box 902, Cairns, Qld 4214, Australia
| | - David J Smith
- Lismore Sexual Health Services, 4 Shepherd Lane, Lismore, NSW 2480, Australia
| | - David J Templeton
- The Kirby Institute for Infection and Immunity in Society, Wallace Wurth Building, University of New South Wales, Sydney, NSW 2052, Australia
| | | | - Matthew G Law
- The Kirby Institute for Infection and Immunity in Society, Wallace Wurth Building, University of New South Wales, Sydney, NSW 2052, Australia
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LeMessurier J, Traversy G, Varsaneux O, Weekes M, Avey MT, Niragira O, Gervais R, Guyatt G, Rodin R. Risk of sexual transmission of human immunodeficiency virus with antiretroviral therapy, suppressed viral load and condom use: a systematic review. CMAJ 2019; 190:E1350-E1360. [PMID: 30455270 DOI: 10.1503/cmaj.180311] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The Public Health Agency of Canada reviewed sexual transmission of HIV between serodiscordant partners to support examination of the criminal justice system response to HIV nondisclosure by the Department of Justice of Canada. We sought to determine HIV transmission risk when an HIV-positive partner takes antiretroviral therapy, has a suppressed viral load or uses condoms. METHODS We conducted an overview and systematic review update by searching MEDLINE and other databases (Jan. 1, 2007, to Mar. 13, 2017; and Nov. 1, 2012, to Apr. 27, 2017, respectively). We considered reviews and studies about absolute risk of sexual transmission of HIV between serodiscordant partners to be eligible for inclusion. We used A Measurement Tool to Assess Systematic Reviews (AMSTAR) for review quality, Quality in Prognosis Studies (QUIPS) instrument for study risk of bias and then the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to assess the quality of evidence across studies. We calculated HIV incidence per 100 person-years with 95% confidence intervals (CIs). We assigned risk categories according to potential for and evidence of HIV transmission. RESULTS We identified 12 reviews. We selected 1 review to estimate risk of HIV transmission for condom use without antiretroviral therapy (1.14 transmissions/100 person-years, 95% CI 0.56-2.04; low risk). We identified 11 studies with 23 transmissions over 10 511 person-years with antiretroviral therapy (0.22 transmissions/ 100 person-years, 95% CI 0.14-0.33; low risk). We found no transmissions with antiretroviral therapy and a viral load of less than 200 copies/mL across consecutive measurements 4 to 6 months apart (0.00 transmissions/100 person-years, 95% CI 0.00-0.28; negligible risk regardless of condom use). INTERPRETATION Based on high-quality evidence, there is a negligible risk of sexual transmission of HIV when an HIV-positive sex partner adheres to antiretroviral therapy and maintains a suppressed viral load of less than 200 copies/mL measured every 4 to 6 months. Sexual transmissions of HIV have occurred when viral load was more than 200 copies/mL with antiretroviral therapy or condoms alone were used, although the risk remains low. These findings will help to support patient and clinician decision-making, affect public health case management and contact tracing, and inform justice system responses to HIV nondisclosure.
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Affiliation(s)
- Jennifer LeMessurier
- Centre for Communicable Diseases and Infection Control (Traversy, Varsaneux, Weekes, Avey, Niragira, Gervais, Rodin), Public Health Agency of Canada; Department of Family Medicine (LeMessurier) and School of Epidemiology and Public Health (LeMessurier), University of Ottawa, Ottawa, Ont.; Department of Health Research Methods, Evidence, and Impact (Guyatt), McMaster University, Hamilton, Ont
| | - Gregory Traversy
- Centre for Communicable Diseases and Infection Control (Traversy, Varsaneux, Weekes, Avey, Niragira, Gervais, Rodin), Public Health Agency of Canada; Department of Family Medicine (LeMessurier) and School of Epidemiology and Public Health (LeMessurier), University of Ottawa, Ottawa, Ont.; Department of Health Research Methods, Evidence, and Impact (Guyatt), McMaster University, Hamilton, Ont
| | - Olivia Varsaneux
- Centre for Communicable Diseases and Infection Control (Traversy, Varsaneux, Weekes, Avey, Niragira, Gervais, Rodin), Public Health Agency of Canada; Department of Family Medicine (LeMessurier) and School of Epidemiology and Public Health (LeMessurier), University of Ottawa, Ottawa, Ont.; Department of Health Research Methods, Evidence, and Impact (Guyatt), McMaster University, Hamilton, Ont
| | - Makenzie Weekes
- Centre for Communicable Diseases and Infection Control (Traversy, Varsaneux, Weekes, Avey, Niragira, Gervais, Rodin), Public Health Agency of Canada; Department of Family Medicine (LeMessurier) and School of Epidemiology and Public Health (LeMessurier), University of Ottawa, Ottawa, Ont.; Department of Health Research Methods, Evidence, and Impact (Guyatt), McMaster University, Hamilton, Ont
| | - Marc T Avey
- Centre for Communicable Diseases and Infection Control (Traversy, Varsaneux, Weekes, Avey, Niragira, Gervais, Rodin), Public Health Agency of Canada; Department of Family Medicine (LeMessurier) and School of Epidemiology and Public Health (LeMessurier), University of Ottawa, Ottawa, Ont.; Department of Health Research Methods, Evidence, and Impact (Guyatt), McMaster University, Hamilton, Ont
| | - Oscar Niragira
- Centre for Communicable Diseases and Infection Control (Traversy, Varsaneux, Weekes, Avey, Niragira, Gervais, Rodin), Public Health Agency of Canada; Department of Family Medicine (LeMessurier) and School of Epidemiology and Public Health (LeMessurier), University of Ottawa, Ottawa, Ont.; Department of Health Research Methods, Evidence, and Impact (Guyatt), McMaster University, Hamilton, Ont
| | - Robert Gervais
- Centre for Communicable Diseases and Infection Control (Traversy, Varsaneux, Weekes, Avey, Niragira, Gervais, Rodin), Public Health Agency of Canada; Department of Family Medicine (LeMessurier) and School of Epidemiology and Public Health (LeMessurier), University of Ottawa, Ottawa, Ont.; Department of Health Research Methods, Evidence, and Impact (Guyatt), McMaster University, Hamilton, Ont
| | - Gordon Guyatt
- Centre for Communicable Diseases and Infection Control (Traversy, Varsaneux, Weekes, Avey, Niragira, Gervais, Rodin), Public Health Agency of Canada; Department of Family Medicine (LeMessurier) and School of Epidemiology and Public Health (LeMessurier), University of Ottawa, Ottawa, Ont.; Department of Health Research Methods, Evidence, and Impact (Guyatt), McMaster University, Hamilton, Ont
| | - Rachel Rodin
- Centre for Communicable Diseases and Infection Control (Traversy, Varsaneux, Weekes, Avey, Niragira, Gervais, Rodin), Public Health Agency of Canada; Department of Family Medicine (LeMessurier) and School of Epidemiology and Public Health (LeMessurier), University of Ottawa, Ottawa, Ont.; Department of Health Research Methods, Evidence, and Impact (Guyatt), McMaster University, Hamilton, Ont.
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Saravanan S, Gomathi S, Delong A, Kausalya B, Sivamalar S, Poongulali S, Brooks K, Kumarasamy N, Balakrishnan P, Solomon SS, Cu-Uvin S, Kantor R. High discordance in blood and genital tract HIV-1 drug resistance in Indian women failing first-line therapy. J Antimicrob Chemother 2019; 73:2152-2161. [PMID: 29800305 DOI: 10.1093/jac/dky154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 03/30/2018] [Indexed: 11/12/2022] Open
Abstract
Objectives Examine HIV-1 plasma viral load (PVL) and genital tract (GT) viral load (GVL) and drug resistance in India. Methods At the YRG Centre for AIDS Research and Education, Chennai, we tested: PVL in women on first-line ART for ≥6 months; GVL when PVL >2000 copies/mL; and plasma, genital and proviral reverse transcriptase drug resistance when GVL >2000 copies/mL. Wilcoxon rank-sum and Fisher's exact tests were used to identify failure and resistance associations. Pearson correlations were calculated to evaluate PVL-GVL associations. Inter-compartmental resistance discordance was evaluated using generalized estimating equations. Results Of 200 women, 37% had detectable (>400 copies/mL) PVL and 31% had PVL >1000 copies/mL. Of women with detectable PVL, 74% had PVL >2000 copies/mL, of which 74% had detectable GVL. Higher PVL was associated with higher GVL. Paired plasma and genital sequences were available for 21 women; mean age of 34 years, median ART duration of 33 months, median CD4 count of 217 cells/mm3, median PVL of 5.4 log10 copies/mL and median GVL of 4.6 log10 copies/mL. Drug resistance was detected in 81%-91% of samples and 67%-76% of samples had dual-class resistance. Complete three-compartment concordance was seen in only 10% of women. GT-proviral discordance was significantly larger than plasma-proviral discordance. GT or proviral mutations discordant from plasma led to clinically relevant resistance in 24% and 30%, respectively. Conclusions We identified high resistance and high inter-compartmental resistance discordance in Indian women, which might lead to unrecognized resistance transmission and re-emergence compromising treatment outcomes, particularly relevant to countries like India, where sexual HIV transmission is predominant.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Sunil S Solomon
- YRG Centre for AIDS Research and Education, Chennai, India.,Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Brief Report: Per Sex-Act Risk of HIV Transmission Under Antiretroviral Treatment: A Data-Driven Approach. J Acquir Immune Defic Syndr 2019; 79:440-444. [PMID: 30179982 DOI: 10.1097/qai.0000000000001845] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Before the completion of HPTN 052, PARTNER, and Opposites Attract studies, data were lacking to directly estimate HIV transmission risk under effective combined antiretroviral treatment (cART). Rather, estimates were obtained by extrapolating a dose-response relationship between viral load and risk of HIV transmission, observed among untreated individuals, to treated individuals. Presently, data have accumulated from 9 clinical studies for a direct validation of this extrapolation. METHODS Using estimates of per sex-act risk of HIV transmission on effective cART obtained by extrapolation, sexual behavior data, and a simple mathematical model, we estimated the number of seroconversions that should have been observed in HIV-serodiscordant couples where the HIV-positive partner was on cART across the 9 studies. We compared this with the number of seroconversions actually observed. Next, we directly estimated the risk of HIV transmission on effective cART, using Bayesian statistics to combine all available data. RESULTS We found that at least 4.7 (uncertainty bounds: 1.7-12.6) and 35.1 (uncertainty bounds: 13.2-92.0) seroconversions should have been observed among, respectively, heterosexual and men who have sex with men (MSM) serodiscordant couples. This is not validated by observations across the studies, which reported at most 1 seroconversion among heterosexual couples and 0 for MSM. Combining all available data, we found that the maximum per sex-act risk of HIV transmission under effective cART is 3.9:100,000 for heterosexuals and 4.4:100,000 for MSM. CONCLUSIONS Data have accumulated to render obsolete estimates of the risk of HIV transmission on cART obtained by extrapolation. Direct estimates are substantially lower and should be used in practice.
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87
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Abstract
OBJECTIVES To assess the cost-effectiveness of increased consistent HIV testing among MSM in the Netherlands. METHODS Among MSM testing at sexually transmitted infection clinics in the Netherlands in 2014-2015, approximately 20% tested consistently every 6 months. We examined four scenarios with increased percentage of MSM testing every 6 months: a small and a moderate increase among all MSM; a small and a moderate increase only among MSM with at least 10 partners in the preceding 6 months. We used an agent-based model to calculate numbers of HIV infections and AIDS cases prevented with increased HIV testing. These numbers were used in an economic model to calculate costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) due to increased testing, over 2018-2027, taking a healthcare payer perspective. RESULTS A small increase in the percentage testing every 6 months among all MSM resulted in 490 averted HIV infections and an average ICER of &OV0556;27 900/QALY gained. A moderate increase among all MSM, resulted in 1380 averted HIV infections and an average ICER of &OV0556;36 700/QALY gained. Both were not cost-effective, with a &OV0556;20 000 willingness-to-pay threshold. Increasing the percentage testing every 6 months only among MSM with at least 10 partners in the preceding 6 months resulted in less averted HIV infections than increased testing among all MSM, but was on average cost-saving. CONCLUSION Increased HIV testing can prevent considerable numbers of new HIV infections among MSM, but may be cost-effective only if targeted at high-risk individuals, such as those with many partners.
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Li F, Juan BK, Wozniak M, Watson SK, Katz AR, Whiticar PM, McCormick T, Qiu YS, Wasserman GM. Trends and Racial Disparities of Late-Stage HIV Diagnosis: Hawaii, 2010-2016. Am J Public Health 2019; 108:S292-S298. [PMID: 30383422 DOI: 10.2105/ajph.2018.304506] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To examine racial/ethnic disparities in Hawaii in stage 3 classification at HIV diagnosis and trends in such disparities from 2010 through 2016. METHODS We analyzed data including patients' demographic information, behavioral risk factors, residential county at HIV diagnosis, and type of facility where HIV was diagnosed. Multivariable logistic regression modeling was used to examine racial/ethnic disparities in late-stage diagnoses after adjustment for known or possible confounders. RESULTS About 30% of HIV diagnoses were classified as late-stage (stage 3) diagnoses, and there were significant racial/ethnic disparities in stage 3 classification at diagnosis. Relative to Whites, the odds of being diagnosed at stage 3 were 3.7 times higher among Native Hawaiians and other Pacific Islanders (NHPIs; odds ratio [OR] = 3.69; 95% confidence interval [CI] = 1.89, 7.22) and more than twice as high among Asians (OR = 2.46; 95% CI = 1.16, 5.20). Older age and being diagnosed in an inpatient setting were associated with stage 3 classification. CONCLUSIONS Targeted preventive services need to be strengthened for Asians and NHPIs in Hawaii.
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Affiliation(s)
- Fenfang Li
- Fenfang Li and Glenn M. Wasserman are with the Communicable Disease and Public Health Nursing Division, Hawaii State Department of Health, Honolulu. Brandi K. Juan, Michelle Wozniak, Stuart K. Watson, Peter M. Whiticar, Timothy McCormick, and Yuanshan "Sandy" Qiu are with the Harm Reduction Services Branch, Communicable Disease and Public Health Nursing Division, Hawaii State Department of Health. Alan R. Katz is with the Office of Public Health Studies, University of Hawaii, Honolulu
| | - Brandi K Juan
- Fenfang Li and Glenn M. Wasserman are with the Communicable Disease and Public Health Nursing Division, Hawaii State Department of Health, Honolulu. Brandi K. Juan, Michelle Wozniak, Stuart K. Watson, Peter M. Whiticar, Timothy McCormick, and Yuanshan "Sandy" Qiu are with the Harm Reduction Services Branch, Communicable Disease and Public Health Nursing Division, Hawaii State Department of Health. Alan R. Katz is with the Office of Public Health Studies, University of Hawaii, Honolulu
| | - Michelle Wozniak
- Fenfang Li and Glenn M. Wasserman are with the Communicable Disease and Public Health Nursing Division, Hawaii State Department of Health, Honolulu. Brandi K. Juan, Michelle Wozniak, Stuart K. Watson, Peter M. Whiticar, Timothy McCormick, and Yuanshan "Sandy" Qiu are with the Harm Reduction Services Branch, Communicable Disease and Public Health Nursing Division, Hawaii State Department of Health. Alan R. Katz is with the Office of Public Health Studies, University of Hawaii, Honolulu
| | - Stuart K Watson
- Fenfang Li and Glenn M. Wasserman are with the Communicable Disease and Public Health Nursing Division, Hawaii State Department of Health, Honolulu. Brandi K. Juan, Michelle Wozniak, Stuart K. Watson, Peter M. Whiticar, Timothy McCormick, and Yuanshan "Sandy" Qiu are with the Harm Reduction Services Branch, Communicable Disease and Public Health Nursing Division, Hawaii State Department of Health. Alan R. Katz is with the Office of Public Health Studies, University of Hawaii, Honolulu
| | - Alan R Katz
- Fenfang Li and Glenn M. Wasserman are with the Communicable Disease and Public Health Nursing Division, Hawaii State Department of Health, Honolulu. Brandi K. Juan, Michelle Wozniak, Stuart K. Watson, Peter M. Whiticar, Timothy McCormick, and Yuanshan "Sandy" Qiu are with the Harm Reduction Services Branch, Communicable Disease and Public Health Nursing Division, Hawaii State Department of Health. Alan R. Katz is with the Office of Public Health Studies, University of Hawaii, Honolulu
| | - Peter M Whiticar
- Fenfang Li and Glenn M. Wasserman are with the Communicable Disease and Public Health Nursing Division, Hawaii State Department of Health, Honolulu. Brandi K. Juan, Michelle Wozniak, Stuart K. Watson, Peter M. Whiticar, Timothy McCormick, and Yuanshan "Sandy" Qiu are with the Harm Reduction Services Branch, Communicable Disease and Public Health Nursing Division, Hawaii State Department of Health. Alan R. Katz is with the Office of Public Health Studies, University of Hawaii, Honolulu
| | - Timothy McCormick
- Fenfang Li and Glenn M. Wasserman are with the Communicable Disease and Public Health Nursing Division, Hawaii State Department of Health, Honolulu. Brandi K. Juan, Michelle Wozniak, Stuart K. Watson, Peter M. Whiticar, Timothy McCormick, and Yuanshan "Sandy" Qiu are with the Harm Reduction Services Branch, Communicable Disease and Public Health Nursing Division, Hawaii State Department of Health. Alan R. Katz is with the Office of Public Health Studies, University of Hawaii, Honolulu
| | - Yuanshan Sandy Qiu
- Fenfang Li and Glenn M. Wasserman are with the Communicable Disease and Public Health Nursing Division, Hawaii State Department of Health, Honolulu. Brandi K. Juan, Michelle Wozniak, Stuart K. Watson, Peter M. Whiticar, Timothy McCormick, and Yuanshan "Sandy" Qiu are with the Harm Reduction Services Branch, Communicable Disease and Public Health Nursing Division, Hawaii State Department of Health. Alan R. Katz is with the Office of Public Health Studies, University of Hawaii, Honolulu
| | - Glenn M Wasserman
- Fenfang Li and Glenn M. Wasserman are with the Communicable Disease and Public Health Nursing Division, Hawaii State Department of Health, Honolulu. Brandi K. Juan, Michelle Wozniak, Stuart K. Watson, Peter M. Whiticar, Timothy McCormick, and Yuanshan "Sandy" Qiu are with the Harm Reduction Services Branch, Communicable Disease and Public Health Nursing Division, Hawaii State Department of Health. Alan R. Katz is with the Office of Public Health Studies, University of Hawaii, Honolulu
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Antiretroviral Adherence Following Prison Release in a Randomized Trial of the imPACT Intervention to Maintain Suppression of HIV Viremia. AIDS Behav 2019; 23:2386-2395. [PMID: 30963321 DOI: 10.1007/s10461-019-02488-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Many people living with HIV (PLWH) pass through correctional facilities each year, a large proportion of whom do not maintain viral suppression following release. We examined the effects of imPACT, an intervention designed to promote post-release viral suppression, on antiretroviral therapy (ART) adherence. PLWH awaiting release from prisons in two southern states were randomized to imPACT (consisting of motivational interviewing, care linkage coordination, and text message medication reminders) versus standard care (SC). ART adherence, measured by unannounced monthly telephone pill counts, was compared between study arms over 6 months post-release. Of 381 participants eligible for post-release follow-up, 302 (79%) completed ≥ 1 of 6 possible pill counts (median: 4; IQR 1-6). Average adherence over follow-up was 80.3% (95% CI 77.5, 83.1) and 81.0% (78.3, 83.6) of expected doses taken in the imPACT and SC arms, respectively. There was no difference between arms when accounting for missing data using multiple imputation (mean difference = - 0.2 percentage points [- 3.7, 3.3]), controlling for study site and week of follow-up. Of the 936 (40.9%) pill counts that were missed, 212 (22.7%) were due to re-incarceration. Those who missed pill counts for any reason were more likely to be unsuppressed, suggesting that they had lower adherence. However, missingness was balanced between arms. Among PLWH released from prison, ART adherence averaged > 80% in both study arms over 6 months-a level higher than seen with most other chronic diseases. However, missing data may have led to an overestimate of adherence. Factors independent of the intervention influence ART adherence in this population and should be identified to inform future targeted interventions.
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90
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Jeulin H, Jeanmaire E, Murray JM, Malve B, André M, Melliez H, Lanoix JP, Hustache-Mathieu L, Partisani M, Goehringer F, May T, Schvoerer E. Treatment as prevention enrolling at least 75% of individuals on ART will be needed to significantly reduce HIV prevalence in a HIV cohort. J Clin Virol 2019; 120:27-32. [PMID: 31541773 DOI: 10.1016/j.jcv.2019.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 07/01/2019] [Accepted: 08/23/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND "Treatment as Prevention" (TasP) aims to reduce new HIV infections through higher enrolment on suppressive antiretroviral therapy (ART). OBJECTIVES We studied the current epidemic and possible impact of TasP in a French HIV cohort including MSM and migrant subjects. STUDY DESIGN Socio-demographic, clinical and laboratory variables were collected during the follow-up of 6995 HIV-infected patients. The numbers of individuals living with HIV in each year were estimated from diagnoses up to that year minus recorded deaths. Patients were classified according to gender, transmission mode, country of birth and treatment status. RESULTS The cohort includes 6995 individuals diagnosed from 1985 to 2015, of whom 72% were men. Unprotected sexual intercourse was the main mode of transmission. Women were more likely to be migrants (45% versus 13%), whereas men were more likely to have been born in France (52% versus 27%). Diagnoses were more correlated with untreated than treated prevalence in each group. MSM diagnoses was strongly correlated to untreated prevalence whatever the country of birth (p < 0.0001). However, heterosexual diagnoses were better correlated with prevalence within individual country groups (b = 0.29 female diagnoses/year per untreated male born in France, compared to b = 0.73 for foreigners). Using these transmission rates, mathematical modelling estimated that enrolling 75% of untreated individuals per year would decrease diagnoses ten-fold by 2021. CONCLUSIONS Enrolling at least 75% of individuals on ART is necessary to substantially impact numbers of new HIV infections in this cohort. Treatment as prevention will actually be effective to reduce HIV prevalence.
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Affiliation(s)
- Hélène Jeulin
- Laboratoire de Virologie, Hôpital Brabois, CHRU de Nancy, Vandoeuvre-les-Nancy, France; LCPME (Laboratoire de Chimie Physique et Microbiologie pour les Matériaux et l'Environnement), UMR 7564, Faculté de Pharmacie, Nancy, F-54000, France
| | - Eliette Jeanmaire
- Service de Maladies Infectieuses et Tropicales, Hôpital Brabois, CHRU de Nancy, Vandoeuvre-les-Nancy, France
| | - John M Murray
- School of Mathematics and Statistics, UNSW Sydney, NSW, 2052, Australia; Cancer Research Division, Cancer Council NSW, Woolloomooloo, NSW, 2021, Australia
| | - Brice Malve
- Laboratoire de Virologie, Hôpital Brabois, CHRU de Nancy, Vandoeuvre-les-Nancy, France
| | - Marie André
- Service de Maladies Infectieuses et Tropicales, Hôpital Brabois, CHRU de Nancy, Vandoeuvre-les-Nancy, France
| | - Hugues Melliez
- Service de Maladies Infectieuses et Tropicales, Hôpital Guy Chatiliez, CH Tourcoing, Tourcoing, France
| | | | | | - Marialuisa Partisani
- HIV Infection care Center, Hôpitaux Universitaires Strasbourg, Strasbourg, France
| | - François Goehringer
- Service de Maladies Infectieuses et Tropicales, Hôpital Brabois, CHRU de Nancy, Vandoeuvre-les-Nancy, France
| | - Thierry May
- Service de Maladies Infectieuses et Tropicales, Hôpital Brabois, CHRU de Nancy, Vandoeuvre-les-Nancy, France
| | - Evelyne Schvoerer
- Laboratoire de Virologie, Hôpital Brabois, CHRU de Nancy, Vandoeuvre-les-Nancy, France; LCPME (Laboratoire de Chimie Physique et Microbiologie pour les Matériaux et l'Environnement), UMR 7564, Faculté de Pharmacie, Nancy, F-54000, France.
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91
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Harrington BJ, DiPrete BL, Jumbe AN, Ngongondo M, Limarzi L, Wallie SD, Chagomerana MB, Hosseinipour MC. Safety and efficacy of Option B+ ART in Malawi: few severe maternal toxicity events or infant HIV infections among pregnant women initiating tenofovir/lamivudine/efavirenz. Trop Med Int Health 2019; 24:1221-1228. [PMID: 31381233 DOI: 10.1111/tmi.13296] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Malawi's Option B+ universal antiretroviral therapy (ART) program for pregnant and breastfeeding women does not include routine laboratory monitoring. We report safety outcomes of pregnant women who initiated ART through Option B+. METHODS We analysed 12-month data from an observational cohort study on Option B+ among women newly initiating tenofovir/lamivudine/efavirenz (TDF/3TC/EFV) at a government antenatal clinic in Lilongwe, Malawi. Proportions of women engaged in care, incidence of DAIDS grade ≥ 2 laboratory toxicity, grade ≥ 3 adverse events (AEs), viral suppression (<1000 copies/mL), birth outcomes and infant HIV infections are reported. RESULTS At ART initiation, participants (n = 299) had a median age of 26 years (IQR 22-30), median CD4 count of 352 cells/μl (IQR 231-520) and 94% were in WHO Stage 1. We noted 76 incident DAIDS Grade ≥ 2 laboratory results among 58 women, most commonly elevated liver function tests (n = 30 events) and low haemoglobin (n = 27). No women had elevated creatinine. Clinical AEs (n = 45) were predominantly infectious diseases and Grade 3. Five participants (2%) discontinued TDF/3TC/EFV due to virologic failure (3) or toxicity (2). Twelve months after ART initiation, most women were engaged in care (89%) and had HIV RNA < 1000 copies/ml (90%). 8% of pregnancies resulted in preterm birth, 9% were low birthweight (<2500 g), and 2% resulted in infant HIV infection at 6 weeks post-delivery. CONCLUSION Most women remained on ART and were virally suppressed 12 months after starting Option B+. Few infants contracted HIV perinatally. While some women experienced adverse laboratory events, clinical symptom monitoring is likely reasonable.
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Affiliation(s)
- Bryna J Harrington
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bethany L DiPrete
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Allan N Jumbe
- UNC Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
| | | | - Laura Limarzi
- UNC Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
| | | | | | - Mina C Hosseinipour
- UNC Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi.,Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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92
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Abstract
Voluntary counselling and testing (VCT) for HIV has been promoted as a strategy to prevent HIV pandemics by changing sexual behaviour. Despite the provision of VCT in countries with generalized or high-burden epidemics, including Nigeria, the extent of its influence on behavioural change remains a conjecture. The main objective of this study was to examine the influence of HIV VCT on sexual behaviour changes among youths in Nigeria. The study utilized 2013 Nigeria Demographic and Health Survey (NDHS) data. Data were analysed from a nationally representative sample drawn from 8046 females and 6031 males aged 15-24 giving a total sample of 14,077 never-married youths. Descriptive and analytical analyses were carried out, including multivariate logistic regression. The study found a low uptake of HIV VCT and regional variation in behavioural changes between female and male youths. Voluntary HIV counselling and testing was found to be a protective factor for condom use at last sex for female youths, but significantly reduced the likelihood of primary sexual abstinence for both females and males, as well as having a single sexual partner for female youths. After controlling HIV VCT with other variables, certain socioeconomic factors were found to be significantly associated with behavioural changes. Thus, the attitudes of most Nigerian youths towards voluntary HIV counselling and testing needs to be improved through socioeconomic factors for healthy sexual activity. To achieve this, government and non-governmental organizations, as well as religious leaders and policymakers, should engage in appropriate and long-term activities directed at the sexual health needs of never-married youths, through voluntary HIV counselling and testing, to encourage them to change their sexual behaviour.
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93
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Abstract
Black people living with HIV (BPLWH) are less likely to adhere to antiretroviral treatment than are members of other racial/ethnic groups. Data were combined from two studies of BPLWH (n = 239) to estimate adherence trajectories using a semiparametric, group-based modeling strategy over three time-points (spanning 6 months). Analyses identified three groups of individuals (high-stable, moderately low-stable, low-decreasing). Multinomial logistic regressions were used to predict trajectory membership with multiple levels of socio-ecological factors (structural, institutional/health system, community, interpersonal/network, individual). Older age was associated with being in the high-stable group, whereas substance use, lower perceived treatment effectiveness, and lower quality healthcare ratings were related to being in the moderately low-stable group. In sum, multiple socio-ecological factors contribute to adherence among BPLWH and thus could be targeted in future intervention efforts.
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94
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Crawford FW, Morozova O, Buchanan AL, Spiegelman D. Interpretation of the Individual Effect Under Treatment Spillover. Am J Epidemiol 2019; 188:1407-1409. [PMID: 31094425 PMCID: PMC6686621 DOI: 10.1093/aje/kwz108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/08/2019] [Accepted: 04/08/2019] [Indexed: 11/13/2022] Open
Abstract
Some interventions are intended to benefit both individuals and the groups to which they belong. When a treatment given to one person exerts a causal effect on others, the treatment is said to exhibit spillover, dissemination, or interference. However, defining meaningful causal effects under spillover can be challenging. In this commentary, we discuss the meaning of the "individual effect," a quantity proposed to summarize the effect of treatment on the person who receives it, when spillover may be present.
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Affiliation(s)
- Forrest W Crawford
- Department of Biostatistics, School of Public Health, Yale University, New Haven, Connecticut
- Department of Ecology and Evolutionary Biology, Graduate School of Arts and Sciences, Yale University, New Haven, Connecticut
- School of Management, Yale University, New Haven, Connecticut
| | - Olga Morozova
- Department of Biostatistics, School of Public Health, Yale University, New Haven, Connecticut
| | - Ashley L Buchanan
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island
| | - Donna Spiegelman
- Department of Biostatistics, School of Public Health, Yale University, New Haven, Connecticut
- Department of Statistics and Data Science, Graduate School of Arts and Sciences, Yale University, New Haven, Connecticut
- Center for Methods of Implementation and Prevention Science, School of Public Health, Yale University, New Haven, Connecticut
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95
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Kostaki EG, Frampton D, Paraskevis D, Pantavou K, Ferns B, Raffle J, Grant P, Kozlakidis Z, Hadjikou A, Pavlitina E, Williams LD, Hatzakis A, Friedman SR, Nastouli E, Nikolopoulos GK. Near Full-length Genomic Sequencing and Molecular Analysis of HIV-Infected Individuals in a Network-based Intervention (TRIP) in Athens, Greece: Evidence that Transmissions Occur More Frequently from those with High HIV-RNA. Curr HIV Res 2019; 16:345-353. [PMID: 30706819 PMCID: PMC6446520 DOI: 10.2174/1570162x17666190130120757] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 01/21/2019] [Accepted: 01/27/2019] [Indexed: 11/25/2022]
Abstract
Background: TRIP (Transmission Reduction Intervention Project) was a network-based, contact tracing approach to locate and link to care, mostly people who inject drugs (PWID) with recent HIV infection. Objective: We investigated whether sequences from HIV-infected participants with high viral load cluster together more frequently than what is expected by chance. Methods: Paired end reads were generated for 104 samples using Illumina MiSeq next-generation se-quencing. Results: 63 sequences belonged to previously identified local transmission networks of PWID (LTNs) of an HIV outbreak in Athens, Greece. For two HIV-RNA cut-offs (105 and 106 IU/mL), HIV transmissions were more likely between PWID with similar levels of HIV-RNA (p<0.001). 10 of the 14 sequences (71.4%) from PWID with HIV-RNA >106 IU/mL were clustered in 5 pairs. For 4 of these clusters (80%), there was in each one of them at least one sequence from a recently HIV-infected PWID. Conclusion: We showed that transmissions are more likely among PWID with high viremia.
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Affiliation(s)
- Evangelia-Georgia Kostaki
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Daniel Frampton
- Department of Infection and Immunity, UCL, London, United Kingdom
| | - Dimitrios Paraskevis
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Bridget Ferns
- NIHR Biomedical Research Centre, UCLH/UCL, London, United Kingdom
| | - Jade Raffle
- Department of Infection and Immunity, UCL, London, United Kingdom
| | - Paul Grant
- Department of Clinical Virology, UCLH, London, United Kingdom
| | - Zisis Kozlakidis
- Division of Infection and Immunity, Faculty of Medical Sciences, UCL and Farr Institute of Health Informatics Research, London, United Kingdom
| | - Andria Hadjikou
- Medical School, University of Cyprus, Nicosia, Cyprus.,European University Cyprus, Nicosia, Cyprus
| | - Eirini Pavlitina
- Transmission Reduction Intervention Project, Athens site, Athens, Greece
| | - Leslie D Williams
- National Development and Research Institutes, New York, United States
| | - Angelos Hatzakis
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Samuel R Friedman
- National Development and Research Institutes, New York, United States
| | - Eleni Nastouli
- NIHR Biomedical Research Centre, UCLH/UCL, London, United Kingdom.,Department of Population, Policy and Practice, UCL GOS Institute of Child Health, London, United Kingdom
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96
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Selinger C, Dimitrov DT, Welkhoff PA, Bershteyn A. The future of a partially effective HIV vaccine: assessing limitations at the population level. Int J Public Health 2019; 64:957-964. [PMID: 30982082 PMCID: PMC6614161 DOI: 10.1007/s00038-019-01234-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 03/02/2019] [Accepted: 03/12/2019] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Mathematical models have unanimously predicted that a first-generation HIV vaccine would be useful and cost-effective to roll out, but that its overall impact would be insufficient to reverse the epidemic. Here, we explore what factors contribute most to limiting the impact of such a vaccine. METHODS Ranging from a theoretical ideal to a more realistic regimen, mirroring the one used in the currently ongoing trial in South Africa (HVTN 702), we model a nested hierarchy of vaccine attributes such as speed of scale-up, efficacy, durability, and return rates for booster doses. RESULTS The predominant reasons leading to a substantial loss of vaccine impact on the HIV epidemic are the time required to scale up mass vaccination, limited durability, and waning of efficacy. CONCLUSIONS A first-generation partially effective vaccine would primarily serve as an intermediate milestone, furnishing correlates of immunity and platforms that could serve to accelerate future development of a highly effective, durable, and scalable next-generation vaccine capable of reversing the HIV epidemic.
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Affiliation(s)
- Christian Selinger
- Institute for Disease Modeling, 3150 139th Ave SE, Bellevue, WA 98005 USA
| | - Dobromir T. Dimitrov
- Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA 98109 USA
| | - Philip A. Welkhoff
- Institute for Disease Modeling, 3150 139th Ave SE, Bellevue, WA 98005 USA
| | - Anna Bershteyn
- Institute for Disease Modeling, 3150 139th Ave SE, Bellevue, WA 98005 USA
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97
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Ortblad KF, Musoke DK, Ngabirano T, Salomon JA, Haberer JE, McConnell M, Oldenburg CE, Bärnighausen T. Is knowledge of HIV status associated with sexual behaviours? A fixed effects analysis of a female sex worker cohort in urban Uganda. J Int AIDS Soc 2019; 22:e25336. [PMID: 31287625 PMCID: PMC6615530 DOI: 10.1002/jia2.25336] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 06/05/2019] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Female sex workers (FSWs) have strong economic incentives for sexual risk-taking behaviour. We test whether knowledge of HIV status affects such behaviours among FSWs. METHODS We used longitudinal data from a FSW cohort in urban Uganda, which was formed as part of an HIV self-testing trial with four months of follow-up. Participants reported perceived knowledge of HIV status, number of clients per average working night, and consistent condom use with clients at baseline, one month, and four months. We measured the association between knowledge of HIV status and FSWs' sexual behaviours using linear panel regressions with individual fixed effects, controlling for study round and calendar time. RESULTS Most of the 960 participants tested for HIV during the observation period (95%) and experienced a change in knowledge of HIV status (71%). Knowledge of HIV status did not affect participants' number of clients but did affect their consistent condom use. After controlling for individual fixed effects, study round and calendar month, knowledge of HIV-negative status was associated with a significant increase in consistent condom use by 9.5 percentage points (95% CI 5.2 to 13.5, p < 0.001), while knowledge of HIV-positive status was not associated with a significant change in consistent condom use (2.5 percentage points, 95% CI -8.0 to 3.1, p = 0.38). CONCLUSIONS In urban Uganda, FSWs engaged in safer sex with clients when they perceived that they themselves were not living with HIV. Even in communities with very high HIV prevalence, the majority of the population will test HIV-negative. Our results thus imply that expansion of HIV testing programmes may serve as a behavioural HIV prevention measure among FSWs.
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Affiliation(s)
| | | | | | - Joshua A Salomon
- Department of Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonMAUSA
- Department of MedicineStanford UniversityStanfordCAUSA
| | - Jessica E Haberer
- Department of General Internal MedicineMassachusetts General Hospital Global HealthBostonMAUSA
| | - Margaret McConnell
- Department of Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonMAUSA
| | - Catherine E Oldenburg
- Francis I. Proctor FoundationUniversity of California San FranciscoSan FranciscoCAUSA
- Department of OphthalmologyUniversity of CaliforniaSan FranciscoSan FranciscoCAUSA
- Department of Epidemiology & BiostatisticsUniversity of CaliforniaSan FranciscoCAUSA
| | - Till Bärnighausen
- Department of Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonMAUSA
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Heidelberg Institute of Public HealthUniversity of HeidelbergHeidelbergGermany
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98
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Heendeniya A, Bogoch II. Antiretroviral Medications for the Prevention of HIV Infection: A Clinical Approach to Preexposure Prophylaxis, Postexposure Prophylaxis, and Treatment as Prevention. Infect Dis Clin North Am 2019; 33:629-646. [PMID: 31239092 DOI: 10.1016/j.idc.2019.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Preventing new human immunodeficiency virus (HIV) infections is essential to halting the global pandemic. HIV prevention strategies include integrating both nonpharmacologic (eg, safe sexual counseling, circumcision) and pharmacologic approaches. Several pharmacologic HIV prevention strategies are increasingly used globally and include postexposure prophylaxis, preexposure prophylaxis, and treatment as prevention. These prevention modalities have enormous clinical and public health appeal, as they effectively reduce HIV acquisition in individuals and also may lower HIV incidence in communities when integrated and implemented broadly. Efforts are now underway to scale HIV prevention programs using these techniques in both high- and low-resource settings.
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Affiliation(s)
- Amila Heendeniya
- Division of Infectious Diseases, Toronto General Hospital, Toronto General Hospital, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Isaac I Bogoch
- Division of Infectious Diseases, Toronto General Hospital, Toronto General Hospital, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada; Department of Medicine, University of Toronto, 190 Elizabeth Street, R. Fraser Elliott Building, 3-805, Toronto, Ontario M5G 2C4, Canada; Division of General Internal Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
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99
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Kimemia G, Ngure K, Baeten JM, Celum C, Dew K, Njuguna N, Mugo N, Heffron R. Perceptions of pregnancy occurring among HIV-serodiscordant couples in Kenya. Reprod Health 2019; 16:85. [PMID: 31215447 PMCID: PMC6582525 DOI: 10.1186/s12978-019-0751-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 06/10/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Among HIV serodiscordant couples, most conception involves condomless sex and may confer a period with increased HIV transmission risk if HIV viral load is not suppressed and other precautions are not used. Safer conception strategies enable HIV serodiscordant couples to attain their pregnancy goals while markedly reducing this risk. We explored the perceptions and beliefs held by HIV serodiscordant couples and health care providers concerning pregnancy among HIV serodiscordant couples in Kenya and gathered their thoughts about how these might influence use of safer conception methods. METHODS We conducted 20 Key Informant Interviews (KIIs) with health care providers offering safer conception counseling and 21 In-Depth Interviews (IDIs) and 4 Focus Group Discussions (FGDs) with members of HIV serodiscordant couples with immediate pregnancy goals in Thika, Kenya. Data were analyzed using an inductive approach that identified two emergent themes: perceptions towards pregnancy among HIV serodiscordant couples and access to safer conception services. RESULTS The perceptions held by the community towards couples in HIV serodiscordant relationships having children were largely negative. The participants were aware of the increased HIV transmission risk to the HIV uninfected partners while trying to become pregnant. In the community, having biological children was cherished yet the majority of the couples shied away from accessing safer conception services offered at health facilities due to stigma and lack of knowledge of the existence of such services. Some providers had limited knowledge on safer conception strategies and services and consequently discouraged HIV serodiscordant couples from natural conception. CONCLUSIONS Negative perceptions towards HIV serodiscordant couples becoming pregnant has hindered access to safer conception services. Therefore, there is need to create a supportive environment for HIV serodiscordant couples with fertility intentions that normalizes their desire to have children and informs the community about the availability of safer conception services.
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Affiliation(s)
- Grace Kimemia
- African Population & Health Research Center, Nairobi, Kenya
| | - Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Jared M. Baeten
- Department of Global Health, University of Washington, 325 Ninth Avenue Box 359927, Seattle, WA 98104 USA
- Department of Epidemiology, University of Washington, 325 Ninth Avenue Box 359927, Seattle, WA 98104 USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Connie Celum
- Department of Global Health, University of Washington, 325 Ninth Avenue Box 359927, Seattle, WA 98104 USA
- Department of Epidemiology, University of Washington, 325 Ninth Avenue Box 359927, Seattle, WA 98104 USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Kristin Dew
- Department of Human Centered Design and Engineering, University of Washington, Seattle, USA
| | | | - Nelly Mugo
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Renee Heffron
- Department of Global Health, University of Washington, 325 Ninth Avenue Box 359927, Seattle, WA 98104 USA
- Department of Epidemiology, University of Washington, 325 Ninth Avenue Box 359927, Seattle, WA 98104 USA
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100
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Rodger AJ, Cambiano V, Bruun T, Vernazza P, Collins S, Degen O, Corbelli GM, Estrada V, Geretti AM, Beloukas A, Raben D, Coll P, Antinori A, Nwokolo N, Rieger A, Prins JM, Blaxhult A, Weber R, Van Eeden A, Brockmeyer NH, Clarke A, Del Romero Guerrero J, Raffi F, Bogner JR, Wandeler G, Gerstoft J, Gutiérrez F, Brinkman K, Kitchen M, Ostergaard L, Leon A, Ristola M, Jessen H, Stellbrink HJ, Phillips AN, Lundgren J. Risk of HIV transmission through condomless sex in serodifferent gay couples with the HIV-positive partner taking suppressive antiretroviral therapy (PARTNER): final results of a multicentre, prospective, observational study. Lancet 2019; 393:2428-2438. [PMID: 31056293 PMCID: PMC6584382 DOI: 10.1016/s0140-6736(19)30418-0] [Citation(s) in RCA: 561] [Impact Index Per Article: 112.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 02/09/2019] [Accepted: 02/14/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND The level of evidence for HIV transmission risk through condomless sex in serodifferent gay couples with the HIV-positive partner taking virally suppressive antiretroviral therapy (ART) is limited compared with the evidence available for transmission risk in heterosexual couples. The aim of the second phase of the PARTNER study (PARTNER2) was to provide precise estimates of transmission risk in gay serodifferent partnerships. METHODS The PARTNER study was a prospective observational study done at 75 sites in 14 European countries. The first phase of the study (PARTNER1; Sept 15, 2010, to May 31, 2014) recruited and followed up both heterosexual and gay serodifferent couples (HIV-positive partner taking suppressive ART) who reported condomless sex, whereas the PARTNER2 extension (to April 30, 2018) recruited and followed up gay couples only. At study visits, data collection included sexual behaviour questionnaires, HIV testing (HIV-negative partner), and HIV-1 viral load testing (HIV-positive partner). If a seroconversion occurred in the HIV-negative partner, anonymised phylogenetic analysis was done to compare HIV-1 pol and env sequences in both partners to identify linked transmissions. Couple-years of follow-up were eligible for inclusion if condomless sex was reported, use of pre-exposure prophylaxis or post-exposure prophylaxis was not reported by the HIV-negative partner, and the HIV-positive partner was virally suppressed (plasma HIV-1 RNA <200 copies per mL) at the most recent visit (within the past year). Incidence rate of HIV transmission was calculated as the number of phylogenetically linked HIV infections that occurred during eligible couple-years of follow-up divided by eligible couple-years of follow-up. Two-sided 95% CIs for the incidence rate of transmission were calculated using exact Poisson methods. FINDINGS Between Sept 15, 2010, and July 31, 2017, 972 gay couples were enrolled, of which 782 provided 1593 eligible couple-years of follow-up with a median follow-up of 2·0 years (IQR 1·1-3·5). At baseline, median age for HIV-positive partners was 40 years (IQR 33-46) and couples reported condomless sex for a median of 1·0 years (IQR 0·4-2·9). During eligible couple-years of follow-up, couples reported condomless anal sex a total of 76 088 times. 288 (37%) of 777 HIV-negative men reported condomless sex with other partners. 15 new HIV infections occurred during eligible couple-years of follow-up, but none were phylogenetically linked within-couple transmissions, resulting in an HIV transmission rate of zero (upper 95% CI 0·23 per 100 couple-years of follow-up). INTERPRETATION Our results provide a similar level of evidence on viral suppression and HIV transmission risk for gay men to that previously generated for heterosexual couples and suggest that the risk of HIV transmission in gay couples through condomless sex when HIV viral load is suppressed is effectively zero. Our findings support the message of the U=U (undetectable equals untransmittable) campaign, and the benefits of early testing and treatment for HIV. FUNDING National Institute for Health Research.
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Affiliation(s)
- Alison J Rodger
- Institute for Global Health, University College London, London, UK.
| | | | - Tina Bruun
- Department of Infectious Diseases (CHIP), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Pietro Vernazza
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital, St Gallen, Switzerland
| | | | - Olaf Degen
- University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | | | - Vicente Estrada
- Hospital Clinico San Carlos and Universidad Complutense, Madrid, Spain
| | - Anna Maria Geretti
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Apostolos Beloukas
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK; Department of Biomedical Sciences, University of West Attica, Athens, Greece
| | - Dorthe Raben
- Department of Infectious Diseases (CHIP), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Pep Coll
- AIDS Research Institute-IrsiCaixa, Hospital Universitari Germans Trias i Pujol and BCN Checkpoint, Badalona and Barcelona, Spain
| | - Andrea Antinori
- Istituto Nazionale per le Malattie Infettive Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Nneka Nwokolo
- Chelsea and Westminster NHS Foundation Trust, London, UK
| | | | - Jan M Prins
- Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | | | - Rainer Weber
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | - Norbert H Brockmeyer
- Centre for Sexual Health and Medicine, Walk in Ruhr, Ruhr University Bochum, Bochum, Germany
| | - Amanda Clarke
- Brighton and Sussex University Hospitals NHS Trust, and Brighton and Sussex Medical School, Brighton, UK
| | | | - Francois Raffi
- Infectious Diseases Department, University Hospital (Centre Hospitalier Universitaire de Nantes) Hotel-Dieu, and INSERM UIC 1413 Nantes University, Nantes, France
| | - Johannes R Bogner
- Medizinische Klinik und Poliklinik IV, University Hospital Munich, Munich, Germany
| | - Gilles Wandeler
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Felix Gutiérrez
- Hospital General de Elche and Universidad Miguel Hernández, Alicante, Spain
| | - Kees Brinkman
- Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, Netherlands
| | | | | | - Agathe Leon
- Hospital Clinic - IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Matti Ristola
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | | | | | - Jens Lundgren
- Department of Infectious Diseases (CHIP), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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