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Boakye DS, Kumah E, Adjorlolo S. Policies and Practices Facilitating Access to and Uptake of HIV Testing Services among Adolescents in Sub-Sahara Africa: A Narrative Review. Curr HIV/AIDS Rep 2024; 21:220-236. [PMID: 38814361 DOI: 10.1007/s11904-024-00701-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 05/31/2024]
Abstract
PURPOSE OF REVIEW Expanding access to HIV testing services and linking newly diagnosed positive adolescents to antiretroviral therapy is critical to epidemic control. However, testing coverage and treatment initiation rates continue to lag behind adult counterparts. This article synthesizes evidence on facilitative policies and service delivery practices focused on adolescents to inform programming. RECENT FINDINGS Our narrative review found that national policies are growing more adolescent-inclusive but barriers around the age of consent, waiver frameworks and dissemination constrain translate into practice. Facility-based provider-initiated testing through integrated sexual health services and dedicated youth centres demonstrates uptake effectiveness if confidentiality and youth-friendly adaptations are assured. Supportive policies, youth-responsive adaptations across testing models and strengthening age-disaggregated monitoring are vital to improving adolescents' engagement across the HIV testing and treatment cascade. Further implementation research is imperative to expand the reach of adolescent HIV testing in sub-Saharan Africa.
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Affiliation(s)
- Dorothy Serwaa Boakye
- Department of Health Administration and Education, University of Education, Winneba, Ghana, P.O. Box 25, South Campus.
| | - Emmanuel Kumah
- Department of Health Administration and Education, University of Education, Winneba, Ghana, P.O. Box 25, South Campus
| | - Samuel Adjorlolo
- School of Nursing and Midwifery, College of Health Sciences, University of Ghana, Accra, Ghana
- Research and Grant Institute of Ghana, Legon, Ghana
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Lu IJ, Silhol R, d'Elbée M, Boily M, Soni N, Ky‐Zerbo O, Vautier A, Simo Fosto A, Badiane K, Traoré M, Terris‐Prestholt F, Larmarange J, Maheu‐Giroux M. Cost-effectiveness analysis of community-led HIV self-testing among key populations in Côte d'Ivoire, Mali, and Senegal. J Int AIDS Soc 2024; 27:e26334. [PMID: 39034541 PMCID: PMC11260876 DOI: 10.1002/jia2.26334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 06/27/2024] [Indexed: 07/23/2024] Open
Abstract
INTRODUCTION HIV self-testing (HIVST) is a promising strategy to improve diagnosis coverage among key populations (KP). The ATLAS (Auto Test VIH, Libre d'Accéder à la connaissance de son Statut) programme implemented HIVST in three West African countries, distributing over 380,000 kits up between 2019 and 2021, focussing on community-led distribution by KP to their peers and subsequent secondary distribution to their partners and clients. We aim to evaluate the cost-effectiveness of community-led HIVST in Côte d'Ivoire, Mali and Senegal. METHODS An HIV transmission dynamics model was adapted and calibrated to country-specific epidemiological data and used to predict the impact of HIVST. We considered the distribution of HIVST among two KP-female sex workers (FSW), and men who have sex with men (MSM)-and their sexual partners and clients. We compared the cost-effectiveness of two scenarios against a counterfactual without HIVST over a 20-year horizon (2019-2039). The ATLAS-only scenario mimicked the 2-year implemented ATLAS programme, whereas the ATLAS-scale-up scenario achieved 95% coverage of HIVST distribution among FSW and MSM by 2025 onwards. The primary outcome is the number of disability-adjusted life-years (DALY) averted. Scenarios were compared using incremental cost-effectiveness ratios (ICERs). Costing was performed using a healthcare provider's perspective. Costs were discounted at 4%, converted to $USD 2022 and estimated using a cost-function to accommodate economies of scale. RESULTS The ATLAS-only scenario was highly cost-effective over 20 years, even at low willingness-to-pay thresholds. The median ICERs were $126 ($88-$210) per DALY averted in Côte d'Ivoire, $92 ($88-$210) in Mali and 27$ ($88-$210) in Senegal. Scaling-up the ATLAS programme would also be cost-effective, and substantial epidemiological impacts would be achieved. The ICERs for the scale-up scenario were $199 ($122-$338) per DALY averted in Côte d'Ivoire, $224 ($118-$415) in Mali and $61 ($18-$128) in Senegal. CONCLUSIONS Both the implemented and the potential scale-up of community-led HIVST programmes in West Africa, where KP are important to overall transmission dynamics, have the potential to be highly cost-effective, as compared to a scenario without HIVST. These findings support the scale-up of community-led HIVST to reach populations that otherwise may not access conventional testing services.
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Affiliation(s)
- Ingrid Jiayin Lu
- Department of Epidemiology and BiostatisticsSchool of Population and Global HealthFaculty of Medicine and Health SciencesMcGill UniversityMontréalQuébecCanada
| | - Romain Silhol
- Medical Research Council Centre for Global Infectious Disease AnalysisImperial College LondonLondonUK
| | - Marc d'Elbée
- University of BordeauxNational Institute for Health and Medical Research (INSERM) UMR 1219Research Institute for Sustainable Development (IRD) EMR 271Bordeaux Population Health CentreBordeauxFrance
- CepedUniversité Paris CitéIRDInsermParisFrance
| | - Marie‐Claude Boily
- Medical Research Council Centre for Global Infectious Disease AnalysisImperial College LondonLondonUK
| | - Nirali Soni
- Medical Research Council Centre for Global Infectious Disease AnalysisImperial College LondonLondonUK
| | - Odette Ky‐Zerbo
- TransVIHMIUniversité de MontpellierIRDINSERMMontpellierFrance
| | | | - Artlette Simo Fosto
- L'Institut national d’études démographiques (INED)AubervilliersFrance
- Ceped UMR 196, Université Paris CitéResearch Institute for Sustainable Development (IRD)InsermParisFrance
| | | | - Metogara Traoré
- Université LavalQuébec CityQuébecCanada
- VITAM ‐ Centre de recherche en santé durableQuébec CityQuébecCanada
- Centre de recherche du CHU de QuébecQuébec CityQuébecCanada
| | | | | | - Mathieu Maheu‐Giroux
- Department of Epidemiology and BiostatisticsSchool of Population and Global HealthFaculty of Medicine and Health SciencesMcGill UniversityMontréalQuébecCanada
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West BS, Darisheva M, McCrimmon T, Zholnerova N, Grigorchuk E, Starbird L, Terlikbayeva A, Primbetova S, Baiserkin B, Mussina Z, Kasymbekova S, Cordingley O, Frye VA. Scaling Up HIV Self-Testing and Linkage to Care Among Women Who Exchange Sex and/or Use Drugs in Kazakhstan. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2024; 36:216-228. [PMID: 38917303 DOI: 10.1521/aeap.2024.36.3.216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
HIV testing is the point of entry for linkage to treatment and prevention and is critically important to ending the HIV epidemic. HIV self-testing (HST) is an acceptable, user-controlled tool that can address testing barriers, which is especially important for populations who need to test frequently, like women who exchange or trade sex for money or other needed resources (WES) and women who use drugs. HST is feasible and acceptable among WES, but research among WES who also use drugs is limited, particularly in places like Kazakhstan, where HIV rates remain high and where scale-up of HST and pre-exposure prophylaxis (PrEP) is in process. To develop effective programming, there is a need to develop tailored services for WES and/or use drugs that address key barriers. We discuss opportunities to increase HST and linkage to services among WES and/or use drugs in Kazakhstan, with a focus on stigma reduction.
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Affiliation(s)
- Brooke S West
- School of Social Work, Columbia University, New York, New York
| | | | - Tara McCrimmon
- Sociomedical Sciences, Columbia University, New York, New York
| | | | | | - Laura Starbird
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Baurzhan Baiserkin
- Kazakh Scientific Center of Dermatology and Infectious Diseases, Almaty, Kazakhstan
| | - Zhannat Mussina
- Kazakh Scientific Center of Dermatology and Infectious Diseases, Almaty, Kazakhstan
| | | | | | - Victoria A Frye
- School of Social Work, Columbia University, New York, New York
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Mujwara D, Kelvin EA, Dahman B, George G, Nixon D, Adera T, Mwai E, Kimmel AD. The economic costs and cost-effectiveness of HIV self-testing among truck drivers in Kenya. Health Policy Plan 2024; 39:355-362. [PMID: 38441272 PMCID: PMC11005835 DOI: 10.1093/heapol/czae013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 02/06/2024] [Accepted: 02/28/2024] [Indexed: 04/11/2024] Open
Abstract
HIV status awareness is critical for ending the HIV epidemic but remains low in high-HIV-risk and hard-to-reach sub-populations. Targeted, efficient interventions are needed to improve HIV test-uptake. We examined the incremental cost-effectiveness of offering the choice of self-administered oral HIV-testing (HIVST-Choice) compared with provider-administered testing only [standard-of-care (SOC)] among long-distance truck drivers. Effectiveness data came from a randomized-controlled trial conducted at two roadside wellness clinics in Kenya (HIVST-Choice arm, n = 150; SOC arm, n = 155). Economic cost data came from the literature, reflected a societal perspective and were reported in 2020 international dollars (I$), a hypothetical currency with equivalent purchasing power as the US dollar. Generalized Poisson and linear gamma regression models were used to estimate effectiveness and incremental costs, respectively; incremental effectiveness was reported as the number of long-distance truck drivers needing to receive HIVST-Choice for an additional HIV test-uptake. We calculated the incremental cost-effectiveness ratio (ICER) of HIVST-Choice compared with SOC and estimated 95% confidence intervals (CIs) using non-parametric bootstrapping. Uncertainty was assessed using deterministic sensitivity analysis and the cost-effectiveness acceptability curve. HIV test-uptake was 23% more likely for HIVST-Choice, with six individuals needing to be offered HIVST-Choice for an additional HIV test-uptake. The mean per-patient cost was nearly 4-fold higher in HIVST-Choice (I$39.28) versus SOC (I$10.80), with an ICER of I$174.51, 95% CI [165.72, 194.59] for each additional test-uptake. HIV self-test kit and cell phone service costs were the main drivers of the ICER, although findings were robust even at highest possible costs. The probability of cost-effectiveness approached 1 at a willingness-to-pay of I$200 for each additional HIV test-uptake. HIVST-Choice improves HIV-test-uptake among truck drivers at low willingness-to-pay thresholds, suggesting that HIV self-testing is an efficient use of resources. Policies supporting HIV self-testing in similar high risk, hard-to-reach sub-populations may expedite achievement of international targets.
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Affiliation(s)
- Deo Mujwara
- Department of Health Policy, Virginia Commonwealth University, 830 East Main Street, Richmond, VA 23298, USA
- Analysis Group, Inc, 111 Huntington Ave 4th floor, Boston, MA 02199, USA
| | - Elizabeth A Kelvin
- Department of Epidemiology and Biostatistics & CUNY Institute for Implementation Science in Population Health, City University of New York, 205 East 42nd Street, New York, NY 10017, USA
| | - Bassam Dahman
- Department of Health Policy, Virginia Commonwealth University, 830 East Main Street, Richmond, VA 23298, USA
| | - Gavin George
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Westville Campus, Private Bag X54001, Durban 4000, South Africa
| | - Daniel Nixon
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University, 1200 E Broad St, Richmond, VA 23219, USA
| | - Tilahun Adera
- Department of Family Medicine and Population Health, Division of Epidemiology, 1200 E. Broad Street, Richmond, VA 23298, USA
| | - Eva Mwai
- North Star Alliance, 8 Silanga Road, Nairobi, Kenya
| | - April D Kimmel
- Department of Health Policy, Virginia Commonwealth University, 830 East Main Street, Richmond, VA 23298, USA
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University, 1200 E Broad St, Richmond, VA 23219, USA
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McGee K, d'Elbée M, Dekova R, Sande LA, Dube L, Masuku S, Dlamini M, Mangenah C, Mwenge L, Johnson C, Hatzold K, Neuman M, Meyer-Rath G, Terris-Prestholt F. Costs of distributing HIV self-testing kits in Eswatini through community and workplace models. BMC Infect Dis 2024; 22:976. [PMID: 38424538 PMCID: PMC10902928 DOI: 10.1186/s12879-023-08694-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 10/10/2023] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND This study evaluates the implementation and running costs of an HIV self-testing (HIVST) distribution program in Eswatini. HIVST kits were delivered through community-based and workplace models using primary and secondary distribution. Primary clients could self-test onsite or offsite. This study presents total running economic costs of kit distribution per model between April 2019 and March 2020, and estimates average cost per HIVST kit distributed, per client self-tested, per client self-tested reactive, per client confirmed positive, and per client initiating antiretroviral therapy (ART). METHODS Distribution data and follow-up phone interviews were analysed to estimate implementation outcomes. Results were presented for each step of the care cascade using best-case and worst-case scenarios. A top-down incremental cost-analysis was conducted from the provider perspective using project expenditures. Sensitivity and scenario analyses explored effects of economic and epidemiological parameters on average costs. RESULTS Nineteen thousand one hundred fifty-five HIVST kits were distributed to 13,031 individuals over a 12-month period, averaging 1.5 kits per recipient. 83% and 17% of kits were distributed via the community and workplace models, respectively. Clients reached via the workplace model were less likely to opt for onsite testing than clients in the community model (8% vs 29%). 6% of onsite workplace testers tested reactive compared to 2% of onsite community testers. Best-case scenario estimated 17,458 (91%) clients self-tested, 633 (4%) received reactive-test results, 606 (96%) linked to confirmatory testing, and 505 (83%) initiated ART. Personnel and HIVST kits represented 60% and 32% of total costs, respectively. Average costs were: per kit distributed US$17.23, per client tested US$18.91, per client with a reactive test US$521.54, per client confirmed positive US$550.83, and per client initiating ART US$708.60. Lower rates for testing, reactivity, and linkage to care in the worst-case scenario resulted in higher average costs along the treatment cascade. CONCLUSION This study fills a significant evidence gap regarding costs of HIVST provision along the client care cascade in Eswatini. Workplace and community-based distribution of HIVST accompanied with effective linkage to care strategies can support countries to reach cascade objectives.
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Affiliation(s)
- Kathleen McGee
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
| | - Marc d'Elbée
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Linda A Sande
- Malawi Liverpool Wellcome Trust Research Programme, Blantyre, Malawi
| | | | - Sanele Masuku
- Population Services International, Mbabane, Eswatini
| | | | - Collin Mangenah
- Centre for Sexual Health and HIV/AIDS Research, Harare, Zimbabwe
| | | | - Cheryl Johnson
- World Health Organisation, Global HIV, Hepatitis and STI Programmes, Geneva, Switzerland
| | - Karin Hatzold
- Population Services International, Cape Town, South Africa
| | - Melissa Neuman
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Gesine Meyer-Rath
- Center for Global Heath and Development, Boston University School of Public Health, Boston, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Fern Terris-Prestholt
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Wang D, Zhou Y, Wu D, Tucker JD, Ni Y, Lu Y, Lyu H, Ong J, He X, Huang S, Tang W. Factors Associated with the First-time HIV Testing Among Chinese men who have sex with men Who Received HIV Self-tests from Partners or Friends. AIDS Behav 2024; 28:705-712. [PMID: 38194057 DOI: 10.1007/s10461-023-04259-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2023] [Indexed: 01/10/2024]
Abstract
Secondary distribution of HIV self-testing (HIVST) among individual social networks was an effective approach to expanding HIV testing among men who have sex with men (MSM). However, understanding the factors associated with first-time HIV testing behaviors in the secondary distribution of HIVST programs is limited. Hence, this study aims to identify factors related to first-time testers in the secondary distribution of HIVST. Participants were recruited from five provinces in southern China through Blued, a geo-social gay networking app in China from January 2021 to December 2021. Eligible consented participants (referred to as "seeds") finished a baseline survey and then applied for up to five HIVST kits. They were encouraged to distribute HIVST kits to other MSM (referred to as "alters") and alters were encouraged to scan a QR code to return their photographed testing results. All alters were invited to finish an online survey. In total, 229 seeds reached 292 alters, among whom 126 (43.2%) were first-time testers whereas 166 (56.8%) were non-first-time testers. Importantly, our results demonstrated that the first-time HIV testers were more likely to self-report as heterosexual (aOR = 4.88, 95% CI 1.01-23.61), disclose sexual orientation and/or SSB (aOR = 1.73, 95% CI 1.01-2.96), and receive HIVST knowledge from the seeds (aOR = 3.25, 95% CI 1.02-10.34). However, those who had sex with male partners in the last three months were less likely to be first-time testers (aOR = 0.43, 95% CI 0.23-0.82). Practical implications and limitations were also discussed to improve future HIV prevention programs.
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Affiliation(s)
- Dongya Wang
- School of Communication, University of Miami, Miami, FL, USA
- Dermatology Hospital of Southern Medical University, Guangzhou, China
- University of North Carolina Project-China, Guangzhou, China
| | - Yi Zhou
- Zhuhai Center for Diseases Control and Prevention, Zhuhai, China
| | - Dan Wu
- University of North Carolina Project-China, Guangzhou, China
- London School of Hygiene and Tropical Medicine, London, UK
| | - Joseph D Tucker
- University of North Carolina Project-China, Guangzhou, China
- London School of Hygiene and Tropical Medicine, London, UK
| | - Yuxin Ni
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA
| | - Ying Lu
- Dermatology Hospital of Southern Medical University, Guangzhou, China
- University of North Carolina Project-China, Guangzhou, China
| | - Hang Lyu
- Zhuhai Center for Diseases Control and Prevention, Zhuhai, China
| | - Jason Ong
- London School of Hygiene and Tropical Medicine, London, UK
| | - Xi He
- Zhuhai Xutong Voluntary Services Center, Zhuhai, China
| | - Shanzi Huang
- Zhuhai Center for Diseases Control and Prevention, Zhuhai, China
| | - Weiming Tang
- Dermatology Hospital of Southern Medical University, Guangzhou, China.
- University of North Carolina Project-China, Guangzhou, China.
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Empringham B, Karellis A, Kashkary A, D’Silva O, Carmona S, Suarez MF, Addae A, Pai NP, Zwerling AA. How much does HIV self-testing cost in low and middle income countries? A systematic review of evidence from economic studies. Front Public Health 2023; 11:1135425. [PMID: 38026397 PMCID: PMC10679730 DOI: 10.3389/fpubh.2023.1135425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 09/27/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives HIV self-testing (HIVST) has been proposed as an innovative strategy to diagnose human immunodeficiency virus (HIV). While HIVST offers the potential to broaden accessibility of early HIV diagnosis and treatment initiation, this testing strategy incurs additional cost and requires confirmatory testing and treatment. We have conducted the first systematic review to summarize the current economic literature for HIVST in low- and middle-income countries (LMICs). Design A search strategy was developed including key terms for HIV, self-testing and cost-effectiveness and was conducted in Medline and Embase databases. Studies were included that reported costs per outcome and included both cost-effectiveness and cost-utility outcome measures. The search strategy identified publications up until August 15, 2023 were included. Abstract and full text screening was conducted and a standardized data abstraction form was used for included studies. Costs are reported in USD, 2020. Results Our search strategy identified 536 total titles from the search strategy, which were screened down to 25 relevant studies that provided both cost and outcome data on HIVST. There was significant heterogeneity in the HIVST intervention, study population, costs and outcomes reported among included studies. Cost per person tested ranged from $1.09-155. Cost per case diagnosed ranged from $20-1,277. Cost-utility estimates ranged from cost-saving to $1846 per DALY averted. Higher cost-effectiveness estimates were associated with more expensive testing algorithms with increased support for linkage to care and post-test counseling. Conclusion All studies considered HIVST cost-effective although major drivers were identified included underlying HIV prevalence, testing cost and linkage to care. HIVST is likely to be cost-effective in a LMIC context, however policy makers should be aware of the drivers of cost-effectiveness when implementing HIVST programs as these underlying factors can impact the overall cost-effectiveness of HIVST.
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Affiliation(s)
- Brianna Empringham
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Angela Karellis
- Division of Clinical Epidemiology & Experimental Medicine, McGill University, Montreal, QC, Canada
| | - Abdulhameed Kashkary
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Public Health Authority, Riyadh, Saudi Arabia
| | - Olivia D’Silva
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Sergio Carmona
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | | | - Angelina Addae
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Nitika Pant Pai
- Division of Clinical Epidemiology & Experimental Medicine, McGill University, Montreal, QC, Canada
| | - Alice Anne Zwerling
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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Mavhu W, Makamba M, Hatzold K, Maringwa G, Takaruza A, Mutseta M, Ncube G, Cowan FM, Sibanda EL. Preferences for oral-fluid-based or blood-based HIV self-testing and provider-delivered testing: an observational study among different populations in Zimbabwe. BMC Infect Dis 2023; 22:973. [PMID: 37848810 PMCID: PMC10583299 DOI: 10.1186/s12879-023-08624-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 09/18/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND There is limited data on client preferences for different HIV self-testing (HIVST) and provider-delivered testing options and associated factors. We explored client preferences for oral-fluid-based self-testing (OFBST), blood-based self-testing (BBST) and provider-delivered blood-based testing (PDBBT) among different populations. METHODS At clinics providing HIV testing services to general populations (1 urban, 1 rural clinic), men seeking voluntary medical male circumcision (VMMC, 1 clinic), and female sex workers (FSW, 1 clinic), clients had the option to test using OFBST, BBST or PDBBT. A pre-test questionnaire collected information on demographics and testing history. Two weeks after collecting a self-test kit, participants responded to a questionnaire. We used logistic regression to determine predictors of choices. We also conducted 20 in-depth interviews to contextualise quantitative findings. RESULTS May to June 2019, we recruited 1244 participants of whom 249 (20%), 251 (20%), 244 (20%) and 500 (40%) were attending urban general, rural, VMMC and FSW clinics, respectively. Half (n = 619, 50%) chose OFBST, 440 (35%) and 185 (15%) chose BBST and PDBBT, respectively. In multivariable analysis comparing those choosing HIVST (OFBST and BBST combined) versus not, those who had never married aOR 0.57 (95% CI 0.34-0.93) and those previously married aOR0.56 (0.34-0.93) were less likely versus married participants to choose HIVST. HIVST preference increased with education, aOR 2.00 (1.28-3.13), 2.55 (1.28-5.07), 2.76 (1.48-5.14) for ordinary, advanced and tertiary education, respectively versus none/primary education. HIVST preference decreased with age aOR 0.97 (0.96-0.99). Urban participants were more likely than rural ones to choose HIVST, aOR 9.77 (5.47-17.41), 3.38 (2.03-5.62) and 2.23 (1.38-3.61) for FSW, urban general and VMMC clients, respectively. Comparing those choosing OFBST with those choosing BBST, less literate participants were less likely to choose oral fluid tests, aOR 0.29 (0.09-0.92). CONCLUSIONS Most testing clients opted for OFBST, followed by BBST and lastly, PDBBT. Those who self-assessed as less healthy were more likely to opt for PDBBT which likely facilitated linkage. Results show importance of continued provision of all strategies in order to meet needs of different populations, and may be useful to inform both HIVST kit stock projections and tailoring of HIVST programs to meet the needs of different populations.
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Affiliation(s)
- Webster Mavhu
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, 4 Bath Road, Belgravia, Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Memory Makamba
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, 4 Bath Road, Belgravia, Harare, Zimbabwe
| | - Karin Hatzold
- Population Services International, Cape Town, South Africa
| | - Galven Maringwa
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, 4 Bath Road, Belgravia, Harare, Zimbabwe
| | - Albert Takaruza
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, 4 Bath Road, Belgravia, Harare, Zimbabwe
| | | | | | - Frances M Cowan
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, 4 Bath Road, Belgravia, Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Euphemia L Sibanda
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, 4 Bath Road, Belgravia, Harare, Zimbabwe.
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.
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Vasantharoopan A, Simms V, Chan Y, Guinness L, Maheswaran H. Modelling Methods of Economic Evaluations of HIV Testing Strategies in Sub-Saharan Africa: A Systematic Review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:585-601. [PMID: 36853553 DOI: 10.1007/s40258-022-00782-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/04/2022] [Indexed: 06/01/2023]
Abstract
BACKGROUND AND OBJECTIVE Economic evaluations, a decision-support tool for policy makers, will be crucial in planning and tailoring HIV prevention and treatment strategies especially in the wake of stalled and decreasing funding for the global HIV response. As HIV testing and treatment coverage increase, case identification becomes increasingly difficult and costly. Determining which subset of the population these strategies should be targeted to becomes of vital importance as well. Generating quality economic evidence begins with the validity of the modelling approach and the model structure employed. This study synthesises and critiques the reporting around modelling methodology of economic models in the evaluation of HIV testing strategies in sub-Saharan Africa. METHODS The following databases were searched from January 2000 to September 2020: MEDLINE, Embase, Scopus, EconLit and Global Health. Any model-based economic evaluation of a unique HIV testing strategy conducted in sub-Saharan Africa presenting a cost-effectiveness measure published from 2013 onwards was eligible. Data were extracted around three components: general study characteristics; economic evaluation design; and quality of model reporting using a novel tool developed for the purposes of this study. RESULTS A total of 21 studies were included; 10 cost-effectiveness analyses, 11 cost-utility analyses. All but one study was conducted in Eastern and Southern Africa. Modelling approaches for HIV testing strategies can be broadly characterised as static aggregate models (3/21), static individual models (6/21), dynamic aggregate models (5/21) and dynamic individual models (7/21). Adequate reporting around data handling was the highest of the three categories assessed (74%), and model validation, the lowest (45%). Limitations to model structure, justification of chosen time horizon and cycle length, and description of external model validation process were all adequately reported in less than 40% of studies. The predominant limitation of this review relates to the potential implications of the narrow inclusion criteria. CONCLUSIONS This review is the first to synthesise economic evaluations of HIV testing strategies in sub-Saharan Africa. The majority of models exhibited dynamic, stochastic and individual properties. Model reporting against the 13 criteria in our novel tool was mixed. Future model-based economic evaluations of HIV testing strategies would benefit from transparency around the choice of modelling approach, model structure, data handling procedures and model validation techniques.
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Affiliation(s)
- Arthi Vasantharoopan
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Victoria Simms
- MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Yuyen Chan
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, UK
| | - Lorna Guinness
- London School of Hygiene and Tropical Medicine, London, UK
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10
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Hardiawan D, Juwita MN, Vadra J, Prawiranegara R, Mambea IY, Wisaksana R, Handayani M, Subronto YW, Kusmayanti NA, Januraga P, Sukmaningrum E, Nurhayati, Prameswari HD, Sulaiman N, Siregar AYM. Cost of improved test and treat strategies in Indonesia. AIDS 2023; 37:1189-1201. [PMID: 36927656 DOI: 10.1097/qad.0000000000003547] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
OBJECTIVE To estimate and compare the cost of improved test and treat strategies in Indonesia under HIV Awal (Early) Testing and Treatment Indonesia (HATI) implementation trial in community-based and hospital-based clinics. DESIGN The cost and outcome [i.e. CD4 + cell count] and viral load (VL) at the beginning of interventions and their change overtime) analysis of Simplifying ART Initiation (SAI), Community-based Organization and community-based ART Service (CBO), Motivational Interviewing (MI), Oral Fluid-based Testing (OFT), and Short Message Service (SMS) reminder in community-based and hospital-based clinics in 2018-2019. METHOD We estimated the total and unit costs per patient (under HATI implementation trial interventions) per year from societal perspective in various settings, including costs from patients' perspective for SAI and MI. We also analyzed the outcome variables (i.e. CD4 + cell count and VL at the beginning of each intervention, the change in CD4 + cell count and VL over time, and adherence rate). RESULT The unit cost per patient per year of SAI and SMS were lower at the community-based clinics, and more patients visited community-based clinics. The cost per patient visit from patient perspective for SAI and MI was mostly lower than 10% of the patients' household monthly expenditure. Average CD4 + cell count was higher and average VL was lower at the start of interventions at the community-based clinics, while average CD4 + cell count and VL changes and adherence rate were similar between the two types of clinics. CONCLUSION Community-based clinics hold the potential for scaling up the interventions as it costs less from societal perspective and showed better outcome improvement during the HATI implementation trial.
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Affiliation(s)
- Donny Hardiawan
- Center for Economics and Development Studies (CEDS), Department of Economics, Faculty of Economics and Business, Universitas Padjadjaran
| | - Mery N Juwita
- Center for Economics and Development Studies (CEDS), Department of Economics, Faculty of Economics and Business, Universitas Padjadjaran
| | - Jorghi Vadra
- Center for Economics and Development Studies (CEDS), Department of Economics, Faculty of Economics and Business, Universitas Padjadjaran
| | - Rozar Prawiranegara
- Center for Economics and Development Studies (CEDS), Department of Economics, Faculty of Economics and Business, Universitas Padjadjaran
| | - Indra Y Mambea
- Center for Economics and Development Studies (CEDS), Department of Economics, Faculty of Economics and Business, Universitas Padjadjaran
| | - Rudi Wisaksana
- Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin Hospital, Bandung
- Research Centre for Care and Control of Infectious Disease, Universitas Padjadjaran
| | - Miasari Handayani
- Research Centre for Care and Control of Infectious Disease, Universitas Padjadjaran
| | - Yanri W Subronto
- Center for Tropical Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada
- Department of Internal Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada
| | - Nur A Kusmayanti
- Center for Tropical Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada
| | - Pande Januraga
- Center for Public Health Innovation, Faculty of Medicine, Udayana University
| | - Evi Sukmaningrum
- University Center of Excellence - AIDS Research Center Health Policy and Social Innovation, Atma Jaya Catholic University of Indonesia
| | - Nurhayati
- Department of Epidemiology, Faculty of Public Health, Universitas Indonesia
| | | | | | - Adiatma Y M Siregar
- Center for Economics and Development Studies (CEDS), Department of Economics, Faculty of Economics and Business, Universitas Padjadjaran
- Center for Health Technology Assessment (CHTA), Universitas Padjadjaran
- West Java Development Institute (INJABAR), Universitas Padjadjaran, Indonesia
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11
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Mfuh KO, Abanda NN, Titanji BK. Strengthening diagnostic capacity in Africa as a key pillar of public health and pandemic preparedness. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001998. [PMID: 37310963 DOI: 10.1371/journal.pgph.0001998] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Kenji O Mfuh
- Department of Anatomic Pathology and Clinical Laboratories, Stanford Medicine, Palo Alto, California, United States of America
| | - Ngu Njei Abanda
- Department of Virology, Centre Pasteur of Cameroon, Yaoundé, Cameroon
| | - Boghuma K Titanji
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
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12
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Mital S, Kelly D, Hughes C, Nosyk B, Thavorn K, Nguyen HV. Estimated cost-effectiveness of point-of-care testing in community pharmacies vs. self-testing and standard laboratory testing for HIV. AIDS 2023; 37:1125-1135. [PMID: 36928760 DOI: 10.1097/qad.0000000000003526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
OBJECTIVE Point-of-care-testing (POCT) for HIV at community pharmacies can enhance care linkage compared with self-tests and increase testing uptake relative to standard lab testing. While the higher test uptake may increase testing costs, timely diagnosis and treatment can reduce downstream HIV treatment costs and improve health outcomes. This study provides the first evidence on the cost-effectiveness of pharmacist-led POCT vs. HIV self-testing and standard lab testing. DESIGN Dynamic transmission model. METHODS We compared three HIV testing strategies: POCT at community pharmacies; self-testing using HIV self-test kits; and standard lab testing. Analyses were conducted from the Canadian health system perspective over a 30-year time horizon for all individuals aged 15-64 years in Canada. Costs were measured in 2021 Canadian dollars and effectiveness was captured using quality-adjusted life-years (QALYs). RESULTS Compared with standard lab testing, POCT at community pharmacies would save $885 million in testing costs over 30 years. Though antiretroviral treatment costs would increase by $190 million with POCT as more persons living with HIV are identified and treated, these additional costs would be partly offset by their lower downstream healthcare utilization (savings of $150 million). POCT at community pharmacies would also yield over 5000 additional QALYs. Compared with HIV self-testing, POCT at community pharmacies would generate both higher costs and higher QALYs and would be cost-effective with an incremental cost-effectiveness ratio of $47 475 per QALY gained. CONCLUSIONS Offering POCT at community pharmacies can generate substantial cost savings and improve health outcomes compared with standard lab testing. It would also be cost-effective vs. HIV self-testing.
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Affiliation(s)
- Shweta Mital
- College of Pharmacy, University of Manitoba, Winnipeg
| | - Deborah Kelly
- School of Pharmacy, Memorial University of Newfoundland, St. John's
| | - Christine Hughes
- Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton
| | - Bohdan Nosyk
- Faculty of Health Sciences, Simon Fraser University, Burnaby
| | | | - Hai V Nguyen
- School of Pharmacy, Memorial University of Newfoundland, St. John's
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Ramponi F, Twea P, Chilima B, Nkhoma D, Kazanga Chiumia I, Manthalu G, Mfutso-Bengo J, Revill P, Drummond M, Sculpher M. Assessing the potential of HTA to inform resource allocation decisions in low-income settings: The case of Malawi. Front Public Health 2022; 10:1010702. [PMID: 36388387 PMCID: PMC9650047 DOI: 10.3389/fpubh.2022.1010702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 10/03/2022] [Indexed: 01/27/2023] Open
Abstract
Health technology assessment (HTA) offers a set of analytical tools to support health systems' decisions about resource allocation. Although there is increasing interest in these tools across the world, including in some middle-income countries, they remain rarely used in low-income countries (LICs). In general, the focus of HTA is narrow, mostly limited to assessments of efficacy and cost-effectiveness. However, the principles of HTA can be used to support a broader series of decisions regarding new health technologies. We examine the potential for this broad use of HTA in LICs, with a focus on Malawi. We develop a framework to classify the main decisions on health technologies within health systems. The framework covers decisions on identifying and prioritizing technologies for detailed assessment, deciding whether to adopt an intervention, assessing alternative investments for implementation and scale-up, and undertaking further research activities. We consider the relevance of the framework to policymakers in Malawi and we use two health technologies as examples to investigate the main barriers and enablers to the use of HTA methods. Although the scarcity of local data, expertise, and other resources could risk limiting the operationalisation of HTA in LICs, we argue that even in highly resource constrained health systems, such as in Malawi, the use of HTA to support a broad range of decisions is feasible and desirable.
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Affiliation(s)
- Francesco Ramponi
- Centre for Health Economics, University of York, Heslington, United Kingdom
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Pakwanja Twea
- Department of Planning and Policy Development, Ministry of Health Malawi, Lilongwe, Malawi
| | - Benson Chilima
- Public Health Institute, Ministry of Health Malawi, Lilongwe, Malawi
| | - Dominic Nkhoma
- Health Economics and Policy Unit (HEPU), College of Medicine, University of Malawi, Zomba, Malawi
| | - Isabel Kazanga Chiumia
- Health Economics and Policy Unit (HEPU), College of Medicine, University of Malawi, Zomba, Malawi
| | - Gerald Manthalu
- Department of Planning and Policy Development, Ministry of Health Malawi, Lilongwe, Malawi
| | - Joseph Mfutso-Bengo
- Health Economics and Policy Unit (HEPU), College of Medicine, University of Malawi, Zomba, Malawi
| | - Paul Revill
- Centre for Health Economics, University of York, Heslington, United Kingdom
| | - Michael Drummond
- Centre for Health Economics, University of York, Heslington, United Kingdom
| | - Mark Sculpher
- Centre for Health Economics, University of York, Heslington, United Kingdom
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14
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Kabwama SN, Wanyenze RK, Kiwanuka SN, Namale A, Ndejjo R, Monje F, Wang W, Lazenby S, Kizito S, Troeger C, Liu A, Lindgren H, Razaz N, Ssenkusu J, Sambisa W, Bartlein R, Alfvén T. Interventions for Maintenance of Essential Health Service Delivery during the COVID-19 Response in Uganda, between March 2020 and April 2021. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191912522. [PMID: 36231823 PMCID: PMC9566395 DOI: 10.3390/ijerph191912522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/19/2022] [Accepted: 09/27/2022] [Indexed: 06/03/2023]
Abstract
INTRODUCTION The COVID-19 pandemic overwhelmed health systems globally and affected the delivery of health services. We conducted a study in Uganda to describe the interventions adopted to maintain the delivery of other health services. METHODS We reviewed documents and interviewed 21 key informants. Thematic analysis was conducted to identify themes using the World Health Organization health system building blocks as a guiding framework. RESULTS Governance strategies included the establishment of coordination committees and the development and dissemination of guidelines. Infrastructure and commodity strategies included the review of drug supply plans and allowing emergency orders. Workforce strategies included the provision of infection prevention and control equipment, recruitment and provision of incentives. Service delivery modifications included the designation of facilities for COVID-19 management, patient self-management, dispensing drugs for longer periods and the leveraging community patient networks to distribute medicines. However, multi-month drug dispensing led to drug stock-outs while community drug distribution was associated with stigma. CONCLUSIONS Health service maintenance during emergencies requires coordination to harness existing health system investments. The essential services continuity committee coordinated efforts to maintain services and should remain a critical element of emergency response. Self-management and leveraging patient networks should address stigma to support service continuity in similar settings and strengthen service delivery beyond the pandemic.
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Affiliation(s)
- Steven Ndugwa Kabwama
- Department of Community Health and Behavioral Sciences, School of Public Health, Makerere University, Kampala P.O. Box 7062, Uganda
- Department of Global Public Health, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Rhoda K. Wanyenze
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University, Kampala P.O. Box 7072, Uganda
| | - Suzanne N. Kiwanuka
- Department of Health Policy Planning and Management, School of Public Health, Makerere University, Kampala P.O. Box 7072, Uganda
| | - Alice Namale
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University, Kampala P.O. Box 7072, Uganda
| | - Rawlance Ndejjo
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University, Kampala P.O. Box 7072, Uganda
| | - Fred Monje
- School of Public Health, Makerere University, Kampala P.O. Box 7072, Uganda
| | | | | | - Susan Kizito
- School of Public Health, Makerere University, Kampala P.O. Box 7072, Uganda
| | | | - Anne Liu
- Gates Ventures, Kirkland, WA 98033, USA
| | - Helena Lindgren
- Department of Women’s and Children’s Health, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Neda Razaz
- Department of Medicine, Karolinska Institutet, 17177 Stockholm, Sweden
| | - John Ssenkusu
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala P.O. Box 7072, Uganda
| | | | | | - Tobias Alfvén
- Department of Global Public Health, Karolinska Institutet, 17177 Stockholm, Sweden
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15
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Resch SC, Foote JHA, Wirth KE, Lasry A, Scott JA, Moore J, Shebl FM, Gaolathe T, Feser MK, Lebelonyane R, Hyle EP, Mmalane MO, Bachanas P, Yu L, Makhema JM, Holme MP, Essex M, Alwano MG, Lockman S, Freedberg KA. Health Impact and Cost-Effectiveness of HIV Testing, Linkage, and Early Antiretroviral Treatment in the Botswana Combination Prevention Project. J Acquir Immune Defic Syndr 2022; 90:399-407. [PMID: 35420554 PMCID: PMC9295776 DOI: 10.1097/qai.0000000000002996] [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] [Received: 10/19/2021] [Accepted: 03/18/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The Botswana Combination Prevention Project tested the impact of combination prevention (CP) on HIV incidence in a community-randomized trial. Each trial arm had ∼55,000 people, 26% HIV prevalence, and 72% baseline ART coverage. Results showed intensive testing and linkage campaigns, expanded antiretroviral treatment (ART), and voluntary male medical circumcision referrals increased coverage and decreased incidence over ∼29 months of follow-up. We projected lifetime clinical impact and cost-effectiveness of CP in this population. SETTING Rural and periurban communities in Botswana. METHODS We used the Cost-Effectiveness of Preventing AIDS Complications model to estimate lifetime health impact and cost of (1) earlier ART initiation and (2) averting an HIV infection, which we applied to incremental ART initiations and averted infections calculated from trial data. We determined the incremental cost-effectiveness ratio [US$/quality-adjusted life-years (QALY)] for CP vs. standard of care. RESULTS In CP, 1418 additional people with HIV initiated ART and an additional 304 infections were averted. For each additional person started on ART, life expectancy increased 0.90 QALYs and care costs increased by $869. For each infection averted, life expectancy increased 2.43 QALYs with $9200 in care costs saved. With CP, an additional $1.7 million were spent on prevention and $1.2 million on earlier treatment. These costs were mostly offset by decreased care costs from averted infections, resulting in an incremental cost-effectiveness ratio of $79 per QALY. CONCLUSIONS Enhanced HIV testing, linkage, and early ART initiation improve life expectancy, reduce transmission, and can be cost-effective or cost-saving in settings like Botswana.
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Affiliation(s)
- Stephen C. Resch
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Kresge 3 & 4 Floors, Boston, MA 02115, USA
| | - Julia H. A. Foote
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA 02114, USA
| | - Kathleen E. Wirth
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, 651 Huntington Avenue, Boston, MA 02115, USA
| | - Arielle Lasry
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329, USA
| | - Justine A. Scott
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA 02114, USA
| | - Janet Moore
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329, USA
| | - Fatma M. Shebl
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA 02114, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Tendani Gaolathe
- Botswana-Harvard AIDS Institute Partnership, Princess Marina Hospital, Plot No. 1836, Northring Road, Gaborone, Botswana
| | - Mary K. Feser
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA 02114, USA
| | - Refeletswe Lebelonyane
- Botswana Ministry of Health and Wellness, Plot 54609, 24 Amos Street, Government Enclave, Gaborone, Botswana
| | - Emily P. Hyle
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA 02114, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
- Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02144, USA
- Harvard University Center for AIDS Research, 42 Church Street, Cambridge, MA 02138, USA
| | - Mompati O. Mmalane
- Botswana-Harvard AIDS Institute Partnership, Princess Marina Hospital, Plot No. 1836, Northring Road, Gaborone, Botswana
| | - Pamela Bachanas
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329, USA
| | - Liyang Yu
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA 02114, USA
| | - Joseph M. Makhema
- Botswana-Harvard AIDS Institute Partnership, Princess Marina Hospital, Plot No. 1836, Northring Road, Gaborone, Botswana
| | - Molly Pretorius Holme
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, 651 Huntington Avenue, Boston, MA 02115, USA
| | - Max Essex
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, 651 Huntington Avenue, Boston, MA 02115, USA
- Botswana-Harvard AIDS Institute Partnership, Princess Marina Hospital, Plot No. 1836, Northring Road, Gaborone, Botswana
| | | | - Shahin Lockman
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, 651 Huntington Avenue, Boston, MA 02115, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
- Botswana-Harvard AIDS Institute Partnership, Princess Marina Hospital, Plot No. 1836, Northring Road, Gaborone, Botswana
- Division of Infectious Diseases, Brigham and Women’s Hospital, 45 Francis Street, 2 Floor, Boston, MA 02115, USA
| | - Kenneth A. Freedberg
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Kresge 3 & 4 Floors, Boston, MA 02115, USA
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA 02114, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
- Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02144, USA
- Harvard University Center for AIDS Research, 42 Church Street, Cambridge, MA 02138, USA
- Division of General Internal Medicine, Massachusetts General Hospital, 50 Staniford Street, 9 Floor, Boston, MA 02114, USA
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Fajardo E, Watson V, Kumwenda M, Usharidze D, Gogochashvili S, Kakhaberi D, Giguashvili A, Johnson CC, Jamil MS, Dacombe R, Stvilia K, Easterbrook P, Ivanova Reipold E. Usability and acceptability of oral-based HCV self-testing among key populations: a mixed-methods evaluation in Tbilisi, Georgia. BMC Infect Dis 2022; 22:510. [PMID: 35641908 PMCID: PMC9154030 DOI: 10.1186/s12879-022-07484-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 05/18/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Hepatitis C virus self-testing (HCVST) is an additional approach that may expand access to HCV testing. We conducted a mixed-methods cross-sectional observational study to assess the usability and acceptability of HCVST among people who inject drugs (PWID), men who have sex with men (MSM) and transgender (TG) people in Tbilisi, Georgia. METHODS The study was conducted from December 2019 to June 2020 among PWID at one harm reduction site and among MSM/TG at one community-based organization. We used a convergent parallel mixed-methods design. Usability was assessed by observing errors made and difficulties faced by participants. Acceptability was assessed using an interviewer-administered semi-structured questionnaire. A subset of participants participated in cognitive and in-depth interviews. RESULTS A total of 90 PWID, 84 MSM and 6 TG were observed performing HCVST. PWID were older (median age 35 vs 24) and had a lower level of education compared to MSM/TG (27% vs 59%). The proportion of participants who completed all steps successfully without assistance was 60% among PWID and 80% among MSM/TG. The most common error was in sample collection and this was observed more often among PWID than MSM/TG (21% vs 6%; p = 0.002). More PWID requested assistance during HCVST compared to MSM/TG (22% vs 8%; p = 0.011). Acceptability was high in both groups (98% vs 96%; p = 0.407). Inter-reader agreement was 97% among PWID and 99% among MSM/TG. Qualitative data from cognitive (n = 20) and in-depth interviews (n = 20) was consistent with the quantitative data confirming a high usability and acceptability. CONCLUSIONS HCVST was highly acceptable among key populations in Georgia of relatively high educational level, and most participants performed HCVST correctly. A significant difference in usability was observed among PWID compared to MSM/TG, indicating that PWID may benefit from improved messaging and education as well as options to receive direct assistance when self-testing for HCV.
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Affiliation(s)
- Emmanuel Fajardo
- grid.452485.a0000 0001 1507 3147The Foundation for Innovative New Diagnostics (FIND), Campus Biotech, Chemin des Mines 9, 1202 Geneva, Switzerland
| | - Victoria Watson
- grid.48004.380000 0004 1936 9764Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
| | - Moses Kumwenda
- grid.419393.50000 0004 8340 2442Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), Blantyre, Malawi ,grid.10595.380000 0001 2113 2211College of Medicine, University of Malawi (CoM), Blantyre, Malawi
| | | | | | - David Kakhaberi
- Community-Based Organization Equality Movement, Tbilisi, Georgia
| | - Ana Giguashvili
- National Centre for Disease Control and Public Health of Georgia, Tbilisi, Georgia
| | - Cheryl C. Johnson
- grid.3575.40000000121633745Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Muhammad S. Jamil
- grid.3575.40000000121633745Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Russell Dacombe
- grid.48004.380000 0004 1936 9764Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
| | - Ketevan Stvilia
- National Centre for Disease Control and Public Health of Georgia, Tbilisi, Georgia
| | - Philippa Easterbrook
- grid.3575.40000000121633745Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Elena Ivanova Reipold
- grid.452485.a0000 0001 1507 3147The Foundation for Innovative New Diagnostics (FIND), Campus Biotech, Chemin des Mines 9, 1202 Geneva, Switzerland
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17
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Jordão T, Magno L, Pereira M, Rossi TRA, de Almeida Silva P, Figueiredo MAA, de Brito Lima Prado NM, Dos Santos AM, Cangussu MC, Dourado I. Willingness of health care providers to offer HIV self-testing from specialized HIV care services in the northeast of Brazil. BMC Health Serv Res 2022; 22:713. [PMID: 35637470 PMCID: PMC9149328 DOI: 10.1186/s12913-022-08091-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 05/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background The insufficient knowledge regarding the serological status of people affected with human immunodeficiency virus (HIV) is a concern in Brazil. HIV self-testing (HIVST) has been proved to have great potential for increasing testing, especially among vulnerable populations. The large-scale distribution of HIVST by the Brazilian public health system has increased in recent years. We aimed to investigate the awareness of HIVST among health care providers (HCP) from specialized HIV/AIDS care services in the state of Bahia, Northeast Brazil. Further we investigated HCP acceptability and willingness to offer its use. Methods A cross-sectional study on HCP from 29 specialized care services (SCS) located in 21 cities in the state of Bahia. HCP working in the service for at least 6 months were included. Sociodemographic, occupational, and behavioral data were collected using a questionnaire. Descriptive statistics were carried out. Bivariate, and multivariate analyses estimating adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) using logistic regression were conducted. Results The awareness and acceptability of HIVST and the willingness to provide it were 79.8, 55.2, and 47.1%, respectively. Few HCP reported that the SCS where they worked dispensed HIVST (3.6%), and 13.5% received some information or training on HIVST. Factors associated with willingness to offer HIVST were: HIVST acceptability (aOR = 9.45; 95% CI: 4.53–19.71), willingness to use HIVST on themselves (aOR = 4.45; 95% CI: 1.62–12.24), confidence in offering HIVST to clients (aOR = 5.73; 95% CI: 2.26–12.72), and considering everyone eligible for HIVST (aOR = 2.88; 95% CI: 1.25–6.59). Conclusions Although most HCP were aware of HIVST, acceptability and willingness to provide it to the clients was moderate. The scale up of HIVST as a mean for the HIV prevention and control policy in Brazil, requires further training of HCP and better implementation of this program. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08091-2.
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Affiliation(s)
- Tiago Jordão
- Departamento de Ciências da Vida, Universidade do Estado da Bahia, Rua Silveira Martins, 2555, Cabula, Salvador, 41.150-000, Brazil.,Diretoria de Vigilância Epidemiológica da Bahia, Secretaria de Saúde do Estado da Bahia, Salvador, Brazil
| | - Laio Magno
- Departamento de Ciências da Vida, Universidade do Estado da Bahia, Rua Silveira Martins, 2555, Cabula, Salvador, 41.150-000, Brazil. .,Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brazil.
| | - Marcos Pereira
- Departamento de Ciências da Vida, Universidade do Estado da Bahia, Rua Silveira Martins, 2555, Cabula, Salvador, 41.150-000, Brazil.,Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brazil
| | - Thais Regis Aranha Rossi
- Departamento de Ciências da Vida, Universidade do Estado da Bahia, Rua Silveira Martins, 2555, Cabula, Salvador, 41.150-000, Brazil
| | - Pedro de Almeida Silva
- Departamento de Ciências da Vida, Universidade do Estado da Bahia, Rua Silveira Martins, 2555, Cabula, Salvador, 41.150-000, Brazil
| | | | | | - Adriano Maia Dos Santos
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista, Brazil
| | | | - Inês Dourado
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brazil
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18
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Sundararajan R, Ponticiello M, Nansera D, Jeremiah K, Muyindike W. Interventions to Increase HIV Testing Uptake in Global Settings. Curr HIV/AIDS Rep 2022; 19:184-193. [PMID: 35441985 PMCID: PMC9110462 DOI: 10.1007/s11904-022-00602-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 12/16/2022]
Abstract
Purpose of Review HIV testing is the critical first step to direct people living with HIV (PLWH) to treatment. However, progress is still being made towards the UNAIDS benchmark of 95% of PLWH knowing their status by 2030. Here, we discuss recent interventions to improve HIV testing uptake in global settings. Recent Findings Successful facility-based HIV testing interventions involve couples and index testing, partner notification, and offering of incentives. Community-based interventions such as home-based self-testing, mobile outreach, and hybrid approaches have improved HIV testing in low-resource settings and among priority populations. Partnerships with trusted community leaders have also increased testing among populations disproportionally impacted by HIV. Summary Recent HIV testing interventions span a breadth of facility- and community-based approaches. Continued research is needed to engage men in sub-Saharan Africa, people who inject drugs, and people who avoid biomedical care. Interventions should consider supporting linkage to care for newly diagnosed PLWH.
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Affiliation(s)
- Radhika Sundararajan
- Department of Emergency Medicine, Weill Cornell Medicine, 525 East 68th Street, M-130, New York, NY, 10065, USA. .,Weill Cornell Center for Global Health, New York, NY, USA.
| | - Matthew Ponticiello
- Department of Emergency Medicine, Weill Cornell Medicine, 525 East 68th Street, M-130, New York, NY, 10065, USA
| | - Denis Nansera
- Mbarara Regional Referral Hospital, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Winnie Muyindike
- Mbarara Regional Referral Hospital, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda
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19
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Expanding syphilis test uptake using rapid dual self-testing for syphilis and HIV among men who have sex with men in China: A multiarm randomized controlled trial. PLoS Med 2022; 19:e1003930. [PMID: 35235573 PMCID: PMC8890628 DOI: 10.1371/journal.pmed.1003930] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 01/25/2022] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Low syphilis testing uptake is a major public health issue among men who have sex with men (MSM) in many low- and middle-income countries. Syphilis self-testing (SST) may complement and extend facility-based testing. We aimed to evaluate the effectiveness and costs of providing SST on increasing syphilis testing uptake among MSM in China. METHODS AND FINDINGS An open-label, parallel 3-arm randomized controlled trial (RCT) was conducted between January 7, 2020 and July 17, 2020. Men who were at least 18 years of age, had condomless anal sex with men in the past year, reported not testing for syphilis in the last 6 months, and had a stable residence with mailing addresses were recruited from 124 cities in 26 Chinese provinces. Using block randomization with blocks of size 12, enrolled participants were randomly assigned (1:1:1) into 3 arms: standard of care arm, standard SST arm, and lottery incentivized SST arm (1 in 10 chance to win US$15 if they had a syphilis test). The primary outcome was the proportion of participants who tested for syphilis during the trial period and confirmed with photo verification and between arm comparisons were estimated with risk differences (RDs). Analyses were performed on a modified intention-to-treat basis: Participants were included in the complete case analysis if they had initiated at least 1 follow-up survey. The Syphilis/HIV Duo rapid test kit was used. A total of 451 men were enrolled. In total, 136 (90·7%, 136/150) in the standard of care arm, 142 (94·0%, 142/151) in the standard of SST arm, and 137 (91·3%, 137/150) in the lottery incentivized SST arm were included in the final analysis. The proportion of men who had at least 1 syphilis test during the trial period was 63.4% (95% confidence interval [CI]: 55.5% to 71.3%, p = 0.001) in the standard SST arm, 65.7% (95% CI: 57.7% to 73.6%, p = 0.0002) in the lottery incentivized SST arm, and 14.7% (95% CI: 8.8% to 20.7%, p < 0.001) in the standard of care arm. The estimated RD between the standard SST and standard of care arm was 48.7% (95% CI: 37.8% to 58.4%, p < 0.001). The majority (78.5%, 95% CI: 72.7% to 84.4%, p < 0.001) of syphilis self-testers reported never testing for syphilis. The cost per person tested was US$26.55 for standard SST, US$28.09 for the lottery incentivized SST, and US$66.19 for the standard of care. No study-related adverse events were reported during the study duration. Limitation was that the impact of the Coronavirus Disease 2019 (COVID-19) restrictions may have accentuated demand for decentralized testing. CONCLUSIONS Compared to standard of care, providing SST significantly increased the proportion of MSM testing for syphilis in China and was cheaper (per person tested). TRIAL REGISTRATION Chinese Clinical Trial Registry: ChiCTR1900022409.
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20
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Chimbindi N, Mthiyane N, Zuma T, Baisley K, Pillay D, McGrath N, Harling G, Sherr L, Birdthistle I, Floyd S, Dreyer J, Nakasone S, Seeley J, Shahmanesh M. Antiretroviral therapy based HIV prevention targeting young women who sell sex: a mixed method approach to understand the implementation of PrEP in a rural area of KwaZulu-Natal, South Africa. AIDS Care 2022; 34:232-240. [PMID: 33769156 PMCID: PMC8464632 DOI: 10.1080/09540121.2021.1902933] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Pre-Exposure Prophylaxis (PrEP) is a potential game-changer for HIV. We used PrEP introduction for Young Women Who Sell Sex (YWSS) in a rural South Africa district to understand community norms and PrEP coverage in YWSS. Between 2017 and 2018, we measured awareness and uptake of PrEP in a representative cohort of 2184 Adolescent Girls and Young Women (AGYW) aged 13-22. We conducted group discussions with young people and community members (19); key informant interviews (9), in-depth interviews with 15-24 year-olds (58) and providers (33). Interviews were analysed using thematic analysis. PrEP awareness increased from 2% to 9%. Among 965 AGYW sexually-active by 2018, 13.4% (95%CI: 11.4%-15.7%) reported transactional sex and 10.6% (95%CI: 8.85-12.7%) sex for money. Of the 194 YWSS, 21 were aware of PrEP, but none had used it. Youth were enthusiastic about PrEP as tool for HIV prevention; whilst older community members were cautious about a technology they had limited experience with but could benefit select groups. Teachers and healthcare providers were concerned that PrEP would lower personal responsibility for sexual health. In conclusion, the narrow and limited introduction of PrEP to YWSS reduced the accessibility and reach. Introducing PrEP as part of sexual healthcare may improve demand and access for YWSS.
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Affiliation(s)
- Natsayi Chimbindi
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa,,University College London, United Kingdom
| | | | - Thembelihle Zuma
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
| | - Kathy Baisley
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa,,London School of Hygiene & Tropical Medicine, United Kingdom
| | - Deenan Pillay
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa,,University College London, United Kingdom
| | - Nuala McGrath
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa,,University of Southampton, United Kingdom
| | - Guy Harling
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa,,University College London, United Kingdom,Harvard University, United States of America,University of the Witwatersrand, South Africa
| | | | | | - Sian Floyd
- London School of Hygiene & Tropical Medicine, United Kingdom
| | - Jaco Dreyer
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
| | | | - Janet Seeley
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa,,London School of Hygiene & Tropical Medicine, United Kingdom
| | - Maryam Shahmanesh
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa,,University College London, United Kingdom,Corresponding author: Maryam Shahmanesh, University College London (UCL) Institute for Global Health, Mortimer Market Centre off Capper Street, London, WC1E 6JB, United Kingdom. Phone number: +44 7776185572
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21
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Traore MM, Badiane K, Vautier A, Simo Fotso A, Kanku Kabemba O, Rouveau N, Maheu-Giroux M, Boily MC, Larmarange J, Terris-Prestholt F, d'Elbée M. Economic Analysis of Low Volume Interventions Using Real-World Data: Costs of HIV Self-Testing Distribution and HIV Testing Services in West Africa From the ATLAS Project. FRONTIERS IN HEALTH SERVICES 2022; 2:886513. [PMID: 36925821 PMCID: PMC10012764 DOI: 10.3389/frhs.2022.886513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/23/2022] [Indexed: 11/13/2022]
Abstract
Achieving the first 95 of the UNAIDS targets requires the implementation of innovative approaches to knowing one's HIV status. Among these innovations is the provision of HIV self-testing (HIVST) kits in west Africa by the international partner organization Solthis (IPO). In order to provide guidance for the optimal use of financial resources, this study aims to estimate the program and site level costs of dispensing HIVST as well as HIV testing services (HTS)-excluding HIVST-in health facilities in Côte d'Ivoire, Mali and Senegal as part of the ATLAS project. We estimated from the provider's perspective, HIVST and HTS incremental costs using top-down and bottom-up costing approaches and conducted a time and motion study. We identified costs at the program level for HIVST (including IPO central costs) and at the site level for HIVST and HTS. The economic costs of distributing HIVST kits were assessed in 37 health facilities between July 2019 and March 2021 (21 months). Sensitivity analyses were also performed on unit costs to examine the robustness of our estimates related to key assumptions. In total, 16,001 HIVST kits were dispensed for 32,194 HTS sessions carried out. Program level HIVST average costs ranged $12-286, whereas site level costs ranged $4-26 across distribution channels and countries. Site level HTS costs ranged $7-8 per testing session, and ranged $72-705 per HIV diagnosis. Across countries and channels, HIVST costs were driven by personnel (27-68%) and HIVST kits (32-73%) costs. The drivers of HTS costs were personnel costs ranging between 65 and 71% of total costs across distribution channels and countries, followed by supplies costs between 21 and 30%. While program level HIVST average costs were high, site level HIVST average costs remained comparable to HTS costs in all countries. Health facility-based distribution channels operating at low volume exhibit high proportion of central costs which should be considered carefully for financial planning when run alongside high volumes mobile outreach distribution channels. HIVST can diversify the HIV testing offer at health facilities, thus improving access to screening for target populations not reached by HTS services.
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Affiliation(s)
| | - Kéba Badiane
- Solidarité Thérapeutique et Initiative pour la Santé, Dakar, Senegal
| | - Anthony Vautier
- Solidarité Thérapeutique et Initiative pour la Santé, Dakar, Senegal
| | - Arlette Simo Fotso
- Centre Population et Développement (Ceped), Institut de Recherche pour le Développement (IRD), Université de Paris, Inserm, Paris, France
| | | | - Nicolas Rouveau
- Centre Population et Développement (Ceped), Institut de Recherche pour le Développement (IRD), Université de Paris, Inserm, Paris, France
| | - Mathieu Maheu-Giroux
- Department of Epidemiology, Biostatistics, and Occupational Health, School of Population and Global Health, McGill University, Montréal, QC, Canada
| | - Marie-Claude Boily
- Department of Infectious Disease Epidemiology, Medical Research Council Centre for Global Infectious Disease Analysis, Imperial College London, London, United Kingdom
| | - Joseph Larmarange
- Centre Population et Développement (Ceped), Institut de Recherche pour le Développement (IRD), Université de Paris, Inserm, Paris, France
| | - Fern Terris-Prestholt
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Marc d'Elbée
- Department of Global Health in the Global South, Bordeaux Population Health, Institut National de la Santé et de la Recherche Médicale (Inserm), University of Bordeaux, Bordeaux, France
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22
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Chirisa I, Mavhima B, Nyevera T, Chigudu A, Makochekanwa A, Matai J, Masunda T, Chandaengerwa EK, Machingura F, Moyo S, Chirisa H, Mhloyi M, Murwira A, Mhandara L, Katsande R, Muchena K, Manjeya E, Nyika T, Mundau L. The impact and implications of COVID-19: Reflections on the Zimbabwean society. ACTA ACUST UNITED AC 2021; 4:100183. [PMID: 34746754 PMCID: PMC8558728 DOI: 10.1016/j.ssaho.2021.100183] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/16/2021] [Accepted: 06/29/2021] [Indexed: 01/10/2023]
Abstract
The article is an attempt to provide a kaleidoscopic interpretation of how social science scholarship views the socio-cultural terrain of Zimbabwe during and after the global health crisis, and the societal and business haemorrhage induced by the coronavirus (COVID-19). Built through a multi-perspective and triangulation involving a modified Delphic approach that engages archival methods involving document and literature review, content analysis and expert interpretation; the article unveils the various effects of COVID-19 on Zimbabwe. It is concluded that COVID-19 by its nature is disruptive to everyday life, restrictive to human-social relations and is an instigator to tradition, spirituality and intellectuality in the country. The challenge of the virus brings to society a deliberate consciousness that global processes and events are converging (borders are porous) while local embeddedness is being entrenched through practices like lockdowns and confinement.
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Affiliation(s)
- Innocent Chirisa
- Department of Architecture and Real Estate, University of Zimbabwe, Zimbabwe.,Department of Urban and Regional Planning, University of the Free State, Zimbabwe
| | - Brilliant Mavhima
- Department of Architecture and Real Estate, University of Zimbabwe, Zimbabwe
| | - Tariro Nyevera
- Department of Architecture and Real Estate, University of Zimbabwe, Zimbabwe
| | - Andrew Chigudu
- Department of Architecture and Real Estate, University of Zimbabwe, Zimbabwe
| | | | - Joefrey Matai
- Department of Architecture and Real Estate, University of Zimbabwe, Zimbabwe
| | | | - Eve K Chandaengerwa
- Department of Community & Social Development, University of Zimbabwe, Zimbabwe
| | | | - Stanzia Moyo
- Demography Settlement and Development, University of Zimbabwe, Zimbabwe
| | - Halleluah Chirisa
- Population Services International & National AIDS Council Zimbabwe, Zimbabwe
| | - Marvellous Mhloyi
- Demography Settlement and Development, University of Zimbabwe, Zimbabwe
| | - Ashton Murwira
- Department of Governance and Public Management, University of Zimbabwe, Zimbabwe
| | - Lawrence Mhandara
- Department of Governance and Public Management, University of Zimbabwe, Zimbabwe
| | | | | | - Elton Manjeya
- Department of Architecture and Real Estate, University of Zimbabwe, Zimbabwe
| | - Teresa Nyika
- Department of Economics & Development, University of Zimbabwe, Zimbabwe
| | - Langton Mundau
- Department of Social Work, University of Zimbabwe, Zimbabwe
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23
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Sundararajan R, Ponticiello M, Lee MH, Strathdee SA, Muyindike W, Nansera D, King R, Fitzgerald D, Mwanga-Amumpaire J. Traditional healer-delivered point-of-care HIV testing versus referral to clinical facilities for adults of unknown serostatus in rural Uganda: a mixed-methods, cluster-randomised trial. Lancet Glob Health 2021; 9:e1579-e1588. [PMID: 34678199 PMCID: PMC8562591 DOI: 10.1016/s2214-109x(21)00366-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 07/27/2021] [Accepted: 08/03/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND HIV counselling and testing are essential to control the HIV epidemic. However, HIV testing uptake is low in sub-Saharan Africa, where many people use informal health-care resources such as traditional healers. We hypothesised that uptake of HIV tests would increase if provided by traditional healers. We aimed to determine the effectiveness of traditional healers delivering HIV testing at point of care compared with referral to local clinics for HIV testing in rural southwestern Uganda. METHODS We did a mixed-methods study that included a cluster-randomised trial followed by individual qualitative interviews among a sample of participants in Mbarara, Uganda. Traditional healers aged 18 years or older who were located within 8 km of the Mbarara District HIV clinic, were identified in the 2018 population-level census of traditional healers in Mbarara District, and delivered care to at least seven clients per week were randomly assigned (1:1) as clusters to an intervention or a control group. Healers screened their clients for eligibility, and research assistants confirmed eligibility and enrolled clients who were aged 18 years or older, were receiving care from a participating healer, were sexually active (ever had intercourse), self-reported not having received an HIV test in the previous 12 months (and therefore considered to be of unknown serostatus), and had not previously been diagnosed with HIV infection. Intervention group healers provided counselling and offered point-of-care HIV tests to adult clients. Control group healers provided referral for HIV testing at nearby clinics. The primary outcome was the individual receipt of an HIV test within 90 days of study enrolment. Safety and adverse events were recorded and defined on the basis of prespecified criteria. This study is registered with ClinicalTrials.gov, NCT03718871. FINDINGS Between Aug 2, 2019, and Feb 7, 2020, 17 traditional healers were randomly assigned as clusters (nine to intervention and eight to control), with 500 clients of unknown HIV serostatus enrolled (250 per group). In the intervention group, 250 clients (100%) received an HIV test compared with 57 (23%) in the control group, a 77% (95% CI 73-82) increase in testing uptake, after adjusting for the effect of clustering (p<0·0001). Ten (4%) of 250 clients in the intervention group tested HIV positive, seven of whom self-reported linkage to HIV care. No new HIV cases were identified in the control group. Qualitative interviews revealed that HIV testing delivered by traditional healers was highly acceptable among both providers and clients. No safety or adverse events were reported. INTERPRETATION Delivery of point-of-care HIV tests by traditional healers to adults of unknown serostatus significantly increased rates of HIV testing in rural Uganda. Given the ubiquity of healers in Africa, this approach holds promise as a new pathway to provide community-based HIV testing, and could have a dramatic effect on uptake of HIV testing in sub-Saharan Africa. FUNDING US National Institute of Mental Health, National Institutes of Health.
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Affiliation(s)
- Radhika Sundararajan
- Department of Emergency Medicine, Weill Cornell Medicine, New York, NY, USA; Center for Global Health, Weill Cornell Medicine, New York, NY, USA.
| | | | - Myung Hee Lee
- Center for Global Health, Weill Cornell Medicine, New York, NY, USA
| | | | - Winnie Muyindike
- Mbarara Regional Referral Hospital, Mbarara, Uganda; Mbarara University of Science and Technology, Mbarara, Uganda
| | - Denis Nansera
- Mbarara Regional Referral Hospital, Mbarara, Uganda; Mbarara University of Science and Technology, Mbarara, Uganda
| | - Rachel King
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, USA
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24
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Nagai H, Tagoe H, Tun W, Adiibokah E, Ankomah A, Rahman YAA, Addo SA, Atuahene SK, Essandoh E, Kowalski M. Perspectives of Policymakers on the Introduction and Scale-Up of HIV Self-Testing and Implication for National HIV Programming in Ghana. Front Public Health 2021; 9:694836. [PMID: 34621716 PMCID: PMC8490658 DOI: 10.3389/fpubh.2021.694836] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/02/2021] [Indexed: 11/21/2022] Open
Abstract
Background: HIV self-testing (HIVST) has the potential to greatly increase HIV testing uptake, particularly among key populations (KPs) at higher risk for HIV. Studies have shown high acceptability and feasibility of HIVST among various target populations globally. However, less is known about the perspectives of policymakers, who are critical to the success of HIVST implementation. Their views on barriers to the introduction and scale-up of self-testing are critical to understand in order for HIVST to become part of the national HIV guidelines. We sought to understand policymakers' perspectives of challenges and facilitators to the introduction of HIVST at the client and structural levels. Method: Key informant interviews (KIIs) were conducted with national and regional level policymakers involved in the HIV response. Twenty policymakers were purposively selected from Greater Accra (capital) and Brong-Ahafo (outlying) regions. Qualitative content analysis was used to arrive at the results after the verbatim transcripts were coded. Results: Client-level challenges included lack of pre-test counseling, the need for confirmatory testing if reactive, potential for poor linkage to care and treatment, and client-level facilitator from policy makers' perspectives included increase testing modality that would increase testing uptake. Structural-level challenges mentioned by policymakers were lack of a national policy and implementation guidelines on HIVST, cost of HIVST kits, supply chain management of HIVST commodities, data monitoring and reporting of positive cases. The structural-level appeal of HIVST to policymakers were the reduced burden on health system and HIVST's contribution to achieving testing targets. Despite the challenges mentioned, policymakers unanimously favored and called for the introduction of HIVST in Ghana. Conclusions: Findings indicate that a non-conventional HIV testing strategy such as HIVST is highly acceptable to policymakers. However, successful introduction of HIVST hinges on having national guidelines in place and stakeholder consultations to address various individual and structural -level implementation issues.
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Affiliation(s)
- Henry Nagai
- JSI Research and Training Institute, Inc., Accra, Ghana
| | | | - Waimar Tun
- Population Council, Washington, DC, United States
| | | | | | | | | | | | | | - Mark Kowalski
- JSI Research and Training Institute, Inc., Washington, DC, United States
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25
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Pai N, Esmail A, Saha Chaudhuri P, Oelofse S, Pretorius M, Marathe G, Daher J, Smallwood M, Karatzas N, Fadul M, de Waal A, Engel N, Zwerling AA, Dheda K. Impact of a personalised, digital, HIV self-testing app-based program on linkages and new infections in the township populations of South Africa. BMJ Glob Health 2021; 6:bmjgh-2021-006032. [PMID: 34475026 PMCID: PMC8413877 DOI: 10.1136/bmjgh-2021-006032] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 08/15/2021] [Indexed: 11/08/2022] Open
Abstract
Introduction Implementation data for digital unsupervised HIV self-testing (HIVST) are sparse. We evaluated the impact of an app-based, personalised, oral HIVST program offered by healthcare workers in Western Cape, South Africa. Methods In a quasirandomised study (n=3095), we recruited consenting adults with undiagnosed HIV infection from township clinics. To the HIVST arm participants (n=1535), we offered a choice of an offsite (home, office or kiosk based), unsupervised digital HIVST program (n=962), or an onsite, clinic-based, supervised digital HIVST program (n=573) with 24/7 linkages services. With propensity score analyses, we compared outcomes (ie, linkages, new HIV infections and test referrals) with conventional HIV testing (ConvHT) arm participants (n=1560), recruited randomly from geographically separated clinics. Results In both arms, participants were young (HIVST vs ConvHT) (mean age: 28.2 years vs 29.2 years), female (65.0% vs 76.0%) and had monthly income <3000 rand (80.8% vs 75%). Participants chose unsupervised HIVST (62.7%) versus supervised HIVST and reported multiple sex partners (10.88% vs 8.7%), exposure to sex workers (1.4% vs 0.2%) and fewer comorbidities (0.9% vs 1.9%). Almost all HIVST participants were linked (unsupervised HIVST (99.7%), supervised HIVST (99.8%) vs ConvHT (98.5%)) (adj RR 1.012; 95% CI 1.005 to 1.018) with new HIV infections: overall HIVST (9%); supervised HIVST (10.9%) and unsupervised HIVST (7.6%) versus ConvHT (6.79%) (adj RR 1.305; 95% CI 1.023 to 1.665); test referrals: 16.7% HIVST versus 3.1% ConvHT (adj RR 5.435; 95% CI 4.024 to 7.340). Conclusions Our flexible, personalised, app-based HIVST program, offered by healthcare workers, successfully linked almost all HIV self-testers, detected new infections and increased referrals to self-test. Data are relevant for digital HIVST initiatives worldwide.
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Affiliation(s)
- Nitika Pai
- Department of Medicine, McGill University, Montreal, Québec, Canada .,Research Institute of McGill University, Montreal, Québec, Canada
| | - Aliasgar Esmail
- South African MRC Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa.,Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Paramita Saha Chaudhuri
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Québec, Canada
| | - Suzette Oelofse
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Marietjie Pretorius
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Gayatri Marathe
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Québec, Canada
| | - Jana Daher
- Research Institute of McGill University, Montreal, Québec, Canada
| | - Megan Smallwood
- Research Institute of McGill University, Montreal, Québec, Canada.,Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Québec, Canada
| | - Nicolaos Karatzas
- Department of Experimental Medicine, McGill University, Montreal, Québec, Canada
| | - Mohammed Fadul
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Anna de Waal
- Research Institute of McGill University, Montreal, Québec, Canada.,Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Québec, Canada
| | - Nora Engel
- Department of Health, Ethics & Society/CAPHRI, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Alice Anne Zwerling
- School of Epidemiology & Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Keertan Dheda
- South African MRC Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa.,Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Cape Town, Cape Town, South Africa.,Faculty of Infectious and Tropical Diseases, Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, UK
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Jamieson L, Johnson LF, Matsimela K, Sande LA, d'Elbée M, Majam M, Johnson C, Chidarikire T, Hatzold K, Terris-Prestholt F, Nichols B, Meyer-Rath G. The cost effectiveness and optimal configuration of HIV self-test distribution in South Africa: a model analysis. BMJ Glob Health 2021; 6:bmjgh-2021-005598. [PMID: 34275876 PMCID: PMC8287627 DOI: 10.1136/bmjgh-2021-005598] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/24/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND HIV self-testing (HIVST) has been shown to be acceptable, feasible and effective in increasing HIV testing uptake. Novel testing strategies are critical to achieving the UNAIDS target of 95% HIV-positive diagnosis by 2025 in South Africa and globally. METHODS We modelled the impact of six HIVST kit distribution modalities (community fixed-point, taxi ranks, workplace, partners of primary healthcare (PHC) antiretroviral therapy (ART) patients), partners of pregnant women, primary PHC distribution) in South Africa over 20 years (2020-2039), using data collected alongside the Self-Testing AfRica Initiative. We modelled two annual distribution scenarios: (A) 1 million HIVST kits (current) or (B) up to 6.7 million kits. Incremental economic costs (2019 US$) were estimated from the provider perspective; assumptions on uptake and screening positivity were based on surveys of a subset of kit recipients and modelled using the Thembisa model. Cost-effectiveness of each distribution modality compared with the status-quo distribution configuration was estimated as cost per life year saved (estimated from life years lost due to AIDS) and optimised using a fractional factorial design. RESULTS The largest impact resulted from secondary HIVST distribution to partners of ART patients at PHC (life years saved (LYS): 119 000 (scenario A); 393 000 (scenario B)). However, it was one of the least cost-effective modalities (A: $1394/LYS; B: $4162/LYS). Workplace distribution was cost-saving ($52-$76 million) and predicted to have a moderate epidemic impact (A: 40 000 LYS; B: 156 000 LYS). An optimised scale-up to 6.7 million tests would result in an almost threefold increase in LYS compared with a scale-up of status-quo distribution (216 000 vs 75 000 LYS). CONCLUSION Optimisation-informed distribution has the potential to vastly improve the impact of HIVST. Using this approach, HIVST can play a key role in improving the long-term health impact of investment in HIVST.
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Affiliation(s)
- Lise Jamieson
- Department of Internal Medicine, Health Economics and Epidemiology Research Office, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, Gauteng, South Africa
| | - Leigh F Johnson
- Centre of Infectious Disease Epidemiology and Research (CIDER), University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Katleho Matsimela
- Department of Internal Medicine, Health Economics and Epidemiology Research Office, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, Gauteng, South Africa
| | - Linda Alinafe Sande
- Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Marc d'Elbée
- Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Mohammed Majam
- Ezintsha, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | - Cheryl Johnson
- Global HIV, Hepatitis, STI programmes, World Health Organization, Geneve, Switzerland
| | - Thato Chidarikire
- HIV Prevention Programmes, National Department of Health, Pretoria, South Africa, Pretoria, South Africa
| | - Karin Hatzold
- Population Services International, Johannesburg, South Africa
| | - Fern Terris-Prestholt
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneve, Switzerland
| | - Brooke Nichols
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, USA.,Department of Medical Microbiology, Amsterdam University Medical Centres, Duivendrecht, Noord-Holland, The Netherlands
| | - Gesine Meyer-Rath
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, USA.,Department of Internal Medicine, Health Economics and Epidemiology Research Office, University of the Witwatersrand School of Clinical Medicine, Johannesburg, Gauteng, South Africa
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Duarte A, Walker S, Metry A, Wong R, Panovska-Griffiths J, Sculpher M. Jointly Modelling Economics and Epidemiology to Support Public Policy Decisions for the COVID-19 Response: A Review of UK Studies. PHARMACOECONOMICS 2021; 39:879-887. [PMID: 34145525 PMCID: PMC8213532 DOI: 10.1007/s40273-021-01045-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 05/07/2023]
Abstract
COVID-19 in the UK has had a profound impact on population health and other socially important outcomes, including on education and the economy. Although a range of evidence has guided policy, epidemiological models have been central. It is less clear whether models to support decision making have sought to integrate COVID-19 epidemiology with a consideration of broader health, wellbeing and economic implications. We report on a rapid review of studies seeking to integrate epidemiological and economic modelling to assess the impacts of alternative policies. Overall, our results suggest that few studies have explored broader impacts of different COVID-19 policies in the UK. Three studies looked only at health, capturing impacts on individuals with and without COVID-19, with various methods used to model the latter. Four models considered health and wider impacts on individuals' economic outcomes, such as wages. However, these models made no attempt to consider the dynamic impacts on economic outcomes of others and the wider economy. The most complex analyses sought to link epidemiological and dynamic economic models. Studies compared a wide range of policies, although most were defined in general terms with minimal consideration of their granular specifications. There was minimal exploration of uncertainty, with no consideration in half the studies. Selecting appropriate models to inform decisions requires careful thought of factors relevant to the decision options under consideration such as the outcomes of interest, sectors likely to be impacted and causal pathways. In summary, better linking epidemiological and economic modelling would help to inform COVID-19 policy.
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Affiliation(s)
- Ana Duarte
- Centre for Health Economics, University of York, York, UK.
| | - Simon Walker
- Centre for Health Economics, University of York, York, UK
| | - Andrew Metry
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ruth Wong
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Jasmina Panovska-Griffiths
- Department of Applied Health Research and Institute for Global Health, University College London, London, UK
- Wolfson Centre for Mathematical Biology and The Queen's College, University of Oxford, Oxford, UK
| | - Mark Sculpher
- Centre for Health Economics, University of York, York, UK
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28
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Gupta-Wright A, Barnabas RV, Ingold H, Duneton P, Abubakar I. HIV self-testing: lessons learnt and priorities for adaptation in a shifting landscape. BMJ Glob Health 2021; 6:bmjgh-2020-004418. [PMID: 34275867 PMCID: PMC8287622 DOI: 10.1136/bmjgh-2020-004418] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/02/2021] [Accepted: 02/04/2021] [Indexed: 01/17/2023] Open
Affiliation(s)
- Ankur Gupta-Wright
- Institute for Global Health, University College London, London, UK .,Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Ruanne V Barnabas
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | | | | | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK
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Indravudh PP, Fielding K, Sande LA, Maheswaran H, Mphande S, Kumwenda MK, Chilongosi R, Nyirenda R, Johnson CC, Hatzold K, Corbett EL, Terris-Prestholt F. Pragmatic economic evaluation of community-led delivery of HIV self-testing in Malawi. BMJ Glob Health 2021; 6:e004593. [PMID: 34275869 PMCID: PMC8287609 DOI: 10.1136/bmjgh-2020-004593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/27/2021] [Accepted: 04/16/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Community-based strategies can extend coverage of HIV testing and diagnose HIV at earlier stages of infection but can be costly to implement. We evaluated the costs and effects of community-led delivery of HIV self-testing (HIVST) in Mangochi District, Malawi. METHODS This economic evaluation was based within a pragmatic cluster-randomised trial of 30 group village heads and their catchment areas comparing the community-led HIVST intervention in addition to the standard of care (SOC) versus the SOC alone. The intervention involved mobilising community health groups to lead 7-day HIVST campaigns including distribution of HIVST kits. The SOC included facility-based HIV testing services. Primary costings estimated economic costs of the intervention and SOC from the provider perspective, with costs annualised and measured in 2018 US$. A postintervention survey captured individual-level data on HIV testing events, which were combined with unit costs from primary costings, and outcomes. The incremental cost per person tested HIV-positive and associated uncertainty were estimated. RESULTS Overall, the community-led HIVST intervention costed $138 624 or $5.70 per HIVST kit distributed, with test kits and personnel the main contributing costs. The SOC costed $263 400 or $4.57 per person tested. Individual-level provider costs were higher in the community-led HIVST arm than the SOC arm (adjusted mean difference $3.77, 95% CI $2.44 to $5.10; p<0.001), while the intervention effect on HIV positivity varied based on adjustment for previous diagnosis. The incremental cost per person tested HIV positive was $324 but increased to $1312 and $985 when adjusting for previously diagnosed self-testers or self-testers on treatment, respectively. Community-led HIVST demonstrated low probability of being cost-effective against plausible willingness-to-pay values, with HIV positivity a key determinant. CONCLUSION Community-led HIVST can provide HIV testing at a low additional unit cost. However, adding community-led HIVST to the SOC was not likely to be cost-effective, especially in contexts with low prevalence of undiagnosed HIV. TRIAL REGISTRATION NUMBER NCT03541382.
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Affiliation(s)
- Pitchaya P Indravudh
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Linda A Sande
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Saviour Mphande
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Moses K Kumwenda
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Rose Nyirenda
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Cheryl C Johnson
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, WHO, Geneva, Switzerland
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Karin Hatzold
- Population Services International, Washington, DC, USA
| | - Elizabeth L Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Fern Terris-Prestholt
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
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Indravudh PP, Fielding K, Chilongosi R, Nzawa R, Neuman M, Kumwenda MK, Nyirenda R, Johnson CC, Taegtmeyer M, Desmond N, Hatzold K, Corbett EL. Effect of door-to-door distribution of HIV self-testing kits on HIV testing and antiretroviral therapy initiation: a cluster randomised trial in Malawi. BMJ Glob Health 2021; 6:bmjgh-2020-004269. [PMID: 34275866 PMCID: PMC8287599 DOI: 10.1136/bmjgh-2020-004269] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/19/2021] [Accepted: 02/10/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Reaching high coverage of HIV testing remains essential for HIV diagnosis, treatment and prevention. We evaluated the effectiveness and safety of door-to-door distribution of HIV self-testing (HIVST) kits in rural Malawi. METHODS This cluster randomised trial, conducted between September 2016 and January 2018, used restricted 1:1 randomisation to allocate 22 health facilities and their defined areas to door-to-door HIVST alongside the standard of care (SOC) or the SOC alone. The study population included residents (≥16 years). HIVST kits were provided door-to-door by community-based distribution agents (CBDAs) for at least 12 months. The primary outcome was recent HIV testing (in the last 12 months) measured through an endline survey. Secondary outcomes were lifetime HIV testing and cumulative 16-month antiretroviral therapy (ART) initiations, which were captured at health facilities. Social harms were reported through community reporting systems. Analysis compared cluster-level outcomes by arm. RESULTS Overall, 203 CBDAs distributed 273 729 HIVST kits. The endline survey included 2582 participants in 11 HIVST clusters and 2908 participants in 11 SOC clusters. Recent testing was higher in the HIVST arm (68.5%, 1768/2582) than the SOC arm (48.9%, 1422/2908), with adjusted risk difference (RD) of 16.1% (95% CI 6.5% to 25.7%). Lifetime testing was also higher in the HIVST arm (86.9%, 2243/2582) compared with the SOC arm (78.5%, 2283/2908; adjusted RD 6.3%, 95% CI 2.3% to 10.3%). Differences were most pronounced for adolescents aged 16-19 years (adjusted RD 18.6%, 95% CI 7.3% to 29.9%) and men (adjusted RD 10.2%, 95% CI 3.1% to 17.2%). Cumulative incidence of ART initiation was 1187.2 and 909.0 per 100 000 population in the HIVST and SOC arms, respectively (adjusted RD 309.1, 95% CI -95.5 to 713.7). Self-reported HIVST use was 42.5% (1097/2582), with minimal social harms reported. CONCLUSION Door-to-door HIVST increased recent and lifetime testing at population level and showed high safety, underscoring potential for HIVST to contribute to HIV elimination goals in priority settings. TRIAL REGISTRATION NUMBER NCT02718274.
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Affiliation(s)
- Pitchaya P Indravudh
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK .,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.,School of Public Health, University of the Witwatersrand, Johannesburg-Braamfontein, Gauteng, South Africa
| | | | - Rebecca Nzawa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Melissa Neuman
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Moses K Kumwenda
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Rose Nyirenda
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Cheryl C Johnson
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneve, Switzerland.,Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.,Tropical Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Nicola Desmond
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Karin Hatzold
- Population Services International, Washington, DC, USA
| | - Elizabeth L Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
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Pai NP, Thomas R. Time for HIV self-testing in Canada: a vision and an action plan. CMAJ 2021; 192:E1367-E1368. [PMID: 33139426 DOI: 10.1503/cmaj.201160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Nitika Pant Pai
- Department of Medicine (Pant Pai), McGill University; Research Institute of the McGill University Health Centre (Pant Pai); Clinique médicale l'Actuel (Thomas), Montréal, Que.
| | - Réjean Thomas
- Department of Medicine (Pant Pai), McGill University; Research Institute of the McGill University Health Centre (Pant Pai); Clinique médicale l'Actuel (Thomas), Montréal, Que
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d'Elbée M, Traore MM, Badiane K, Vautier A, Simo Fotso A, Kabemba OK, Rouveau N, Godfrey-Faussett P, Maheu-Giroux M, Boily MC, Medley GF, Larmarange J, Terris-Prestholt F. Costs and Scale-Up Costs of Integrating HIV Self-Testing Into Civil Society Organisation-Led Programmes for Key Populations in Côte d'Ivoire, Senegal, and Mali. Front Public Health 2021; 9:653612. [PMID: 34109146 PMCID: PMC8182047 DOI: 10.3389/fpubh.2021.653612] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/26/2021] [Indexed: 11/13/2022] Open
Abstract
Despite significant progress on the proportion of individuals who know their HIV status in 2020, Côte d'Ivoire (76%), Senegal (78%), and Mali (48%) remain far below, and key populations (KP) including female sex workers (FSW), men who have sex with men (MSM), and people who use drugs (PWUD) are the most vulnerable groups with a HIV prevalence at 5-30%. HIV self-testing (HIVST), a process where a person collects his/her own specimen, performs a test, and interprets the result, was introduced in 2019 as a new testing modality through the ATLAS project coordinated by the international partner organisation Solthis (IPO). We estimate the costs of implementing HIVST through 23 civil society organisations (CSO)-led models for KP in Côte d'Ivoire (N = 7), Senegal (N = 11), and Mali (N = 5). We modelled costs for programme transition (2021) and early scale-up (2022-2023). Between July 2019 and September 2020, a total of 51,028, 14,472, and 34,353 HIVST kits were distributed in Côte d'Ivoire, Senegal, and Mali, respectively. Across countries, 64-80% of HIVST kits were distributed to FSW, 20-31% to MSM, and 5-8% to PWUD. Average costs per HIVST kit distributed were $15 for FSW (Côte d'Ivoire: $13, Senegal: $17, Mali: $16), $23 for MSM (Côte d'Ivoire: $15, Senegal: $27, Mali: $28), and $80 for PWUD (Côte d'Ivoire: $16, Senegal: $144), driven by personnel costs (47-78% of total costs), and HIVST kits costs (2-20%). Average costs at scale-up were $11 for FSW (Côte d'Ivoire: $9, Senegal: $13, Mali: $10), $16 for MSM (Côte d'Ivoire: $9, Senegal: $23, Mali: $17), and $32 for PWUD (Côte d'Ivoire: $14, Senegal: $50). Cost reductions were mainly explained by the spreading of IPO costs over higher HIVST distribution volumes and progressive IPO withdrawal at scale-up. In all countries, CSO-led HIVST kit provision to KP showed relatively high costs during the study period related to the progressive integration of the programme to CSO activities and contextual challenges (COVID-19 pandemic, country safety concerns). In transition to scale-up and integration of the HIVST programme into CSO activities, this model shows large potential for substantial economies of scale. Further research will assess the overall cost-effectiveness of this model.
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Affiliation(s)
- Marc d'Elbée
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | - Arlette Simo Fotso
- Centre Population et Développement (Ceped UMR 196), Institut de Recherche pour le Développement (IRD), Université de Paris, Inserm (ERL 1244), Paris, France
| | | | - Nicolas Rouveau
- Centre Population et Développement (Ceped UMR 196), Institut de Recherche pour le Développement (IRD), Université de Paris, Inserm (ERL 1244), Paris, France
| | - Peter Godfrey-Faussett
- Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mathieu Maheu-Giroux
- Department of Epidemiology, Biostatistics, and Occupational Health, School of Population and Global Health, McGill University, Montréal, QC, Canada
| | - Marie-Claude Boily
- Department of Infectious Disease Epidemiology, Medical Research Council Centre for Global Infectious Disease Analysis, Imperial College London, London, United Kingdom
| | - Graham Francis Medley
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Joseph Larmarange
- Centre Population et Développement (Ceped UMR 196), Institut de Recherche pour le Développement (IRD), Université de Paris, Inserm (ERL 1244), Paris, France
| | - Fern Terris-Prestholt
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
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Rivera AS, Hernandez R, Mag-Usara R, Sy KN, Ulitin AR, O'Dwyer LC, McHugh MC, Jordan N, Hirschhorn LR. Implementation outcomes of HIV self-testing in low- and middle- income countries: A scoping review. PLoS One 2021; 16:e0250434. [PMID: 33939722 PMCID: PMC8092786 DOI: 10.1371/journal.pone.0250434] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/07/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION HIV self-testing (HIV-ST) is an effective means of improving HIV testing rates. Low- and middle-income countries (LMIC) are taking steps to include HIV-ST into their national HIV/AIDS programs but very few reviews have focused on implementation in LMIC. We performed a scoping review to describe and synthesize existing literature on implementation outcomes of HIV-ST in LMIC. METHODS We conducted a systematic search of Medline, Embase, Global Health, Web of Science, and Scopus, supplemented by searches in HIVST.org and other grey literature databases (done 23 September 2020) and included articles if they reported at least one of the following eight implementation outcomes: acceptability, appropriateness, adoption, feasibility, fidelity, cost, penetration, or sustainability. Both quantitative and qualitative results were extracted and synthesized in a narrative manner. RESULTS AND DISCUSSION Most (75%) of the 206 included articles focused on implementation in Africa. HIV-ST was found to be acceptable and appropriate, perceived to be convenient and better at maintaining confidentiality than standard testing. The lack of counselling and linkage to care, however, was concerning to stakeholders. Peer and online distribution were found to be effective in improving adoption. The high occurrence of user errors was a common feasibility issue reported by studies, although, diagnostic accuracy remained high. HIV-ST was associated with higher program costs but can still be cost-effective if kit prices remain low and HIV detection improves. Implementation fidelity was not always reported and there were very few studies on, penetration, and sustainability. CONCLUSIONS Evidence supports the acceptability, appropriateness, and feasibility of HIV-ST in the LMIC context. Costs and user error rates are threats to successful implementation. Future research should address equity through measuring penetration and potential barriers to sustainability including distribution, cost, scale-up, and safety.
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Affiliation(s)
- Adovich S Rivera
- Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Ralph Hernandez
- College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Regiel Mag-Usara
- College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Karen Nicole Sy
- College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Allan R Ulitin
- Institute of Health Policy and Development Studies, National Institutes for Health, Manila, Philippines
| | - Linda C O'Dwyer
- Galter Health Sciences Library & Learning Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Megan C McHugh
- Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Neil Jordan
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, Illinois, United States of America
| | - Lisa R Hirschhorn
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
- Institute of Global Health, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
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Indravudh PP, Fielding K, Kumwenda MK, Nzawa R, Chilongosi R, Desmond N, Nyirenda R, Neuman M, Johnson CC, Baggaley R, Hatzold K, Terris-Prestholt F, Corbett EL. Effect of community-led delivery of HIV self-testing on HIV testing and antiretroviral therapy initiation in Malawi: A cluster-randomised trial. PLoS Med 2021; 18:e1003608. [PMID: 33974621 PMCID: PMC8112698 DOI: 10.1371/journal.pmed.1003608] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 04/04/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Undiagnosed HIV infection remains substantial in key population subgroups including adolescents, older adults, and men, driving ongoing transmission in sub-Saharan Africa. We evaluated the impact, safety, and costs of community-led delivery of HIV self-testing (HIVST), aiming to increase HIV testing in underserved subgroups and stimulate demand for antiretroviral therapy (ART). METHODS AND FINDINGS This cluster-randomised trial, conducted between October 2018 and July 2019, used restricted randomisation (1:1) to allocate 30 group village head clusters in Mangochi district, Malawi to the community-led HIVST intervention in addition to the standard of care (SOC) or the SOC alone. The intervention involved mobilising community health groups to lead the design and implementation of 7-day HIVST campaigns, with cluster residents (≥15 years) eligible for HIVST. The primary outcome compared lifetime HIV testing among adolescents (15 to 19 years) between arms. Secondary outcomes compared: recent HIV testing (in the last 3 months) among older adults (≥40 years) and men; cumulative 6-month incidence of ART initiation per 100,000 population; knowledge of the preventive benefits of HIV treatment; and HIV testing stigma. Outcomes were measured through a post-intervention survey and at neighboring health facilities. Analysis used intention-to-treat for cluster-level outcomes. Community health groups delivered 24,316 oral fluid-based HIVST kits. The survey included 90.2% (3,960/4,388) of listed participants in the 15 community-led HIVST clusters and 89.2% (3,920/4,394) of listed participants in the 15 SOC clusters. Overall, the proportion of men was 39.0% (3,072/7,880). Most participants obtained primary-level education or below, were married, and reported a sexual partner. Lifetime HIV testing among adolescents was higher in the community-led HIVST arm (84.6%, 770/910) than the SOC arm (67.1%, 582/867; adjusted risk difference [RD] 15.2%, 95% CI 7.5% to 22.9%; p < 0.001), especially among 15 to 17 year olds and boys. Recent testing among older adults was also higher in the community-led HIVST arm (74.5%, 869/1,166) than the SOC arm (31.5%, 350/1,111; adjusted RD 42.1%, 95% CI 34.9% to 49.4%; p < 0.001). Similarly, the proportions of recently tested men were 74.6% (1,177/1,577) and 33.9% (507/1,495) in the community-led HIVST and SOC arms, respectively (adjusted RD 40.2%, 95% CI 32.9% to 47.4%; p < 0.001). Knowledge of HIV treatment benefits and HIV testing stigma showed no differences between arms. Cumulative incidence of ART initiation was respectively 305.3 and 226.1 per 100,000 population in the community-led HIVST and SOC arms (RD 72.3, 95% CI -36.2 to 180.8; p = 0.18). In post hoc analysis, ART initiations in the 3-month post-intervention period were higher in the community-led HIVST arm than the SOC arm (RD 97.7, 95% CI 33.4 to 162.1; p = 0.004). HIVST uptake was 74.7% (2,956/3,960), with few adverse events (0.6%, 18/2,955) and at US$5.70 per HIVST kit distributed. The main limitations include the use of self-reported HIV testing outcomes and lack of baseline measurement for the primary outcome. CONCLUSIONS In this study, we found that community-led HIVST was effective, safe, and affordable, with population impact and coverage rapidly realised at low cost. This approach could enable community HIV testing in high HIV prevalence settings and demonstrates potential for economies of scale and scope. TRIAL REGISTRATION Clinicaltrials.gov NCT03541382.
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Affiliation(s)
- Pitchaya P. Indravudh
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Moses K. Kumwenda
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Rebecca Nzawa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Nicola Desmond
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Rose Nyirenda
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Melissa Neuman
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Cheryl C. Johnson
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organisation, Geneva, Switzerland
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Rachel Baggaley
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organisation, Geneva, Switzerland
| | - Karin Hatzold
- Population Services International, Washington, District of Columbia, United States of America
| | - Fern Terris-Prestholt
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Elizabeth L. Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Chamie G, Napierala S, Agot K, Thirumurthy H. HIV testing approaches to reach the first UNAIDS 95% target in sub-Saharan Africa. Lancet HIV 2021; 8:e225-e236. [PMID: 33794183 DOI: 10.1016/s2352-3018(21)00023-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/20/2021] [Accepted: 01/26/2021] [Indexed: 02/06/2023]
Abstract
HIV testing is a crucial first step to accessing HIV prevention and treatment services and to achieving the UNAIDS target of 95% of people living with HIV being aware of their status by 2030. Combined implementation of facility-based and community-based approaches has helped to achieve high levels of HIV testing coverage in many countries including those in sub-Saharan Africa. Approaches such as index testing and self-testing help to reach individuals at higher risk of acquiring HIV, men, and those less likely to use health facilities or community-based services. However, as the proportion of people living with HIV who are aware of their HIV status has risen, the challenge of reaching those who remain undiagnosed or those who are at high risk of acquiring HIV has grown. Demand generation and novel testing approaches will be necessary to reach undiagnosed people living with HIV and to promote frequent retesting among key and priority populations.
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Affiliation(s)
- Gabriel Chamie
- Division of HIV, Infectious Diseases & Global Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Sue Napierala
- RTI International, Women's Global Health Imperative, Berkeley, CA, USA
| | - Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
| | - Harsha Thirumurthy
- Perelman School of Medicine and Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
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Hamilton A, Thompson N, Choko AT, Hlongwa M, Jolly P, Korte JE, Conserve DF. HIV Self-Testing Uptake and Intervention Strategies Among Men in Sub-Saharan Africa: A Systematic Review. Front Public Health 2021; 9:594298. [PMID: 33681120 PMCID: PMC7933016 DOI: 10.3389/fpubh.2021.594298] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/18/2021] [Indexed: 12/16/2022] Open
Abstract
Background: HIV testing is an essential gateway to HIV prevention and treatment services. However, HIV testing uptake remains low among men due to stigma, discrimination, and confidentiality concerns. HIV self-testing (HIVST) is an alternative HIV testing method that can address many of these barriers for men. We conducted a systematic review to examine HIVST uptake and intervention strategies among Men in Sub-Saharan Africa. Methods: We used a systematic approach to survey literature published from January 2010 to June 2020 using five electronic databases (PubMed-Medline, CINAHL Complete, PsychINFO, Google Scholar, and Web of Science) and a manual search. Studies were included if they were peer-reviewed, published in English, and examined HIVST willingness, uptake, and/or linkage to care and included men in Sub-Saharan Africa. Results: Sixty-three articles related to HIVST were reviewed. Of the included articles, 37 discussed HIVST uptake/acceptability and 24 discussed intervention strategies. Both oral swab and finger-prick methods had high acceptability with ease of access and availability of the test cited as important by men. Free HIVST kits were preferred by men. Secondary distribution of kits via peers, sexual partners, and female sex workers were successful. Conclusion: HIV self-testing is highly acceptable to men. More efforts are needed to develop policies to implement HIVST programs targeting men in Sub-Saharan Africa, including a focus on linkage to care in sub-Saharan Africa. Future interventions should directly target men independently in tandem with using peers and their romantic partners to promote self-testing among men in sub-Saharan Africa. HIVST kit distribution strategies should be combined with services that can offer confirmatory tests and counseling for men as well as linkage to care.
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Affiliation(s)
- Akeen Hamilton
- Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, SC, United States
| | - Noah Thompson
- Department of Biological Sciences, University of South Carolina, Columbia, SC, United States
| | - Augustine T Choko
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Mbuzeleni Hlongwa
- Discipline of Public Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Pauline Jolly
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Jeffrey E Korte
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Donaldson F Conserve
- Department of Prevention and Community Health, The George Washington University, Washington, DC, United States
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Broderick K, Ponticiello M, Nabukalu D, Tushemereirwe P, Nuwagaba G, King R, Mwanga-Amumpaire J, Sundararajan R. Shortening "the Road" to Improve Engagement with HIV Testing Resources: A Qualitative Study Among Stakeholders in Rural Uganda. AIDS Patient Care STDS 2021; 35:56-62. [PMID: 33471578 PMCID: PMC7885900 DOI: 10.1089/apc.2020.0235] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In HIV-endemic areas, traditional healers are frequently used with, or instead of, biomedical resources for health care needs. Studies show healers are interested in and capable of supporting patients in the HIV care cascade. However, adults who receive care from healers have low engagement with HIV services. To achieve epidemic control, we must understand gaps between the needs of HIV-endemic communities and the potential for healers to improve HIV service uptake. This study's objective was to characterize stakeholder perspectives on barriers to HIV testing and approaches to mitigate barriers in a medically pluralistic, HIV-endemic region. This study was conducted in Mbarara District, a rural area of southwestern Uganda with high HIV prevalence. Participants included HIV clinical staff, traditional healers, and adults receiving care from healers. Fifty-six participants [N = 30 females (52%), median age 40 years (interquartile range, 32-51.5)] were recruited across three stakeholder groups for minimally structured interviews. Themes were identified using an inductive, grounded theory approach and linked together to create a framework explaining stakeholder perspectives on HIV testing. Stakeholders described the "road" to HIV testing as time-consuming, expensive, and stigmatizing. All agreed healers could mitigate barriers by delivering HIV testing at their practices. Collaborations between biomedical and traditional providers were considered essential to a successful healer-delivered HIV testing program. This work describes a novel approach to "shorten the road" to HIV testing, suggesting that traditional healer-delivered HIV testing holds promise to expand uptake of testing among communities with limited access to existing programs.
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Affiliation(s)
| | - Matthew Ponticiello
- Department of Global and Public Health Sciences, Cornell University, Ithaca, New York, USA
| | - Doreen Nabukalu
- Department of Pediatrics and Child Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Patricia Tushemereirwe
- Department of Pediatrics and Child Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Gabriel Nuwagaba
- Department of Pediatrics and Child Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Rachel King
- Global Health Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Juliet Mwanga-Amumpaire
- Department of Pediatrics and Child Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Radhika Sundararajan
- Center for Global Health, Weill Cornell Medicine, New York, New York, USA
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, USA
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Booton RD, Ong JJ, Lee A, Liu A, Huang W, Wei C, Tang W, Ma W, Vickerman P, Tucker JD, Mitchell KM. Modelling the impact of an HIV testing intervention on HIV transmission among men who have sex with men in China. HIV Med 2021; 22:467-477. [PMID: 33511687 DOI: 10.1111/hiv.13063] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES An intervention developed through participatory crowdsourcing methods increased HIV self-testing among men who have sex with men [MSM; relative risk (RR) = 1.89]. We estimated the long-term impact of this intervention on HIV transmission among MSM in four cities (Guangzhou, Shenzhen, Jinan and Qingdao). METHODS A mathematical model of HIV transmission, testing and treatment among MSM in China was parameterized using city-level demographic and sexual behaviour data and calibrated to HIV prevalence, diagnosis and antiretroviral therapy (ART) coverage data. The model was used to project the HIV infections averted over 20 years (2016-2036) from the intervention to increase self-testing, compared with current testing rates. RESULTS Running the intervention once would avert < 2.2% infections over 20 years. Repeating the intervention (RR = 1.89) annually would avert 6.4-10.7% of new infections, while further increases in the self-testing rate (hypothetical RR = 3) would avert 11.7-20.7% of new infections. CONCLUSIONS Repeated annual interventions would give a three- to seven-fold increase in long-term impact compared with a one-off intervention. Other interventions will be needed to more effectively reduce the HIV burden in this population.
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Affiliation(s)
- Ross D Booton
- University of Bristol, Bristol, UK.,MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Jason J Ong
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Amy Lee
- University of North Carolina Project-China, Guangzhou, China
| | - Aifeng Liu
- University of North Carolina Project-China, Guangzhou, China.,Social Entrepreneurship to Spur Health (SESH) Global, Guangzhou, China
| | - Wenting Huang
- University of North Carolina Project-China, Guangzhou, China.,Social Entrepreneurship to Spur Health (SESH) Global, Guangzhou, China
| | - Chongyi Wei
- Rutgers School of Public Health, Piscataway, NJ, USA
| | - Weiming Tang
- University of North Carolina Project-China, Guangzhou, China.,Social Entrepreneurship to Spur Health (SESH) Global, Guangzhou, China.,University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Wei Ma
- School of Public Health, Shandong University, Jinan, China
| | | | - Joseph D Tucker
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.,University of North Carolina Project-China, Guangzhou, China.,Social Entrepreneurship to Spur Health (SESH) Global, Guangzhou, China.,University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kate M Mitchell
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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Pai NP, Thomas R. Autodépistage du VIH au Canada : vision et plan d’action. CMAJ 2021; 193:E112-E114. [PMID: 33462154 PMCID: PMC7955816 DOI: 10.1503/cmaj.201160-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Nitika Pant Pai
- Département de médecine (Pant Pai), Université McGill; Institut de recherche du Centre universitaire de santé McGill (Pant Pai); clinique médicale l'Actuel (Thomas), Montréal (Qc)
| | - Réjean Thomas
- Département de médecine (Pant Pai), Université McGill; Institut de recherche du Centre universitaire de santé McGill (Pant Pai); clinique médicale l'Actuel (Thomas), Montréal (Qc)
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40
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Dunning L, Gandhi AR, Penazzato M, Soeteman DI, Revill P, Frank S, Phillips A, Dugdale C, Abrams E, Weinstein MC, Newell M, Collins IJ, Doherty M, Vojnov L, Fassinou Ekouévi P, Myer L, Mushavi A, Freedberg KA, Ciaranello AL. Optimizing infant HIV diagnosis with additional screening at immunization clinics in three sub-Saharan African settings: a cost-effectiveness analysis. J Int AIDS Soc 2021; 24:e25651. [PMID: 33474817 PMCID: PMC8992471 DOI: 10.1002/jia2.25651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 10/19/2020] [Accepted: 11/17/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Uptake of early infant HIV diagnosis (EID) varies widely across sub-Saharan African settings. We evaluated the potential clinical impact and cost-effectiveness of universal maternal HIV screening at infant immunization visits, with referral to EID and maternal antiretroviral therapy (ART) initiation. METHODS Using the CEPAC-Pediatric model, we compared two strategies for infants born in 2017 in Côte d'Ivoire (CI), South Africa (SA), and Zimbabwe: (1) existing EID programmes offering six-week nucleic acid testing (NAT) for infants with known HIV exposure (EID), and (2) EID plus universal maternal HIV screening at six-week infant immunization visits, leading to referral for infant NAT and maternal ART initiation (screen-and-test). Model inputs included published Ivoirian/South African/Zimbabwean data: maternal HIV prevalence (4.8/30.8/16.1%), current uptake of EID (40/95/65%) and six-week immunization attendance (99/74/94%). Referral rates for infant NAT and maternal ART initiation after screen-and-test were 80%. Costs included NAT ($24/infant), maternal screening ($10/mother-infant pair), ART ($5 to 31/month) and HIV care ($15 to 190/month). Model outcomes included mother-to-child transmission of HIV (MTCT) among HIV-exposed infants, and life expectancy (LE) and mean lifetime per-person costs for children with HIV (CWH) and all children born in 2017. We calculated incremental cost-effectiveness ratios (ICERs) using discounted (3%/year) lifetime costs and LE for all children. We considered two cost-effectiveness thresholds in each country: (1) the per-capita GDP ($1720/6380/2150) per year-of-life saved (YLS), and (2) the CEPAC-generated ICER of offering 2 versus 1 lifetime ART regimens (e.g. offering second-line ART; $520/500/580/YLS). RESULTS With EID, projected six-week MTCT was 9.3% (CI), 4.2% (SA) and 5.2% (Zimbabwe). Screen-and-test decreased total MTCT by 0.2% to 0.5%, improved LE by 2.0 to 3.5 years for CWH and 0.03 to 0.07 years for all children, and increased discounted costs by $17 to 22/child (all children). The ICER of screen-and-test compared to EID was $1340/YLS (CI), $650/YLS (SA) and $670/YLS (Zimbabwe), below the per-capita GDP but above the ICER of 2 versus 1 lifetime ART regimens in all countries. CONCLUSIONS Universal maternal HIV screening at immunization visits with referral to EID and maternal ART initiation may reduce MTCT, improve paediatric LE, and be of comparable value to current HIV-related interventions in high maternal HIV prevalence settings like SA and Zimbabwe.
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Affiliation(s)
- Lorna Dunning
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
| | - Aditya R Gandhi
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
| | - Martina Penazzato
- Global HIV, Hepatitis, and STIs ProgrammeWorld Health OrganizationGenevaSwitzerland
| | - Djøra I Soeteman
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
- Center for Health Decision ScienceHarvard T.H. Chan School of Public HealthBostonMAUSA
| | - Paul Revill
- Center for Health EconomicsUniversity of YorkYorkUnited Kingdom
| | - Simone Frank
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
| | - Andrew Phillips
- Institute for Global HealthUniversity College LondonLondonUnited Kingdom
| | - Caitlin Dugdale
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Elaine Abrams
- Mailman School of Public HealthICAP at Columbia UniversityNew York CityNYUSA
| | - Milton C Weinstein
- Center for Health Decision ScienceHarvard T.H. Chan School of Public HealthBostonMAUSA
| | - Marie‐Louise Newell
- Institute for Development StudiesHuman Development and HealthFaculty of MedicineUniversity of SouthamptonSouthamptonUnited Kingdom
- School of Public HealthFaculty of Health SciencesUniversity of WitwatersrandJohannesburgSouth Africa
| | - Intira J Collins
- Medical Research Council Clinical Trials UnitUniversity College LondonLondonUnited Kingdom
| | - Meg Doherty
- Global HIV, Hepatitis, and STIs ProgrammeWorld Health OrganizationGenevaSwitzerland
| | - Lara Vojnov
- Global HIV, Hepatitis, and STIs ProgrammeWorld Health OrganizationGenevaSwitzerland
| | | | - Landon Myer
- Division of Epidemiology & BiostatisticsSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | | | - Kenneth A Freedberg
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Andrea L Ciaranello
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
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Magno L, Leal AF, Knauth D, Dourado I, Guimarães MDC, Santana EP, Jordão T, Rocha GM, Veras MA, Kendall C, Pontes AK, de Brito AM, Kerr L. Acceptability of HIV self-testing is low among men who have sex with men who have not tested for HIV: a study with respondent-driven sampling in Brazil. BMC Infect Dis 2020; 20:865. [PMID: 33213389 PMCID: PMC7678175 DOI: 10.1186/s12879-020-05589-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 11/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Brazil has many people living with HIV (PLWH) who are unaware of their serostatus. The public health system has recently added HIV self-testing (HIVST) for key populations such as men who have sex with men (MSM). This study estimates HIVST acceptability among Brazilian MSM and explores factors associated with acceptability among MSM who have never tested for HIV or who had a previous negative result. METHODS Respondent-driven sampling (RDS) was used to recruit 4176 MSM in 12 Brazilian cities in 2016 to this biological and behavioral surveillance study. We excluded from this analysis all MSM who were aware of their positive HIV serostatus. Descriptive, bivariate and multivariate analyses were conducted. Overall proportions were weighted with Gile's estimator in RDS Analyst software and 95% confidence intervals were calculated. The analyses of HIVST acceptability were stratified by prior HIV testing (never or one or more times). RESULTS For this analysis, 3605 MSM were included. The acceptability of HIVST was 49.1%, lower among those who had never tested for HIV (42.7%) compared to those who had a previous HIV negative test (50.1%). In the subgroup of MSM who had never tested for HIV, those who reported discrimination or who had a medical appointment in the last 12 months reported higher HIVST acceptability. Among MSM who had a previous negative HIV test, only those reporting condomless receptive anal sex reported higher HIVST acceptability. In addition, we observed that high levels of knowledge of HIV/AIDS, taking part in lesbian, gay, bisexual, and transgender nongovernmental organizations (LGBT-NGO), or complete secondary or incomplete higher undergraduate education reported higher acceptability. CONCLUSIONS The acceptability of HIVST was low among MSM, especially among those who never tested for HIV. Given access to HIVST in Brazil, we point to the need for programs that enhance promotion of testing addressed to MSM.
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Affiliation(s)
- Laio Magno
- Department of Life Sciences, Bahia State University, Rua Silveira Martins, 2555, Cabula, Salvador, 41.150-000, Bahia, Brazil.
- Institute of Collective Health, Federal University of Bahia, R. Basílio da Gama, s/n - Canela, Salvador, 45760-030, Bahia, Brazil.
| | - Andrea Fachel Leal
- Sociology Department, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Daniela Knauth
- Department of Social Medicine, Universidade Federal do Rio Grande do Sul, School of Medicine, Porto Alegre, Brazil
| | - Inês Dourado
- Institute of Collective Health, Federal University of Bahia, R. Basílio da Gama, s/n - Canela, Salvador, 45760-030, Bahia, Brazil
| | | | - Elis Passos Santana
- Institute of Collective Health, Federal University of Bahia, R. Basílio da Gama, s/n - Canela, Salvador, 45760-030, Bahia, Brazil
| | - Tiago Jordão
- Department of Life Sciences, Bahia State University, Rua Silveira Martins, 2555, Cabula, Salvador, 41.150-000, Bahia, Brazil
| | | | | | - Carl Kendall
- Tulane School of Public Health and Tropical Medicine, New Orleans, USA
- Department of Community Health, Federal University of Ceará, Fortaleza, Brazil
| | | | | | - Ligia Kerr
- Department of Community Health, Federal University of Ceará, Fortaleza, Brazil
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Abstract
OBJECTIVES This study estimates the costs of community-based HIV testing services (HTS) in Lesotho and assesses the potential efficiency gains achieved by adding HIV self-testing (HIVST) and then self-testing booths. DESIGN Micro-costing analysis using longitudinal data from a real-world intervention. METHODS We collected data prospectively on provider's costs and programmatic outcomes over three time periods of approximately 8 months each, between May 2017 and April 2019. The scope of services was extended during each period as follows: HTS only, HTS and HIVST, HTS and HIVST with individual HIVST booths wherein clients were encouraged to self-test on-site followed by on-site confirmative testing for those with reactive self-test. For each implementation period, we estimated the full financial and economic implementation costs, the incremental costs of adding HIVST onto conventional HTS and the cost per HIV positive case identified. RESULTS Costs per HIV-positive case identified increased between period 1 (US$956) and period 2 (US$1249) then dropped in period 3 (US$813). Full versus incremental cost analyses resulted in large differences in the magnitude of costs, attributable to methods rather than resource use: for example, in period 3, the average full and incremental cost estimates for HTS were US$34.3 and US$23.5 per person tested, and for HIVST were US$37.7 and US$14.0 per kit provided, respectively. CONCLUSION In Lesotho, adding HIVST to community-based HTS improves its overall affordability for HIV-positive case finding. The reporting of both full and incremental cost estimates increase transparency for use in priority setting, budgeting and financial planning for scale-up.
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Wang C, Wang YJ, Tucker JD, Xiong MZ, Fu HY, Smith MK, Tang WM, Ong JJ, Zheng HP, Yang B. Correlates of HIV self-testing among female sex workers in China: implications for expanding HIV screening. Infect Dis Poverty 2020; 9:147. [PMID: 33092641 PMCID: PMC7583185 DOI: 10.1186/s40249-020-00765-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 10/14/2020] [Indexed: 11/29/2022] Open
Abstract
Background Human immunodeficiency virus (HIV) self-testing may help improve test uptake among female sex workers. China has implemented many HIV self-testing programs among men who have sex with men, creating an opportunity for promotion among female sex workers. However, there is a limited literature on examining HIV self-testing among female sex workers. This study aimed to examine HIV self-testing experiences and its determinants among female sex workers in China. Methods A venue-based, cross-sectional study was conducted among Chinese female sex workers in 2019. Participants completed a survey including social-demographic characteristics, sexual behaviors, and HIV self-testing history, the distribution of which were analyzed using descriptive analysis. Multivariable logistic regression was conducted to identify associations with HIV self-testing. Results Among 1287 Chinese female sex workers, 1072 (83.3%, 95% confidence interval [CI] 81.2–85.3%) had ever tested for HIV, and 103 (8.0%, 95% CI 6.6–9.6%) had ever used HIV self-testing. More than half reported that the self-test was their first HIV test (59.2%, 61/103), around one-fifth reported HIV self-testing results influenced the price of sex (21.4%, 22/103). A minority of individuals reported ever experiencing pressure to undertake HIV self-testing (6.8%, 7/103). After adjusting for covariates, HIV self-testing was positively associated with receiving anal sex in the past month (adjusted odds ratio [aOR] = 2.2, 95% CI 1.4–3.5), using drugs before or during sex (aOR = 2.8, 95% CI 1.8–4.5), injecting drugs in the past 6 months (aOR = 2.6, 95% CI 1.2–6.0), being diagnosed with other sexually transmitted infections (aOR = 1.6, 95% CI 1.0–2.5), tested for other sexually transmitted infections in the past six months (aOR = 3.4, 95% CI 2.1–5.5), ever tested in the hospital (aOR = 3.4, 95% CI 2.0–5.6), and ever tested in the community (aOR = 1.5, 95% CI 1.2–1.9). Conclusions Our findings suggest that HIV self-testing could expand overall HIV testing uptake, increase HIV testing frequency, reach sub-groups of high-risk female sex workers and has limited potential harms among female sex workers. HIV self-testing should be incorporated among Chinese female sex workers as a complement to facility-based HIV testing services.
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Affiliation(s)
- Cheng Wang
- Dermatology Hospital of Southern Medical University, Guangzhou, Guangdong, China. .,Southern Medical University Institute for Global Health and Sexually Transmitted Diseases, Guangzhou, Guangdong, China.
| | - Ya-Jie Wang
- Dermatology Hospital of Southern Medical University, Guangzhou, Guangdong, China.,Southern Medical University Institute for Global Health and Sexually Transmitted Diseases, Guangzhou, Guangdong, China
| | - Joseph D Tucker
- University of North Carolina Project-China, Guangzhou, Guangdong, China.,Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.,Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina At Chapel Hill, Chapel Hill, USA
| | - Ming-Zhou Xiong
- Dermatology Hospital of Southern Medical University, Guangzhou, Guangdong, China.,Southern Medical University Institute for Global Health and Sexually Transmitted Diseases, Guangzhou, Guangdong, China
| | - Hong-Yun Fu
- Division of Community Health and Research, Eastern Virginia Medical School, Norfolk, VA, USA
| | - M Kumi Smith
- Division of Epidemiology and Community Health, University of Minnesota Twin Cities, Minneapolis, USA
| | - Wei-Ming Tang
- Dermatology Hospital of Southern Medical University, Guangzhou, Guangdong, China.,Southern Medical University Institute for Global Health and Sexually Transmitted Diseases, Guangzhou, Guangdong, China.,University of North Carolina Project-China, Guangzhou, Guangdong, China
| | - Jason J Ong
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.,Central Clinical School, Monash University, Victoria, Melbourne, Australia
| | - He-Ping Zheng
- Dermatology Hospital of Southern Medical University, Guangzhou, Guangdong, China.,Southern Medical University Institute for Global Health and Sexually Transmitted Diseases, Guangzhou, Guangdong, China
| | - Bin Yang
- Dermatology Hospital of Southern Medical University, Guangzhou, Guangdong, China.,Southern Medical University Institute for Global Health and Sexually Transmitted Diseases, Guangzhou, Guangdong, China
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Woods B, Schmitt L, Rothery C, Phillips A, Hallett TB, Revill P, Claxton K. Practical metrics for establishing the health benefits of research to support research prioritisation. BMJ Glob Health 2020; 5:e002152. [PMID: 32868268 PMCID: PMC7462234 DOI: 10.1136/bmjgh-2019-002152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 05/28/2020] [Accepted: 05/31/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION We present practical metrics for estimating the expected health benefits of specific research proposals. These can be used by research funders, researchers and healthcare decision-makers within low-income and middle-income countries to support evidence-based research prioritisation. METHODS The methods require three key assessments: (1) the current level of uncertainty around the endpoints the proposed study will measure; (2) how uncertainty impacts on the health benefits and costs of healthcare programmes and (3) the health opportunity costs imposed by programme costs. Research is valuable because it can improve health by informing the choice of which programmes should be implemented. We provide a Microsoft Excel tool to allow readers to generate estimates of the health benefits of research studies based on these three assessments. The tool can be populated using existing studies, existing cost-effectiveness models and expert opinion. Where such evidence is not available, the tool can quantify the value of research under different assumptions. Estimates of the health benefits of research can be considered alongside research costs, and the consequences of delaying implementation until research reports, to determine whether research is worthwhile. We illustrate the method using a case study of research on HIV self-testing programmes in Malawi. This analysis combines data from the literature with outputs from the HIV synthesis model. RESULTS For this case study, we found a costing study that could be completed and inform decision making within 1 year offered the highest health benefits (67 000 disability-adjusted life years (DALYs) averted). Research on outcomes improved population health to a lesser extent (12 000 DALYs averted) and only if carried out alongside programme implementation. CONCLUSION Our work provides a method for estimating the health benefits of research in a practical and timely fashion. This can be used to support accountable use of research funds.
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Affiliation(s)
- Beth Woods
- Centre for Health Economics, University of York, York, Yorkshire, UK
| | - Laetitia Schmitt
- Centre for Health Economics, University of York, York, Yorkshire, UK
| | - Claire Rothery
- Centre for Health Economics, University of York, York, Yorkshire, UK
| | - Andrew Phillips
- Institute for Global Health, University College London, London, UK
| | - Timothy B Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, London, London, UK
| | - Paul Revill
- Centre for Health Economics, University of York, York, Yorkshire, UK
| | - Karl Claxton
- Centre for Health Economics, University of York, York, Yorkshire, UK
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Napierala S, Bair EF, Marcus N, Ochwal P, Maman S, Agot K, Thirumurthy H. Male partner testing and sexual behaviour following provision of multiple HIV self-tests to Kenyan women at higher risk of HIV infection in a cluster randomized trial. J Int AIDS Soc 2020; 23 Suppl 2:e25515. [PMID: 32589354 PMCID: PMC7319153 DOI: 10.1002/jia2.25515] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 04/04/2020] [Accepted: 04/22/2020] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Without significant increases in uptake of HIV testing among men, it will be difficult to reduce HIV incidence to disease elimination levels. Secondary distribution of HIV self-tests by women to their male partners is a promising approach for increasing male testing that is being implemented in several countries. Here, we examine male partner and couples testing outcomes and sexual decision making associated with this approach in a cluster randomized trial. METHODS We examined data from women at higher risk of HIV participating in the intervention arm of an ongoing pair-matched cluster randomized trial in Kenya. HIV-negative women ≥18 years who self-reported ≥2 partners in the past month were eligible. Participants received self-tests at enrolment and three-monthly intervals. They were encouraged to offer tests to sexual partners with whom they anticipated condomless sex. At six months, we collected data on self-test distribution, male partner and couples testing, and testing and sexual behaviour in the three most recent transactional sex encounters. We used descriptive analyses and generalized estimating equation models to understand how sexual behaviour was influenced by self-test distribution. RESULTS From January 2018 to April 2019, 921/1057 (87%) participants completed six-month follow-up. Average age was 28 years, 65% were married, and 72% reported income through sex work. Participants received 7283 self-tests over six months, a median of eight per participant. Participants offered a median three self-tests to sexual partners. Of participants with a primary partner, 94% offered them a self-test. Of these, 97% accepted the test. When accepted, couples testing was reported among 91% of participants. Among 1954 transactional sex encounters, 64% included an offer to self-test. When offered self-tests were accepted by 93% of partners, and 84% who accepted conducted couples testing. Compared to partners with an HIV-negative result, condom use was higher when men had a reactive result (56.3% vs. 89.7%, p < 0.01), were not offered a self-test (56.3% vs. 62.0%, p = 0.02), or refused to self-test (56.3% vs. 78.3, p < 0.01). CONCLUSIONS Providing women with multiple self-tests facilitated male partner and couples testing, and led to safer sexual behaviour. These findings suggest secondary distribution is a promising approach for reaching men and has HIV prevention potential. Clinical Trial Number: NCT03135067.
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Affiliation(s)
- Sue Napierala
- Women’s Global Health ImperativeRTI InternationalSan FranciscoCAUSA
| | - Elizabeth F Bair
- Department of Medical Ethics and Health PolicyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Noora Marcus
- Department of Medical Ethics and Health PolicyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Perez Ochwal
- Impact Research and Development OrganizationKisumuKenya
| | - Suzanne Maman
- Department of Health BehaviorGillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Kawango Agot
- Impact Research and Development OrganizationKisumuKenya
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health PolicyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
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Shapiro AE, van Heerden A, Krows M, Sausi K, Sithole N, Schaafsma TT, Koole O, van Rooyen H, Celum CL, Barnabas RV. An implementation study of oral and blood-based HIV self-testing and linkage to care among men in rural and peri-urban KwaZulu-Natal, South Africa. J Int AIDS Soc 2020; 23 Suppl 2:e25514. [PMID: 32589337 PMCID: PMC7319114 DOI: 10.1002/jia2.25514] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 04/02/2020] [Accepted: 04/22/2020] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION In South Africa, HIV-infected men are less likely than women to test and know their status (the first UNAIDS "90-90-90" target), and men have worse outcomes across the HIV care cascade. HIV self-testing (HIVST) may address this testing disparity but questions remain over the most effective distribution strategy and linkage following a positive test result. We implemented a men-focused HIVST distribution programme to evaluate components contributing to participation and retention. METHODS We conducted an implementation study of multi-venue HIVST kit distribution in rural and peri-urban KwaZulu-Natal (KZN), South Africa. We distributed HIVST kits at community points, workplaces and social venues for on site or take-home use. Clients could choose blood-based or oral-fluid-based HIVST kits and elect to watch an in-person or video demonstration. We provided a USD2 incentive to facilitate reporting test results by phone or SMS. Persons with reactive HIVST results were provided immediate confirmatory tests (if used HIVST on site) or were referred for confirmatory testing (if took HIVST off site) and linkage to care for ART initiation. We describe the testing and linkage cascade in this sample and describe predictors of reactive HIVST results and linkage. RESULTS Between July and November 2018, we distributed 4496 HIVST kits in two regions of KZN (96% to men, median age 28 (IQR 23 to 35). Most participants (58%) chose blood-based HIVST and 42% chose oral-swab kits. 11% of men were testing for the first time. A total of 3902 (83%) of testers reported their test result to the study team, with 314 (8%) screening positive for HIV. Among 274 men with reactive HIVST results, 68% linked to ART; no significant predictors of linkage were identified. 10% of kit users reported they would prefer a different type (oral vs. blood) of kit for repeat testing than the type they used. CONCLUSIONS HIVST is acceptable to men and rapid distribution with optional testing support is feasible in rural and peri-urban settings. HIVST kits successfully reached younger men and identified undetected infections. Both oral and blood-based HIVST were selected. Scaling up HIVST distribution and guidance may increase the number of first-time testers among men and help achieve the first UNAIDS "90" for men in South Africa.
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Affiliation(s)
- Adrienne E Shapiro
- Department of Global HealthUniversity of WashingtonSeattleUSA
- Department of MedicineDivision of Infectious DiseasesUniversity of WashingtonSeattleUSA
| | - Alastair van Heerden
- Human Sciences Research CouncilSweetwatersSouth Africa
- MRC/Wits Developmental Pathways for Health Research Unit (DPHRU)University of the WitwatersrandJohannesburg‐BraamfonteinSouth Africa
| | - Meighan Krows
- Department of Global HealthUniversity of WashingtonSeattleUSA
| | - Kombi Sausi
- MRC/Wits Developmental Pathways for Health Research Unit (DPHRU)University of the WitwatersrandJohannesburg‐BraamfonteinSouth Africa
| | - Nsika Sithole
- Africa Health Research InstituteMtubatubaSouth Africa
| | | | - Olivier Koole
- Africa Health Research InstituteMtubatubaSouth Africa
- London School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Heidi van Rooyen
- Human Sciences Research CouncilSweetwatersSouth Africa
- MRC/Wits Developmental Pathways for Health Research Unit (DPHRU)University of the WitwatersrandJohannesburg‐BraamfonteinSouth Africa
| | - Connie L Celum
- Department of Global HealthUniversity of WashingtonSeattleUSA
- Department of MedicineDivision of Infectious DiseasesUniversity of WashingtonSeattleUSA
| | - Ruanne V Barnabas
- Department of Global HealthUniversity of WashingtonSeattleUSA
- Department of MedicineDivision of Infectious DiseasesUniversity of WashingtonSeattleUSA
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Johnson C, Neuman M, MacPherson P, Choko A, Quinn C, Wong VJ, Hatzold K, Nyrienda R, Ncube G, Baggaley R, Terris-Prestholt F, Corbett EL. Use and awareness of and willingness to self-test for HIV: an analysis of cross-sectional population-based surveys in Malawi and Zimbabwe. BMC Public Health 2020; 20:779. [PMID: 32450840 PMCID: PMC7249304 DOI: 10.1186/s12889-020-08855-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 05/05/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Many southern African countries are nearing the global goal of diagnosing 90% of people with HIV by 2020. In 2016, 84 and 86% of people with HIV knew their status in Malawi and Zimbabwe, respectively. However, gaps remain, particularly among men. We investigated awareness and use of, and willingness to self-test for HIV and explored sociodemographic associations before large-scale implementation. METHODS We pooled responses from two of the first cross-sectional Demographic and Health Surveys to include HIV self-testing (HIVST) questions in Malawi and Zimbabwe in 2015-16. We investigated sociodemographic factors and sexual risk behaviours associated with previously testing for HIV, and past use, awareness of, and future willingness to self-test using univariable and multivariable logistic regression, adjusting for the sample design and limiting analysis to participants with a completed questionnaire and valid HIV test result. We restricted analysis of willingness to self-test to Zimbabwean men, as women and Malawians were not systematically asked this question. RESULTS Of 31,385 individuals, 31.2% of men had never tested compared with 16.5% of women (p < 0.001). For men, the likelihood of having ever tested increased with age. Past use and awareness of HIVST was very low, 1.2 and 12.6%, respectively. Awareness was lower among women than men (9.1% vs 15.3%, adjusted odds ratio [aOR] = 1.55; 95% confidence interval [CI]: 1.37-1.75), and at younger ages, and lower education and literacy levels. Willingness to self-test among Zimbabwean men was high (84.5%), with greater willingness associated with having previously tested for HIV, being at high sexual risk (highest willingness [aOR = 3.74; 95%CI: 1.39-10.03, p < 0.009]), and being ≥25 years old. Wealthier men had greater awareness of HIVST than poorer men (p < 0.001). The highest willingness to self-test (aOR = 3.74; 95%CI: 1.39-10.03, p < 0.009) was among men at high HIV-related sexual risk. CONCLUSIONS In 2015-16, many Malawian and Zimbabwean men had never tested for HIV. Despite low awareness and minimal HIVST experience, willingness to self-test was high among Zimbabwean men, especially older men with moderate-to-high HIV-related sexual risk. These data provide a valuable baseline against which to investigate population-level uptake of HIVST as programmes scale up. Programmes introducing, or planning to introduce, HIVST should consider including relevant questions in population-based surveys.
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Affiliation(s)
- Cheryl Johnson
- Global HIV, Hepatitis and STI programme, World Health Organization, Geneva, Switzerland
- Department of Clinical Research and Infection Disease, London School of Hygiene and Tropical Medicine, London, UK
| | - Melissa Neuman
- Department of Infectious Disease Epidemiology and MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter MacPherson
- Malawi-Liverpool Wellcome Trust, HIV/TB Group, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Augustine Choko
- Department of Clinical Research and Infection Disease, London School of Hygiene and Tropical Medicine, London, UK
- Malawi-Liverpool Wellcome Trust, HIV/TB Group, Blantyre, Malawi
| | - Caitlin Quinn
- Global HIV, Hepatitis and STI programme, World Health Organization, Geneva, Switzerland
| | - Vincent J. Wong
- U.S. Agency for International Development, Washington, DC USA
| | - Karin Hatzold
- Population Services International, Johannesburg, South Africa
| | | | | | - Rachel Baggaley
- Global HIV, Hepatitis and STI programme, World Health Organization, Geneva, Switzerland
| | - Fern Terris-Prestholt
- Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Elizabeth L. Corbett
- Department of Clinical Research and Infection Disease, London School of Hygiene and Tropical Medicine, London, UK
- Malawi-Liverpool Wellcome Trust, HIV/TB Group, Blantyre, Malawi
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Bulterys MA, Mujugira A, Nakyanzi A, Nampala M, Taasi G, Celum C, Sharma M. Costs of Providing HIV Self-Test Kits to Pregnant Women Living with HIV for Secondary Distribution to Male Partners in Uganda. Diagnostics (Basel) 2020; 10:E318. [PMID: 32438594 PMCID: PMC7277977 DOI: 10.3390/diagnostics10050318] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/14/2020] [Accepted: 05/16/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Secondary distribution of HIV self-testing kits (HIVST) to pregnant women attending antenatal care (ANC) clinics to give to their male partners is a promising strategy to increase testing coverage among men, but its costs are unknown. METHODS We conducted micro-costing of a trial evaluating secondary distribution of HIVST on pregnant women living with HIV (PWLHIV) in an ANC in Kampala, Uganda. Costs (2019 USD) were collected from program budgets, expenditure records, time and motion observations, and staff interviews and estimated for three scenarios: as-studied, reflecting full costs of the research intervention, Ministry of Health (MOH) implementation, reflecting the research intervention if implemented by the MOH, and MOH roll-out, the current strategy being used to roll out HIVST distribution. RESULTS In the as-studied scenario, cost of HIVST provision was $13.96/PWLHIV reached, and $11.89 and $10.55 per HIV-positive and HIV-negative male partner, respectively, who linked to a clinic for facility-based testing. In the MOH implementation scenario, costs were $9.45/PWLHIV, and $7.87 and $6.99, respectively, per HIV-positive and HIV-negative male partner linking to the clinic. In the MOH roll-out scenario, the cost of HIVST provision to pregnant women regardless of HIV status was $3.70/woman, and $6.65/HIV-positive male partner. CONCLUSION Secondary distribution of HIVST from pregnant women can be implemented at reasonable cost to increase testing among men in Uganda and similar settings in Africa.
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Affiliation(s)
- Michelle A. Bulterys
- International Clinical Research Center, Department of Global Health, University of Washington, Seattle, WA 98104, USA; (M.A.B.); (A.M.); (C.C.)
| | - Andrew Mujugira
- International Clinical Research Center, Department of Global Health, University of Washington, Seattle, WA 98104, USA; (M.A.B.); (A.M.); (C.C.)
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 22418, Uganda; (A.N.); (M.N.)
| | - Agnes Nakyanzi
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 22418, Uganda; (A.N.); (M.N.)
| | - Miriam Nampala
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 22418, Uganda; (A.N.); (M.N.)
| | - Geoffrey Taasi
- Division of HIV Testing, Uganda Ministry of Health, Kampala P.O. Box 7272, Uganda;
| | - Connie Celum
- International Clinical Research Center, Department of Global Health, University of Washington, Seattle, WA 98104, USA; (M.A.B.); (A.M.); (C.C.)
| | - Monisha Sharma
- International Clinical Research Center, Department of Global Health, University of Washington, Seattle, WA 98104, USA; (M.A.B.); (A.M.); (C.C.)
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Pasipamire L, Nesbitt RC, Dube L, Mabena E, Nzima M, Dlamini M, Rugongo N, Maphalala N, Obulutsa TA, Ciglenecki I, Kerschberger B. Implementation of community and facility-based HIV self-testing under routine conditions in southern Eswatini. Trop Med Int Health 2020; 25:723-731. [PMID: 32219945 PMCID: PMC7317513 DOI: 10.1111/tmi.13396] [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: 01/08/2023]
Abstract
Objectives WHO recommends HIV self‐testing (HIVST) as an additional approach to HIV testing services. The study describes the strategies used during phase‐in of HIVST under routine conditions in Eswatini (formerly Swaziland). Methods Between May 2017 and January 2018, assisted and unassisted oral HIVST was offered at HIV testing services (HTS) sites to people aged ≥ 16 years. Additional support tools were available, including a telephone hotline answered 24/7, HIVST demonstration videos and printed educational information about HIV prevention and care services. Demographic characteristics of HIVST users were described and compared with standard blood‐based HTS in the community. HIVST results were monitored with follow‐up phone calls and the hotline. Results During the 9‐month period, 1895 people accessed HIVST and 2415 HIVST kits were distributed. More people accessed HIVST kits in the community (n = 1365, 72.0%) than at health facilities (n = 530, 28.0%). The proportion of males and median age among those accessing HIVST and standard HTS in the community were similar (49.3%, 29 years HIVST vs. 48.7%, 27 years standard HTS). In total, 34 (3.9%) reactive results were reported from 938 people with known HIVST results; 32.4% were males, and median age was 30 years (interquartile range 25–36). Twenty‐one (62%) patients were known to have received confirmatory blood‐based HTS; of these, 20 (95%) had concordant reactive results and 19 (95%) were linked to HIV care at a clinic. Conclusion Integration of HIVST into existing HIV facility‐ and community‐based testing strategies in Eswatini was found to be feasible, and HIVST has been adopted by national testing bodies in Eswatini.
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Affiliation(s)
| | - Robin C Nesbitt
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini
| | - Lenhle Dube
- Eswatini National AIDS Programme (ENAP), Ministry of Health, Mbabane, Eswatini
| | - Edwin Mabena
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini
| | - Muzi Nzima
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini
| | - Mduduzi Dlamini
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini
| | - Nozizwe Rugongo
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini
| | | | | | - Iza Ciglenecki
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
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Napierala S, Desmond NA, Kumwenda MK, Tumushime M, Sibanda EL, Indravudh P, Hatzold K, Johnson CC, Baggaley RC, Corbett L, Cowan FM. HIV self-testing services for female sex workers, Malawi and Zimbabwe. Bull World Health Organ 2019; 97:764-776. [PMID: 31673192 PMCID: PMC6802700 DOI: 10.2471/blt.18.223560] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 06/07/2019] [Accepted: 06/20/2019] [Indexed: 11/27/2022] Open
Abstract
Objective To present findings from implementation and scale-up of human immunodeficiency virus (HIV) self-testing programmes for female sex workers in Malawi and Zimbabwe, 2013-2018. Methods In Zimbabwe, we carried out formative research to assess the acceptability and accuracy of HIV self-testing. During implementation we evaluated sex workers' preferences for, and feasibility of, distribution of test kits before the programme was scaled-up. In Malawi, we conducted a rapid ethnographic assessment to explore the context and needs of female sex workers and resources available, leading to a workshop to define the distribution approach for test kits. Once distribution was implemented, we conducted a process evaluation and established a system for monitoring social harm. Findings In Zimbabwe, female sex workers were able to accurately self-test. The preference study helped to refine systems for national scale-up through existing services for female sex workers. The qualitative data helped to identify additional distribution strategies and mediate potential social harm to women. In Malawi, peer distribution of test kits was the preferred strategy. We identified some incidents of social harm among peer distributors and female sex workers, as well as supply-side barriers to implementation which hindered uptake of testing. Conclusion Involving female sex workers in planning and ongoing implementation of HIV self-testing is essential, along with strategies to mitigate potential harm. Optimal strategies for distribution and post-test support are context-specific and need to consider existing support for female sex workers and levels of trust and cohesion within their communities.
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Affiliation(s)
- Sue Napierala
- Women's Global Health Imperative, RTI International, 351 California Street, Suite 500 San Francisco, CA 94104, United States of America
| | - Nicola Ann Desmond
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, England
| | - Moses K Kumwenda
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Mary Tumushime
- Centre for Sexual Health and HIV/AIDS Research, Harare, Zimbabwe
| | | | - Pitchaya Indravudh
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | | | | | - Liz Corbett
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, England
| | - Frances M Cowan
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, England
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