Social network methods for HIV case-finding among people who inject drugs in Tajikistan

Exploring Dynamic Changes in HIV-1 Molecular Transmission Networks and Key Influencing Factors: Cross-Sectional Study

BACKGROUND

The HIV-1 molecular network is an innovative tool, using gene sequences to understand transmission attributes and complementing social and sexual network studies. While previous research focused on static network characteristics, recent studies' emphasis on dynamic features enhances our understanding of real-time changes, offering insights for targeted interventions and efficient allocation of public health resources.

OBJECTIVE

This study aims to identify the dynamic changes occurring in HIV-1 molecular transmission networks and analyze the primary influencing factors driving the dynamics of HIV-1 molecular networks.

METHODS

We analyzed and compared the dynamic changes in the molecular network over a specific time period between the baseline and observed end point. The primary factors influencing the dynamic changes in the HIV-1 molecular network were identified through univariate analysis and multivariate analysis.

RESULTS

A total of 955 HIV-1 polymerase fragments were successfully amplified from 1013 specimens; CRF01_AE and CRF07_BC were the predominant subtypes, accounting for 40.8% (n=390) and 33.6% (n=321) of the specimens, respectively. Through the analysis and comparison of the basic and terminal molecular networks, it was discovered that 144 sequences constituted static molecular networks, and 487 sequences contributed to the formation of dynamic molecular networks. The findings of the multivariate analysis indicated that the factors occupation as a student, floating population, Han ethnicity, engagement in occasional or multiple sexual partnerships, participation in anal sex, and being single were independent risk factors for the dynamic changes observed in the HIV-1 molecular network, and the odds ratio (OR; 95% CIs) values were 2.63 (1.54-4.47), 1.83 (1.17-2.84), 2.91 (1.09-7.79), 1.75 (1.06-2.90), 4.12 (2.48-6.87), 5.58 (2.43-12.80), and 2.10 (1.25-3.54), respectively. Heterosexuality and homosexuality seem to exhibit protective effects when compared to bisexuality, with OR values of 0.12 (95% CI 0.05-0.32) and 0.26 (95% CI 0.11-0.64), respectively. Additionally, the National Eight-Item score and sex education experience were also identified as protective factors against dynamic changes in the HIV-1 molecular network, with OR values of 0.12 (95% CI 0.05-0.32) and 0.26 (95% CI 0.11-0.64), respectively.

CONCLUSIONS

The HIV-1 molecular network analysis showed 144 sequences in static networks and 487 in dynamic networks. Multivariate analysis revealed that occupation as a student, floating population, Han ethnicity, and risky sexual behavior were independent risk factors for dynamic changes, while heterosexuality and homosexuality were protective compared to bisexuality. A higher National Eight-Item score and sex education experience were also protective factors. The identification of HIV dynamic molecular networks has provided valuable insights into the characteristics of individuals undergoing dynamic alterations. These findings contribute to a better understanding of HIV-1 transmission dynamics and could inform targeted prevention strategies.

Respondent-driven sampling is more efficient than facility-based strategies at identifying undiagnosed people who inject drugs living with HIV in India

INTRODUCTION

Injection drug use drives HIV epidemics in many low-resource settings, yet many people who inject drugs (PWID) living with HIV are not diagnosed. We assessed the ability of respondent-driven sampling (RDS) - which uses peer network connections - to identify undiagnosed PWID living with HIV compared to a facility-based strategy in India.

METHODS

In six Indian cities from 2014 to 2017, integrated care centers (ICCs) provided HIV testing. From 2016 to 2017, RDS samples of PWID in these same cities were conducted. Using biometric matching, characteristics associated with identification by RDS only and both RDS and ICC, compared to ICC only were explored. Undiagnosed individuals tested positive and did not report a prior diagnosis. The number needed to recruit (NNR) (average number recruited to find one undiagnosed PWID living with HIV) and the identification rate (average number undiagnosed PWID identified per week) assessed the efficiency of RDS vs. ICCs.

RESULTS

There were 10,759 ICC clients and 6012 RDS participants; 40% of RDS participants were also ICC clients resulting in 14,397 unduplicated PWID. PWID identified by RDS vs. ICC only were more likely to be male (adjusted odds ratios [aOR] RDS only: 6.8, both: 2.7) and living with HIV but undiagnosed (aOR RDS only: 2.5, both: 1.5). Overall, the RDS NNR was 11 and the ICC NNR was 26. The RDS identification rate (18.6/week) was faster than the ICC identification rate (2.7/week) overall and in all cities.

CONCLUSIONS

RDS required screening fewer PWID and more rapidly identified undiagnosed PWID living with HIV as compared to ICCs.

Optimizing respondent-driven sampling to find undiagnosed HIV-infected people who inject drugs

OBJECTIVE

We evaluated whether identification of undiagnosed HIV-infected people who inject drugs (PWID) via respondent-driven sampling (RDS) can be enhanced through a precision RDS (pRDS) approach.

DESIGN/METHODS

First, using prior RDS data from PWID in India, we built a prediction algorithm for recruiting undiagnosed HIV-infected PWID. pRDS was tested in Morinda, Punjab where participants were randomly assigned to standard or pRDS. In the standard RDS approach, all participants received two recruitment coupons. For pRDS, the algorithm determined an individual's probability of recruiting an undiagnosed PWID, and individuals received either two (low probability) or five (high probability) coupons. Efficiency in identifying undiagnosed HIV-infected PWID for the RDS approaches was evaluated in two ways: the number needed to recruit (NNR) and identification rate/week.

RESULTS

Predictors of recruiting undiagnosed PWID included HIV/HCV infection, network size, syringe services utilization, and injection environment. 1631 PWID were recruited in Morinda. From the standard RDS approach, 615 were recruited, including 39 undiagnosed; from pRDS, 1012 were recruited, including 77 undiagnosed. In pRDS, those with higher predicted probability were more likely to recruit others with HIV/HCV co-infection, undiagnosed and viremic HIV, and who utilized services. pRDS had a significantly higher identification rate of undiagnosed PWID (1.5/week) compared with the standard (0.8/week). The NNR for pRDS (13.1) was not significantly lower than the standard approach (15.8).

CONCLUSION

pRDS identified twice as many undiagnosed and viremic PWID significantly faster than the standard approach. Leveraging RDS or similar network-based strategies should be considered alongside other strategies to ensure meeting UNAIDS targets.

Peer Recruitment Strategies for Female Sex Workers Not Engaged in HIV Prevention and Treatment Services in Côte d'Ivoire: Program Data Analysis

Background

In the context of the mostly generalized HIV epidemic in Côte d’Ivoire, key populations bear a higher burden of HIV than that borne by the general reproductive-aged population. Mathematical models have demonstrated the significant potential impact and cost-effectiveness of improving the coverage of HIV prevention and treatment services for key populations in Côte d’Ivoire. However, in 2019, coverage of these services remained limited by multiple intersecting stigmas affecting key populations, necessitating the study of innovative implementation strategies to better meet the needs of those most marginalized. Here, we leverage programmatic data to compare the effectiveness of the enhanced and traditional peer outreach approaches in reaching and providing community HIV testing to female sex workers not readily engaged in HIV prevention and treatment services in Côte d’Ivoire.

Objective

The aim of this study was to describe the characteristics of female sex workers reached by the LINKAGES project in Côte d’Ivoire with enhanced peer outreach and traditional peer outreach and to compare HIV-related outcomes between the women reached by both strategies.

Methods

Deidentified routine programmatic data collected as part of LINKAGES Côte d’Ivoire between October 2017 and April 2018 were used in these analyses. Demographic characteristics and HIV indicators including HIV testing history, HIV case-finding, linkage to HIV treatment, and treatment initiation were assessed using descriptive statistics. Differences in these indicators were compared by outreach strategy using Pearson chi-square tests.

Results

There were 9761 women reached with enhanced peer outreach and routine peer outreach included in these analyses. The overall case-finding rate in the sample was 7.8% (698/8851). Compared with women reached by routine outreach, those reached by enhanced peer outreach were more likely to have previously been tested for HIV (enhanced: 1695/2509, 67.6%; routine: 4302/7252, 60.0%; χ²₁=43.8; P=.001). The enhanced peer outreach approach was associated with a higher HIV case-finding rate (enhanced: 269/2507 10.7%; routine: 429/6344, 6.8%; χ²₁=32.3; P=.001), higher proportion of linkage to treatment (enhanced: 258/269, 95.9%; routine: 306/429, 71.3%; χ²₁=64.4; P=.001), and higher proportion of treatment initiation (enhanced: 212/269, 78.8%; routine: 315/429, 73.3%; χ²₁=2.6; P=.11). Women reached by both approaches were categorized as high risk for HIV-related behaviors such as condomless sex and number of sex acts in the previous week.

Conclusions

These analyses suggest that the novel peer-referral strategy, the enhanced peer outreach approach, was effective in reaching female sex workeres in Côte d’Ivoire with demonstrated acquisition risks for HIV and who had not been effectively engaged by routine outreach approaches. Scaling up novel strategies such as enhanced peer outreach in the context of differentiated service models may be needed to optimize HIV prevention and treatment outcomes for key populations in Côte d’Ivoire.

Providing Unique Support for Health Study Among Young Black and Latinx Men Who Have Sex With Men and Young Black and Latinx Transgender Women Living in 3 Urban Cities in the United States: Protocol for a Coach-Based Mobile-Enhanced Randomized Control Trial

BACKGROUND

The US National HIV/AIDS Strategy 2020 calls for increasing access to care, improving outcomes of people living with HIV, and targeting biomedical prevention efforts, including access to pre-exposure prophylaxis (PrEP) in communities where HIV is most heavily concentrated. The cities of Baltimore, Maryland (MD); Washington, DC; and Philadelphia, Pennsylvania (PA) are disproportionately burdened by high rates of new cases of HIV infection, with high prevalence among young Black and Latinx men who have sex with men (YBLMSM) and young Black and Latinx transgender women (YBLTW) aged 15-24 years.

OBJECTIVE

This study aims (1) to identify and recruit YBLMSM and YBLTW who are at risk or living with HIV in Baltimore, MD; Philadelphia, PA; and Washington, DC, using respondent-driven sampling (RDS) with targeted seed selection, and (2) to assess the efficacy of a coach-based mobile-enhanced intervention (MEI) compared with standard of care (SOC) to increase successful engagement and retention into HIV, PrEP, and substance use treatment care across the HIV care and prevention continua in 3 Mid-Atlantic cities. This paper describes the protocol and progress as of October 20, 2019.

METHODS

This study uses a multiphase mixed methods design. The first phase is a formative, qualitative research with focus group discussions and key informant interviews. The second phase consists of evaluating the ability of RDS with targeted seed selection. The third phase includes 2 embedded randomized controlled trials (RCTs), where participants complete a baseline sociobehavioral survey, rapid HIV testing, and eligible youth enroll in parallel status-dependent RCTs that randomize the participant to 1 of 2 study arms: MEI with coach or SOC. Participants are asked to complete a web-based survey and provide biologic specimens-HIV-1 RNA (viral load) or HIV-1 antibody test and urine drug screen-at baseline and at 3, 6, and 12 months, and an exit interview at 18 months.

RESULTS

A formative qualitative research was conducted in February 2017 and May 2018, and this led to further refinement of recruitment and study methods. Aim 1 recruitment began in September 2017 with subsequent enrollment into the RCTs. Recruitment is ongoing with 520 participants screened and 402 (77.3%) enrolled in aim 1 by October 2020. Of these, 159 are enrolled in the 2 randomized trials: 36 (22.6%) HIV-positive not virally suppressed (aim 2) and 123 (77.4%) high-risk HIV-negative (aim 3).

CONCLUSIONS

This study has the potential to significantly impact the medical and substance use services provided to YBLMSM and YBLTW in the United States by providing rigorous scientific evidence outlining approaches and strategies that improve the uptake and engagement of YBLMSM and YBLTW in the HIV treatment and prevention continuum.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03194477; https://clinicaltrials.gov/ct2/show/NCT03194477.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/17269.

Optimizing HIV prevention and treatment outcomes for persons with substance use in Central Asia: what will it take?

Purpose of review

To summarize the status of HIV and substance use in Central Asia and discuss potential ways to move forward to effective epidemic control among people who inject drugs (PWID) in the region and beyond.

Recent findings

PWID and their partners remain the population most affected by HIV in Central Asia. Lack of effective substance use prevention and treatment options and limited involvement of PWID-led community-based organizations in HIV programs, combined with the requirement for official registration, stigma and discrimination of PWID, and criminalization of drug use remain key barriers to effective HIV prevention and treatment.

Summary

Sustainable HIV epidemic control among PWID will not be feasible without decriminalization of drug use, addressing stigma and discrimination and policy changes to enhance uptake of HIV-related prevention, treatment and support services by PWID. It is also critical to ensure adoption of innovations, particularly those that combine evidence-based biomedical, behavioral and structural interventions tailored to the needs of the PWID.

High prevalence of HIV, HBsAg and anti-HCV positivity among people who injected drugs: results of the first bio-behavioral survey using respondent-driven sampling in two urban areas in Mozambique

Background

Few countries in sub-Saharan Africa know the magnitude of their HIV epidemic among people who inject drugs (PWID). This was the first study in Mozambique to measure prevalence of HIV, HBV, and HCV, and to assess demographic characteristics and risk behaviors in this key population.

Methods

We used respondent-driven sampling (RDS) to conduct a cross-sectional behavioral surveillance survey of PWID in two cities of Mozambique lasting six months. Participants were persons who had ever injected drugs without a prescription. Participants completed a behavioral questionnaire and provided blood specimens for HIV, hepatitis B surface antigen (HBsAg) and hepatitis C virus antibody (anti-HCV) testing. We performed RDS-adjusted analysis in R 3.2 using RDSAT 7.1 weights.

Results

We enrolled 353 PWID in Maputo and 139 in Nampula/Nacala; approximately 95% of participants were men. Disease prevalence in Maputo and Nampula/Nacala, respectively, was 50.1 and 19.9% for HIV, 32.1 and 36.4% for HBsAg positivity, and 44.6 and 7.0% for anti-HCV positivity. Additionally, 8% (Maputo) and 28.6% (Nampula/Nacala) of PWID reported having a genital sore or ulcer in the 12 months preceding the survey. Among PWID who injected drugs in the last month, 50.3% (Maputo) and 49.6% (Nampula/Nacala) shared a needle at least once that month. Condomless sex in the last 12 months was reported by 52.4% of PWID in Maputo and 29.1% in Nampula/Nacala. Among PWID, 31.6% (Maputo) and 41.0% (Nampula/Nacala) had never tested for HIV. In multivariable analysis, PWID who used heroin had 4.3 (Maputo; 95% confidence interval [CI]: 1.2, 18.2) and 2.3 (Nampula/Nacala; 95% CI: 1.2, 4.9) greater odds of having HIV.

Conclusion

Unsafe sexual behaviors and injection practices are frequent among PWID in Mozambique, and likely contribute to the disproportionate burden of disease we found. Intensified efforts in prevention, care, and treatment specific for PWID have the potential to limit disease transmission.

Implementation experiences and insights from the scale-up of an HIV assisted partner notification intervention in Central Asia

INTRODUCTION

WHO recommends assisted partner notification (APN) for people living with HIV (PLHIV). These services have not been widely scaled in Central Asia. We describe the results from an APN intervention implemented within a programme focused on PLHIV and people who inject drugs in Kazakhstan, the Kyrgyz Republic and Tajikistan.

METHODS

Routine data from index cases and their partners were analysed from equal-length periods before and after APN launch. Prior to APN index cases could recruit partners using passive referral, and under APN, had their choice of passive referral or APN (provider, contract or dual-referral). We compared the demographic characteristics of index cases and their sexual/injecting partners from the pre-APN and APN periods, described the number/proportion of HIV cases found (positivity rate) and evaluated predictors of HIV infection among partners using logistic regression.

RESULTS

Under APN 2676 PLHIV served as index cases and recruited 3735 partners for testing, compared to 4418 index cases and 2240 partners during the pre-APN period. A total of 322 (8.6%) partners were rapid test positive during APN versus 161 (7.2%, p = 0.048) before APN. Women represented 38% of APN index cases (vs. 42% pre-APN), 52% of partners tested (vs. 50% pre-APN) and 56% of all PLHIV identified (vs. 63% pre-APN). Compared to the pre-APN period, the number of partners tested per index case recruited increased (0.5 to 1.4, p < 0.001) and the number of index cases needed to find one HIV-positive partner decreased significantly (27.4 to 8.3, p < 0.001) under APN.

CONCLUSIONS

APN was feasibly integrated within a people who inject drugs and PLHIV-focused HIV programme, and was acceptable to high-risk populations in Central Asia. Under APN, large numbers of sexual and injecting partners of PLHIV - including women and non-marital partners - were tested while maintaining high positivity rates. Relative to the pre-APN period, APN approximately tripled the number of partners recruited per index case and reduced the number of index cases needed to find a positive partner by >3 times.