Community viral load as a measure for assessment of HIV treatment as prevention

Inferring Population HIV Viral Load From a Single HIV Clinic's Electronic Health Record: Simulation Study With a Real-World Example

BACKGROUND

Population viral load (VL), the most comprehensive measure of the HIV transmission potential, cannot be directly measured due to lack of complete sampling of all people with HIV.

OBJECTIVE

A given HIV clinic's electronic health record (EHR), a biased sample of this population, may be used to attempt to impute this measure.

METHODS

We simulated a population of 10,000 individuals with VL calibrated to surveillance data with a geometric mean of 4449 copies/mL. We sampled 3 hypothetical EHRs from (A) the source population, (B) those diagnosed, and (C) those retained in care. Our analysis imputed population VL from each EHR using sampling weights followed by Bayesian adjustment. These methods were then tested using EHR data from an HIV clinic in Delaware.

RESULTS

Following weighting, the estimates moved in the direction of the population value with correspondingly wider 95% intervals as follows: clinic A: 4364 (95% interval 1963-11,132) copies/mL; clinic B: 4420 (95% interval 1913-10,199) copies/mL; and clinic C: 242 (95% interval 113-563) copies/mL. Bayesian-adjusted weighting further improved the estimate.

CONCLUSIONS

These findings suggest that methodological adjustments are ineffective for estimating population VL from a single clinic's EHR without the resource-intensive elucidation of an informative prior.

Age and gender profiles of HIV infection burden and viraemia: novel metrics for HIV epidemic control in African populations with high antiretroviral therapy coverage

Introduction

To prioritize and tailor interventions for ending AIDS by 2030 in Africa, it is important to characterize the population groups in which HIV viraemia is concentrating.

Methods

We analysed HIV testing and viral load data collected between 2013-2019 from the open, population-based Rakai Community Cohort Study (RCCS) in Uganda, to estimate HIV seroprevalence and population viral suppression over time by gender, one-year age bands and residence in inland and fishing communities. All estimates were standardized to the underlying source population using census data. We then assessed 95-95-95 targets in their ability to identify the populations in which viraemia concentrates.

Results

Following the implementation of Universal Test and Treat, the proportion of individuals with viraemia decreased from 4.9% (4.6%-5.3%) in 2013 to 1.9% (1.7%-2.2%) in 2019 in inland communities and from 19.1% (18.0%-20.4%) in 2013 to 4.7% (4.0%-5.5%) in 2019 in fishing communities. Viraemia did not concentrate in the age and gender groups furthest from achieving 95-95-95 targets. Instead, in both inland and fishing communities, women aged 25-29 and men aged 30-34 were the 5-year age groups that contributed most to population-level viraemia in 2019, despite these groups being close to or had already achieved 95-95-95 targets.

Conclusions

The 95-95-95 targets provide a useful benchmark for monitoring progress towards HIV epidemic control, but do not contextualize underlying population structures and so may direct interventions towards groups that represent a marginal fraction of the population with viraemia.

Nurse-led approaches to address social determinants of health and advance health equity: A new framework and its implications

BACKGROUND

The U.S. health care system is burdened by inefficiencies, longstanding health inequities, and unstainable costs. Within the nursing profession and the broader health care sector, there is growing recognition of the need for a paradigm shift that addresses persistent structural problems and advances health equity.

PURPOSE

Despite evidence of the importance of the social determinants of health (SDOH) in shaping inequitable health outcomes, practical tools for applying SDOH theory in the development of effective nurse-led programs to mitigate harmful SDOH remain scarce.

METHODS

We synthesize extant SDOH literature into a heuristic framework for conceptualizing core SDOH mechanisms, constructs, and principles.

FINDINGS

To illustrate how nurse scientists can use the framework to guide the development of programs for SDOH mitigation, we outline a three-step exemplar application to the U.S. Latino HIV epidemic.

DISCUSSION

Our framework can inform a paradigm shift toward nurse-led, multi-level SDOH mitigation across practice, education, and research.

The epidemiology of HIV population viral load in twelve sub-Saharan African countries

BACKGROUND

We examined the epidemiology and transmission potential of HIV population viral load (VL) in 12 sub-Saharan African countries.

METHODS

We analyzed data from Population-based HIV Impact Assessments (PHIAs), large national household-based surveys conducted between 2015 and 2019 in Cameroon, Cote d'Ivoire, Eswatini, Kenya, Lesotho, Malawi, Namibia, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe. Blood-based biomarkers included HIV serology, recency of HIV infection, and VL. We estimated the number of people living with HIV (PLHIV) with suppressed viral load (<1,000 HIV-1 RNA copies/mL) and with unsuppressed viral load (viremic), the prevalence of unsuppressed HIV (population viremia), sex-specific HIV transmission ratios (number female incident HIV-1 infections/number unsuppressed male PLHIV per 100 persons-years [PY] and vice versa) and examined correlations between a variety of VL metrics and incident HIV. Country sample sizes ranged from 10,016 (Eswatini) to 30,637 (Rwanda); estimates were weighted and restricted to participants 15 years and older.

RESULTS

The proportion of female PLHIV with viral suppression was higher than that among males in all countries, however, the number of unsuppressed females outnumbered that of unsuppressed males in all countries due to higher overall female HIV prevalence, with ratios ranging from 1.08 to 2.10 (median: 1.43). The spatial distribution of HIV seroprevalence, viremia prevalence, and number of unsuppressed adults often differed substantially within the same countries. The 1% and 5% of PLHIV with the highest VL on average accounted for 34% and 66%, respectively, of countries' total VL. HIV transmission ratios varied widely across countries and were higher for male-to-female (range: 2.3-28.3/100 PY) than for female-to-male transmission (range: 1.5-10.6/100 PY). In all countries mean log10 VL among unsuppressed males was higher than that among females. Correlations between VL measures and incident HIV varied, were weaker for VL metrics among females compared to males and were strongest for the number of unsuppressed PLHIV per 100 HIV-negative adults (R2 = 0.92).

CONCLUSIONS

Despite higher proportions of viral suppression, female unsuppressed PLHIV outnumbered males in all countries examined. Unsuppressed male PLHIV have consistently higher VL and a higher risk of transmitting HIV than females. Just 5% of PLHIV account for almost two-thirds of countries' total VL. Population-level VL metrics help monitor the epidemic and highlight key programmatic gaps in these African countries.

Conceptualizing the Mechanisms of Social Determinants of Health: A Heuristic Framework to Inform Future Directions for Mitigation

Policy Points A large body of scientific work examines the mechanisms through which social determinants of health (SDOH) shape health inequities. However, the nuances described in the literature are infrequently reflected in the applied frameworks that inform health policy and programming. We synthesize extant SDOH research into a heuristic framework that provides policymakers, practitioners, and researchers with a customizable template for conceptualizing and operationalizing key mechanisms that represent intervention opportunities for mitigating the impact of harmful SDOH. In light of scarce existing SDOH mitigation strategies, the framework addresses an important research-to-practice translation gap and missed opportunity for advancing health equity.

CONTEXT

The reduction of health inequities is a broad and interdisciplinary endeavor with implications for policy, research, and practice. Health inequities are most often understood as associated with the social determinants of health (SDOH). However, policy and programmatic frameworks for mitigation often rely on broad SDOH domains, without sufficient attention to the operating mechanisms, and effective SDOH mitigation strategies remain scarce. To expand the cadre of effective SDOH mitigation strategies, a practical, heuristic framework for policymakers, practitioners, and researchers is needed that serves as a roadmap for conceptualizing and targeting the key mechanisms of SDOH influence.

METHODS

We conduct a critical review of the extant conceptual and empirical SDOH literature to identify unifying principles of SDOH mechanisms and to synthesize an integrated framework for conceptualizing such mechanisms.

FINDINGS

We highlight eight unifying principles of SDOH mechanisms that emerge from landmark SDOH research. Building on these principles, we introduce and apply a conceptual model that synthesizes key SDOH mechanisms into one organizing, heuristic framework that provides policymakers, practitioners, and researchers with a customizable template for conceptualizing and operationalizing the key SDOH mechanisms that represent intervention opportunities to maximize potential impact for mitigating a given health inequity.

CONCLUSIONS

Our synthesis of the extant SDOH research into a heuristic framework addresses a scarcity of peer-reviewed organizing frameworks of SDOH mechanisms designed to inform practice. The framework represents a practical tool to facilitate the translation of scholarly SDOH work into evidence-based and targeted policy and programming. Such tools designed to close the research-to-practice translation gap for effective SDOH mitigation are sorely needed, given that health inequities in the United States and in many other parts of the world have widened over the past two decades.

Sexual health discussion practices and HIV clinical care provided by primary care providers in the Southeast United States, K-BAP Study (2017-2018)

OBJECTIVE

Research underscores the importance of providers having routine discussions with patients about their sexual health. We examined the occurrences and association of routine sexual health discussion practices and human immunodeficiency virus (HIV) clinical care among primary care providers (PCPs) in areas with high HIV prevalence.

METHODS

We analysed data collected between April and August 2017 from an online survey that assessed PCPs knowledge, behaviours, attitudes, and practices of HIV-related care in 6 Southeast US jurisdictions (Atlanta, Baltimore, Baton Rouge, District of Columbia, Miami, and New Orleans).

RESULTS

Among PCPs, we found that 39.2% routinely obtained sexual health histories, 78.5% offered HIV testing, and 16.0% ever prescribed preexposure prophylaxis (PrEP). Based on adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs), the proportion of PCPs who routinely obtained sexual histories was higher among female PCPs (aPR = 1.47, 95% CI 1.04, 2.08), PCPs who had a patient population that was >50% men who have sex with men (MSM) (aPR = 1.94, 95% CI 1.72, 2.18), offered HIV testing (aPR = 3.60, 95% CI 2.23, 5.79), and ever prescribed PrEP (aPR = 1.43, 95% CI 1.06, 1.93).

CONCLUSION

Improving patient-provider discussions are needed to reduce HIV-related service barriers for disproportionately affected populations.

PRACTICE IMPLICATIONS

Routine discussions can reduce barriers to important HIV prevention and care services and help reduce disparities among patients living in highly prevalent HIV locations.

At-Risk Groups of Men Who Have Sex With Men Can Be Reached Through Community-Based HIV Testing in Denmark

This study evaluates whether the community-based HIV testing clinic Checkpoint could reach at-risk groups of men who have sex with men (MSM) and link patients to care. A prospective observational study of all Checkpoint visits during 2013-2016 and a retrospective registry study of all MSM diagnosed with HIV in Denmark during the same period were conducted. One percent of the 9,074 tests in Checkpoint were HIV-positive, accounting for 19% of all new HIV diagnoses among MSM in Denmark. Checkpoint testers reported frequent condomless anal sex. Two percent of migrant Checkpoint testers were HIV-positive compared to 1 % among Danish MSM. HIV-positive MSM identified through Checkpoint were significantly younger, more of them were migrant, and a smaller proportion were late testers compared to those testing through the conventional health care system. Checkpoint reaches at-risk populations of MSM and links patients successfully to care.

Regional disparity of HIV incidence and prevalence among men who have sex with men

BACKGROUND

HIV incidence can be estimated with cross-sectional studies using clinical, serological, and molecular data. Worldwide, HIV incidence data in only men who have sex with men (MSM) are scarce and principally focus on those with healthcare or under treatment. However, better estimates can be obtained through studies with national representativeness. The objective was to estimate the prevalence, incidence, and factors associated with acquiring HIV in a national sample of MSM who attend meeting places, considering geographical regions.

METHODS

A nationally representative survey of MSM attending meeting places was performed in Mexico. Participants answered a questionnaire, and a dried blood spot (DBS) was collected. Samples were classified as recent infections using an algorithm with HIV status, antiretroviral therapy, and the result of BED-EIA assay. Parameters were analysed considering regions and demographic and sexual behaviour characteristics.

RESULTS

The national HIV prevalence was 17.4% with regional differences; the highest prevalence (20.7%) was found in Mexico City, and the lowest prevalence was found in the West region (11.5%). The incidence was 9.4 per 100 p/y, with regional values from 6.2 to 13.2 for the Northeast and the Centre regions, respectively. Age, age at sexual debut, low wealth index, and rewarded sex were associated with HIV prevalence. Centre region, use of private clinics as health services, and having sex exclusively with men were associated with recent HIV infections.

CONCLUSIONS

The incidence and prevalence showed regional differences, suggesting a difference in the dynamics of HIV transmission; some regions have a greater case accumulation, and others have a greater rate of new infections. Understanding this dynamic will allow developing health programs focused on HIV prevention or treating people already living with HIV.

Population Viral Load, Viremia, and Recent HIV-1 Infections: Findings From Population-Based HIV Impact Assessments (PHIAs) in Zimbabwe, Malawi, and Zambia

BACKGROUND

HIV population viral load (PVL) can reflect antiretroviral therapy program effectiveness and transmission potential in a community. Using nationally representative data from household surveys conducted in Zimbabwe, Malawi, and Zambia in 2015-16, we examined the association between various VL measures and the probability of at least one recent HIV-1 infection in the community.

METHODS

We used limiting-antigen avidity enzyme immunoassay, viral load suppression (VLS) (HIV RNA <1000 copies/mL), and antiretrovirals in the blood to identify recent HIV-1 cases.

RESULTS

Among 1510 enumeration areas (EAs) across the 3 surveys, 52,036 adults aged 15-59 years resided in 1363 (90.3%) EAs with at least one HIV-positive adult consenting to interview and blood draw and whose VL was tested. Mean HIV prevalence across these EAs was 13.1% [95% confidence intervals (CI) 12.7 to 13.5]. Mean VLS prevalence across these EAs was 58.7% (95% CI: 57.3 to 60.0). In multivariable analysis, PVL was associated with a recent HIV-1 case in that EA (adjusted odds ratio: 1.4, 95% CI: 1.2 to 1.6, P = 0.001). VLS prevalence was inversely correlated with recent infections (adjusted odds ratio: 0.3, 95% CI: 0.1 to 0.6, P = 0.004). The 90-90-90 indicators, namely, the prevalence of HIV diagnosis, antiretroviral therapy coverage, and VLS at the EA level, were inversely correlated with HIV recency at the EA level.

CONCLUSIONS

We found a strong association between PVL and VLS prevalence and recent HIV-1 infection at the EA level across 3 southern African countries with generalized HIV epidemics. These results suggest that population-based measures of VLS in communities may serve as a proxy for epidemic control.

Targeted HIV screening in the emergency department

Despite considerable improvement in human immunodeficiency virus (HIV) knowledge and treatment in the last 3 decades, the overall number of people living with HIV (PLHIV) is still rising with up to one quarter being unaware of their HIV status. Early HIV diagnosis and treatment prolongs life, reduces transmission, improves quality of life, and is a cost-effective public health intervention. The emergency department (ED) sees a large number of patients from marginalized and traditionally underserved populations in whom HIV is known to be more prevalent and who may not attend traditional services because of either cultural reasons or because of a chaotic lifestyle. This article discusses the two main approaches to screening; 'Opt-out' screening offers testing routinely in all clinical settings, and 'Targeted' screening offers testing to individuals presenting with indicator conditions. There are many studies of 'Opt-out' ED HIV screening in urban areas of high-HIV prevalence. However, little is known about the effectiveness of 'targeted' HIV screening, especially in areas of low prevalence. This review discusses the background to HIV screening in the ED and reviews the evidence around 'targeted' HIV screening in adult EDs in different HIV prevalence settings, concluding that targeted HIV screening at the ED can be impactful, cost-effective, and well accepted in the ED population, but its long-term implementation requires extra funding and increased staffing resource limiting its application in low resource setting. Despite most evidence being from areas of high-HIV prevalence, targeted screening might also be appropriate in low-HIV prevalence areas.

Temporal change in population-level prevalence of detectable HIV viraemia and its association with HIV incidence in key populations in India: a serial cross-sectional study

BACKGROUND

Population-level prevalence of detectable HIV viraemia (PDV) has been proposed as a metric for monitoring the population-level effectiveness of HIV treatment as prevention. We aimed to characterise temporal changes in PDV in people who inject drugs (PWID) and men who have sex with men (MSM) in India and evaluate community-level and individual-level associations with cross-sectional HIV incidence.

METHODS

We did a serial cross-sectional study in which baseline (from Oct 1, 2012, to Dec 19, 2013) and follow-up (from Aug 1, 2016, to May 28, 2017) respondent-driven sampling (RDS) surveys were done in MSM (ten community sites) and PWID (12 community sites) across 21 cities in India. Eligible participants were those aged 18 years or older who provided informed consent and possessed a valid RDS referral coupon. Annualised HIV incidence was estimated with validated multiple-assay algorithms. PDV was calculated as the percentage of people with detectable HIV RNA (>150 copies per mL) in a community site. Community-level associations were determined by linear regression. Multivariable, multilevel Poisson regression was used to assess associations with recent HIV infection.

FINDINGS

We recruited 21 990 individuals in the baseline survey and 21 726 individuals in the follow-up survey. The median community-level HIV incidence estimate increased from 0·9% (range 0·0-2·2) at baseline to 1·5% (0·5-3·0) at follow-up in MSM and from 1·6% (0·5-12·4) to 3·6% (0·0-18·4) in PWID. At the community-level, every 1 percentage point increase in baseline PDV and temporal change in PDV between surveys was associated with higher annualised HIV incidence at follow-up: for baseline PDV β=0·41 (95% CI 0·18-0·63) and for change in PDV β=0·52 (0·38-0·66). After accounting for individual-level risk factors, every 10 percentage point increase in baseline PDV and temporal change in PDV was associated with higher individual-level risk of recent HIV infection at follow-up: adjusted risk ratio 1·85 (95% CI 1·44-2·37) for baseline PDV and 1·81 (1·43-2·29) for change in PDV.

INTERPRETATION

PDV was temporally associated with community-level and individual-level HIV incidence. These data support scale-up of treatment as prevention programmes to reduce HIV incidence and the programmatic use of PDV to monitor community HIV risk potential.

FUNDING

US National Institutes of Health, Elton John AIDS Foundation.

How Stigma Toward Anal Sexuality Promotes Concealment and Impedes Health-Seeking Behavior in the U.S. Among Cisgender Men Who Have Sex with Men

Gay, bisexual, and other men who have sex with men (MSM) experience alarming HIV disparities alongside sub-optimal engagement in HIV interventions. Among MSM, stigma toward anal sexuality could interfere with engagement in HIV prevention, yet few studies have examined MSM perspectives on anal sex stigma or its health-related sequelae. Guided by theory, we aimed to characterize anal sex stigma, related sexual concerns, and barriers to health seeking, like concealment. We elicited community input by purposively interviewing 10 experts in MSM health and then 25 racially, ethnically, and geographically diverse cisgender MSM. Participants reported experienced, internalized, and anticipated forms of anal sex stigma that inhibited health seeking. Experienced stigma, including direct and observed experiences as well as the absence of sex education and information, contributed to internalized stigma and anticipation of future devaluation. This process produced psychological discomfort and concealment of health-related aspects of anal sexuality, even from potentially supportive sexual partners, social contacts, and health workers. Participants characterized stigma and discomfort with disclosure as normative, pervasive, and detrimental influences on health-seeking behavior both during sex and within healthcare interactions. Omission of information appears to be a particularly salient determinant of sexual behavior, inhibiting prevention of harm, like pain, and leading to adverse health outcomes. The development of measures of anal sex stigma and related sexual concerns, and testing their impact on comfort with disclosure, sexual practices, and engagement in health services could identify modifiable social pathways that contribute to health disparities among MSM, like those seen in the HIV epidemic.

The Role of Targeted HIV Screening in the Emergency Department: A Scoping Review

BACKGROUND

Human immunodeficiency virus (HIV) infection continues to expand worldwide, and a significant proportion of infection is still undiagnosed. Recent studies have addressed the impact and feasibility of 'opt-out' HIV screening in Emergency Departments (EDs) in urban settings at high HIV prevalence, whereas little is known about the yield of implementing 'targeted' HIV testing, especially in low-prevalence areas.

OBJECTIVE

The present study undertakes a scoping review of research carried out on the implementation of targeted HIV screening of adult in EDs to determine the impact, feasibility and acceptability of HIV testing in different HIV prevalence settings.

DESIGN

Online databases (EMBASE, MEDLINE) were used to identify papers published between 2000 to 2020. A three-concept search was employed with HIV (HIV, Human immunodeficiency virus infection, HIV infections), targeted testing (Target, screening or testing) and emergency medicine (Emergency Service, emergency ward, A&E, accident and emergency or Emergency Department) (28^th February 2020). Only full-text articles written in English, French, Spanish or Italian and using impact and/or feasibility and/or acceptability of the program as primary or secondary outcomes were analysed.

RESULTS

The search provided 416 articles. Of these, 12 met inclusion criteria and were included in the final review. Most of the included studies were carried out in the United States (n=8; 67%) and in areas of high HIV prevalence (n=11; 92%). Three (20%) were randomized control studies. While the rate of newly diagnosed HIV cases varied widely (0.03-2.2%), likely due to methodological heterogeneity between studies, the linkage of new HIV diagnosis was often high (80-100%) and median CD4+ cell count was always greater than 200 cells per microliter. Targeted HIV screening was found to be cost-effective (out of 2 studies) and well accepted by participants (out 2 studies).

CONCLUSIONS

Targeted HIV screening at the ED can be impactful, feasible and well accepted, but often requires extra funding and staff. Most previous work has focused on areas of high disease prevalence.

Getting to 90-90-90: Experiences from the MaxART Early Access to ART for All (EAAA) Trial in Eswatini

PURPOSE OF REVIEW

The MaxART Consortium-led by the Eswatini Ministry of Health-implemented multiple interventions between 2012 and 2017 to achieve UNAIDS 90-90-90 targets. We summarize key findings from community outreach strategies in support of the first 90 goal, and from the Early Access to ART for All (EAAA) trial on the implementation of a "Treat All" strategy to achieve the second and third 90 goals within a government-managed public health system.

RECENT FINDINGS

The MaxART Consortium demonstrated that "Fast Track," a problem-solving approach, was effective at increasing testing coverage in the community. Compared with baseline data at 3 months prior to the start of the Fast Track, there was a 273% proportional increase in HIV tests conducted among adolescent males, adolescent females, and adult men, and 722% over baseline for adolescent males. The MaxART EAAA trial further showed that implementation of the Treat All policy was associated with significant two-fold shorter time from enrollment into care to ART initiation than under the standard CD4+ cell threshold-based treatment guidelines. Finally, through the MaxART trial, Eswatini was able to identify areas for further investment, including addressing the system-side barriers to routine viral load monitoring, and designing and implementing innovative community-based approaches to reach individuals who were not more routinely accessing HIV testing and counseling services. As low- and middle-income countries adopt the Treat All approach in their national HIV care and treatment guidelines, further implementation science research is needed to understand and address the system-level barriers to achieving the benefits of Treat All for HIV-infected individuals and those at risk.

Modeling an integrated HIV prevention and care continuum to achieve the Ending the HIV Epidemic goals

OBJECTIVE

We sought to evaluate, which combinations of HIV prevention and care activities would have the greatest impact towards reaching the US Ending the HIV Epidemic (EHE) plan goals of HIV incidence reduction.

DESIGN

A stochastic network-based HIV transmission model for men who have sex with men (MSM), calibrated to surveillance estimates in the Atlanta area, a focal EHE jurisdiction.

METHODS

Model scenarios varied HIV screening rates under different assumptions of how HIV-negative MSM would be linked to PrEP initiation, and rates of HIV care linkage and retention for those screening positive.

RESULTS

A ten-fold relative increase in HIV screening rates (to approximately biannual screening for black and Hispanic MSM and quarterly for white MSM) would lead to 43% of infections averted if integrated with PrEP initiation. Improvements focused only on black MSM would achieve nearly the same outcome (37% of infections averted). Improvements to HIV care retention would avert 41% of infections if retention rates were improved ten-fold. If both screening and retention were jointly improved ten-fold, up to 74% of cumulative infections would be averted. Under this scenario, it would take 4 years to meet the 75% EHE goal and 12 years to meet the 90% goal for Atlanta MSM.

CONCLUSION

Reaching the EHE 75% incidence reduction goals by their target dates will require immediate and substantial improvements in HIV screening, PrEP, and ART care retention. Meeting these EHE goals in target jurisdictions like Atlanta will be possible only by addressing the HIV service needs of black MSM.

The Evolution of HIV Prevention: From Discipline to Control

HIV prevention has changed since the identification of AIDS in 1981, the discovery of HIV in 1983, and the rollout of HIV antibody testing in 1985. Since this time, HIV prevention changed from behavior modification to testing to treatment as prevention to chemoprophylaxis using HIV medications among HIV-negative persons. While these modifications have been heralded as public health successes, critical evaluations are needed. In this article, we present one such review in which we argue that HIV prevention, while previously disciplinary in the Foucauldian sense, has become controlling in the Deleuzian sense. In this way, the parameters of context are targeted and behavior change is less relevant. This highlights the importance of questioning public health "advancements" and using novel theoretical lens to do so.

Comparison of machine learning methods for predicting viral failure: a case study using electronic health record data

Background

Human immunodeficiency virus (HIV) viral failure occurs when antiretroviral therapy fails to suppress and sustain a person's viral load count below 1,000 copies of viral ribonucleic acid per milliliter. For those newly diagnosed with HIV and living in a setting where healthcare resources are limited, such as a low- and middle-income country, the World Health Organization recommends viral load monitoring six months after initiation of antiretroviral treatment and yearly thereafter. Deviations from this schedule are made in cases where viral failure occurs or at the discretion of the clinician. Failure to detect viral failure in a timely fashion can lead to delayed administration of essential interventions. Clinical prediction models based on information available in the patient medical record are increasingly being developed and deployed for decision support in clinical medicine and public health. This raises the possibility that prediction models can be used to detect potential for viral failure in advance of viral measurements, particularly when those measurements occur infrequently.

Objective

Our goal is to use electronic health record data from a large HIV care program in Kenya to characterize and compare the predictive accuracy of several statistical machine learning methods for predicting viral failure at the first and second measurements following initiation of antiretroviral therapy. Predictive accuracy is measured in terms of sensitivity, specificity and area under the receiver-operator characteristic curve.

Methods

We trained and cross-validated 10 statistical machine learning models and algorithms on data from over 10,000 patients in the Academic Model Providing Access to Healthcare care program in western Kenya. These included parametric, non-parametric, ensemble, and Bayesian methods. The input variables included 50 items from the clinical record, hand picked in consultation with clinician experts. Predictive accuracy measures were calculated using 10-fold cross validation.

Results

Viral load failure rate is about 20% in this patient cohort at both the first and second measurements. Ensemble techniques generally outperformed other methods. For predicting viral failure at the first follow up measure, specificity was over 90% for these methods, but sensitivity was typically in the 50-60% range. Predictive accuracy was greater for the second follow up measure, with sensitivities over 80%. Super Learner, gradient boosting and Bayesian additive regression trees consistently outperformed other methods. For a viral failure rate of 20%, the positive predictive value for the top-performing methods is between 75 and 85%, while the negative predictive value is over 95%.

Conclusion

Evidence from this study suggests that machine learning techniques have potential to identify patients at risk for viral failure prior to their scheduled measurements. Ultimately, prognostic virologic assessment can help guide the administration of earlier targeted intervention such as enhanced drug resistance monitoring, rigorous adherence counseling, or appropriate next-line therapy switching. External validation studies should be used to confirm the results found here.

Successes and gaps in the HIV cascade of care of a high HIV prevalence setting in Zimbabwe: a population-based survey

INTRODUCTION

Gutu, a rural district in Zimbabwe, has been implementing comprehensive HIV care with the support of Médecins Sans Frontières (MSF) since 2011, decentralizing testing and treatment services to all rural healthcare facilities. We evaluated HIV prevalence, incidence and the cascade of care, in Gutu District five years after MSF began its activities.

METHODS

A cross-sectional study was implemented between September and December 2016. Using multistage cluster sampling, individuals aged ≥15 years living in the selected households were eligible. Individuals who agreed to participate were interviewed and tested for HIV at home. All participants who tested HIV-positive had their HIV-RNA viral load (VL) measured, regardless of their antiretroviral therapy (ART) status, and those not on ART with HIV-RNA VL ≥ 1000 copies/mL had Limiting-Antigen-Avidity EIA Assay for cross-sectional estimation of population-level HIV incidence.

RESULTS

Among 5439 eligible adults ≥15 years old, 89.0% of adults were included in the study and accepted an HIV test. The overall prevalence was 13.6% (95%: Confidence Interval (CI): 12.6 to 14.5). Overall HIV-positive status awareness was 87.4% (95% CI: 84.7 to 89.8), linkage to care 85.5% (95% CI: 82.5 to 88.0) and participants in care 83.8% (95% CI: 80.7 to 86.4). ART coverage among HIV-positive participants was 83.0% (95% CI: 80.0 to 85.7). Overall, 71.6% (95% CI 68.0 to 75.0) of HIV-infected participants had a HIV-RNA VL < 1000 copies/mL. Women achieved higher outcomes than men in the five stages of the cascade of care. Viral Load Suppression (VLS) among participants on ART was 83.2% (95% CI: 79.7 to 86.2) and was not statistically different between women and men (p = 0.98). The overall HIV incidence was estimated at 0.35% (95% CI 0.00 to 0.70) equivalent to 35 new cases/10,000 person-years.

CONCLUSIONS

Our study provides population-level evidence that achievement of HIV cascade of care coverage overall and among women is feasible in a context with broad access to services and implementation of a decentralized model of care. However, the VLS was relatively low even among participants on ART. Quality care remains the most critical gap in the cascade of care to further reduce mortality and HIV transmission.

Variation in estimated viral suppression associated with the definition of viral suppression used

OBJECTIVE

The proportion of people living with HIV with suppressed viral load is a key indicator of the HIV care continuum. We explored how this proportion varied depending on how it was calculated.

DESIGN

Observational cohort study.

METHODS

We calculated the proportion of the Johns Hopkins HIV Clinical Cohort who were virally suppressed each year, 2010-2018, based on different denominators; thresholds for suppression (≤20, ≤50, ≤200, or ≤400 copies/ml); and strategies for summarizing multiple viral load measurements (we classified persons as suppressed if they had any lab, ≥50% of labs, last lab, or all labs below the threshold). We also calculated 5-year risk of all-cause mortality associated with each classification of viral suppression.

RESULTS

Three thousand eleven persons contributed 60 858 viral load values to this analysis. Proportion classified as virally suppressed ranged from 51.8 to 92.5%, depending on the definition used and persons included in the calculation. Requiring more labs below the threshold; using a lower threshold; and assuming persons lost to follow-up were not suppressed (stricter definitions) resulted in a lower proportion estimated to be suppressed. Suppression by stricter definitions were associated with better 5-year survival.

DISCUSSION

The proportion suppressed varied greatly as a function of the subset of persons in whom it was calculated, the threshold used for suppression, and the way multiple viral loads per person per year were summarized. Measures of durable viral suppression, and low-level viremia (20-400 copies/ml), should be considered in describing the health of people with HIV, in addition to the standard estimates of suppression.

Community viral load and hepatitis C virus infection: Community viral load measures to aid public health treatment efforts and program evaluation

BACKGROUND

Hepatitis C virus (HCV) infection is the most prevalent blood-borne infection and causes more deaths than any other infectious disease in the US. Incident HCV infection in the US increased nearly 300 % between 2010 and 2015, Community viral load (CVL) measures have been developed for HIV to measure both transmission risk and treatment engagement in programs or areas.

OBJECTIVE

This paper presents a systematic review exploring the published literature on CVL constructs applied to HCV epidemiology and proposes novel CVL measures for HCV.

STUDY DESIGN AND SETTING

A systematic review was conducted of electronic databases; the search sought to identify published literature on HCV which discussed or applied CVL measures to HCV epidemiology. Novel CVL measures were constructed to apply to HCV.

RESULTS

No reports examining quantitative measures of HCV CVL were identified. Using the HIV CVL literature and the specific characteristics of HCV epidemiology, five HCV CVL measures are proposed. Narrower measures focusing on those engaged-in-care may be useful for program evaluation and broader measures including undiagnosed people may be useful for surveillance of HCV transmission potential.

CONCLUSION

Despite their potential value, CVL constructs have not yet formally been developed and applied to HCV epidemiology. The CVL measures proposed here could serve as valuable HCV program and surveillance measures. There is a need for informative surveillance measures to enhance policy and public health responses to achieve HCV control. Further study of these proposed HCV CVL measures to HCV epidemiology is warranted.

Does Stigma Toward Anal Sexuality Impede HIV Prevention Among Men Who Have Sex With Men in the United States? A Structural Equation Modeling Assessment

INTRODUCTION

Men who have sex with men (MSM) are suboptimally engaged in efficacious HIV interventions, due in part to stigma.

AIM

We sought to validate the Anal Health Stigma Model, developed based on theory and prior qualitative data, by testing the magnitude of associations between measures of anal sex stigma and engagement in HIV prevention practices, while adjusting for covariates.

METHODS

We conducted a cross-sectional online survey of 1,263 cisgender MSM living in the United States and analyzed data with structural equation modeling. We tested a direct path from Anal Sex Stigma to Engagement in HIV Prevention alongside 2 indirect paths, 1 through Anal Sex Concerns and another through Comfort Discussing Anal Sexuality with Health Workers. The model adjusted for Social Support, Everyday Discrimination, and Sociodemographics.

MAIN OUTCOME MEASURE

Engagement in HIV Prevention comprised an ad hoc measure of (i) lifetime exposure to a behavioral intervention, (ii) current adherence to biomedical intervention, and (iii) consistent use of a prevention strategy during recent penile-anal intercourse.

RESULTS

In the final model, anal sex stigma was associated with less engagement (β = -0.22, P < .001), mediated by participants' comfort talking about anal sex practices with health workers (β = -0.52; β = 0.44; both P < .001), adjusting for covariates (R2 = 67%; χ2/df = 2.98, root mean square error of approximation = 0.040, comparative fit index = 0.99 and Tucker-Lewis index = 0.99). Sex-related concerns partially mediated the association between stigma and comfort (β = 0.55; β = 0.14, both P < .001). Modification indices also supported total effects of social support on increased comfort discussing anal sex (β = 0.35, P < .001) and, to a lesser degree, on decreased sex-related concerns (β = -0.10; P < .001).

CLINICAL IMPLICATIONS

Higher stigma toward anal sexuality is associated with less engagement in HIV prevention, largely due to discomfort discussing anal sex practices with health workers.

STRENGTH & LIMITATIONS

Adjustment for mediation in a cross-sectional design cannot establish temporal causality. Self-report is vulnerable to social desirability and recall bias. Online samples may not represent cisgender MSM in general. However, findings place HIV- and health-related behaviors within a social and relational context and may suggest points for intervention in health-care settings.

CONCLUSION

Providers' willingness to engage in discussion about anal sexuality, for example, by responding to questions related to sexual well-being, may function as social support and thereby bolster comfort and improve engagement in HIV prevention. Kutner BA, Simoni JM, King KM, et al. Does Stigma Toward Anal Sexuality Impede HIV Prevention Among Men Who Have Sex With Men in the United States? A Structural Equation Modeling Assessment. J Sex Med 2020;17:477-490.

Intersectional Stigma and Multi-Level Barriers to HIV Testing Among Foreign-Born Black Men From the Caribbean

Testing is the entry point into the HIV care continuum that includes linkage to and retention in prevention services, and adherence to prevention strategies, including repeat HIV testing. Despite US policy approaches to expand HIV testing to diverse clinical care and community settings, disparities in HIV testing among Black populations persist. Foreign-born (FB) Black persons from the Caribbean have higher annual rates of HIV diagnosis and a higher percentage of late-stage HIV diagnosis, compared with US-born Black persons; and most HIV infections among FB Blacks are among men. In this article, we provide an overview of HIV testing barriers among FB Black men who engage in HIV risk-taking behaviors (e.g., condomless sex with male and/or female partners of unknown HIV serostatus). Barriers to HIV testing for both FB and US-born Black men, include HIV stigma (anticipated, perceived, internalized), low perceived HIV risk, medical or government mistrust, and perceived low access to testing resources. We examine beliefs about masculinity and gender roles that may perpetuate heteronormative stereotypes associated with perceptions of low HIV risk and barriers to HIV testing. We also discuss the impact of recent immigration policies on accessing HIV testing and treatment services and how intersectional stigmas and structural forms of oppression, such as racism, prejudice against select immigrant groups, and homophobia that may further amplify barriers to HIV testing among FB Black men. Finally, we review comprehensive prevention approaches, and suggest innovative approaches, that may improve the uptake of HIV testing among FB Black men.

Relevance of HTLV-1 proviral load in asymptomatic and symptomatic patients living in endemic and non-endemic areas of Argentina

HTLV-1 proviral load (pVL) in peripheral blood mononuclear cell (PBMCs) is proposed as a marker of disease progression but its role still remains controversial. The aim of this study was to evaluate the levels of HTLV-1 pVL in symptomatic patients and asymptomatic HTLV-1 carriers. In this cross-sectional study the pVL was measured by Real Time PCR in 102 asymptomatic carriers and 22 symptomatic patients (5ATLL, 15 TSP and 2 uveitis). We observed that the HTLV-1 pVL was significantly higher in symptomatic patients (median = 4.99 log10 HTLV-1 copies /106 PBMCs) compared to asymptomatic HTLV-1 carriers (median = 4.38 log₁₀ HTLV-1 copies /10⁶ PBMCs; p = 0.0030). A wide variation on the HTLV-1 pVL levels among asymptomatic HTLV-1 carriers was observed with some pVL as high as those observed in symptomatic patients. The asymptomatic HTLV-1 carriers were divided according to the place of birth and the highest levels of pVL were detected among patients from endemics areas from the North of Argentina. Our results reinforce the usefulness of the proviral load would be a prognostic marker of HTLV-1 disease progression. Moreover, host, viral or socio-environmental factors cannot be excluded as determinant of high proviral load.

Longitudinal Trends in the Prevalence of Detectable HIV Viremia: Population-Based Evidence From Rural KwaZulu-Natal, South Africa

Background

The prevalence of detectable viremia has previously been used to infer the potential for ongoing human immunodeficiency virus (HIV) transmission. To date, no study has evaluated the longitudinal change in the prevalence of detectable viremia within the HIV-positive community (PDV+) and the entire population (PDVP) using data from a sub-Saharan African setting.

Methods

In 2011, 2013, and 2014, we obtained 6752 HIV-positive and 15415 HIV-negative test results from a population-based surveillance system in the KwaZulu-Natal province of South Africa. We quantified the PDV+ as the proportion of the 6752 HIV-positive results with a viral load >1550 copies/mL and the PDVP as the proportion of the 6752 HIV-positive and 15415 HIV-negative results with a viral load >1550 copies/mL.

Results

Between 2011 and 2014, the PDV+ decreased by 16.5 percentage points (pp) for women (from 71.8% to 55.3%) and 10.6 pp for men (from 77.8% to 67.2%). However, a steady rise in the overall HIV prevalence, from 26.7% to 32.4%, offset the declines in the PDV+ for both sexes. For women, the PDVP decreased by only 2.1 pp, from 21.3% to 19.2%, but for men, the PDVP actually increased by 1.6 pp, from 14.6% to 16.2%, over the survey period.

Conclusions

The PDV+, which is currently being tracked under the UNAIDS 90-90-90 targets, may not be an accurate indicator of the potential for ongoing HIV transmission. There is a critical need for countries to monitor and report the prevalence of detectable viremia among all adults, irrespective of HIV status.

Knowledge and Acceptability of HIV pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) in Ghana

In Ghana, men who have sex with men (MSM) are disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) is a biomedical intervention that reduces the risk of HIV infection but is not currently available in Ghana. This paper explores knowledge and acceptability of HIV PrEP among Ghanaian MSM. Qualitative content analysis was conducted on 22 focus group discussions (N = 137) conducted between March and June 2012 in Accra, Kumasi, and Manya Krobo. Overall, participants reported low knowledge of PrEP. However, once information about PrEP was provided, there was high acceptability. The primary reason for acceptability was that PrEP provided an extra level of protection against HIV. Acceptability of PrEP was conditioned on it having minimal side effects, being affordable and efficient in preventing HIV infection. No acceptability of PrEP was attributed to limited knowledge of side effects and perceived lack of effectiveness. The reasons provided to utilize PrEP and condoms were that condoms protect against other STIs, and sexual partner factors. This is the first known study to explore PrEP knowledge and acceptability among Ghanaian MSM. It is important that key stakeholders preemptively address potential barriers to PrEP acceptability, uptake, and adherence, especially among MSM, once PrEP becomes available in Ghana.

An Integrated Examination of County- and Individual-Level Factors in Relation to HIV Pre-exposure Prophylaxis Awareness, Willingness to Use, and Uptake Among Men Who Have Sex with Men in the US

This study explored the extent to which county- and individual-level factors were associated with awareness, willingness to use, and use of pre-exposure prophylaxis (PrEP) among US men who have sex with men (MSM). We conducted multilevel analyses using a sample of 8338 MSM residing in 1257 US counties drawn from the 2014-2015 American Men's Internet Survey to examine these associations, with focuses on variation in PrEP outcomes across counties and proportion variation explained by county-level factors (HIV prevalence, racial composition, median household income, income inequality, health insurance coverage). Results showed that PrEP awareness varied moderately across counties (intraclass correlation coefficients [ICC] = 7.7%), willingness to use did not vary; however, the actual use varied substantially (ICC = 20.7%). Half of the variation in awareness and use was explained by county-level factors. Higher median household income was associated with greater likelihood of awareness and use. Higher income inequality was associated with greater likelihood of PrEP awareness. Findings can inform the development of multilevel interventions to address PrEP uptake among MSM and identify communities where structural intervention is most needed.

A coupled multiscale model to guide malaria control and elimination

In this paper, we share with the biomathematics community a new coupled multiscale model which has the potential to inform policy and guide malaria control and elimination. The formulation of this multiscale model is based on integrating four submodels which are: (i) a sub-model for the mosquito-to-human transmission of malaria parasite, (ii) a sub-model for the human-to-mosquito transmission of malaria parasite, (iii) a within-mosquito malaria parasite population dynamics sub-model and (iv) a within-human malaria parasite population dynamics sub-model. The integration of the four submodels is achieved by assuming that the transmission parameters of the sub-model for the mosquito-to-human transmission of malaria at the epidemiological scale are functions of the dependent variables of the within-mosquito sporozoite population dynamics while the transmission parameters of the sub-model for the human-to-mosquito transmission of malaria are functions of the dependent variables of the within-human gametocyte population dynamics. This establishes a unidirectionally coupled multiscale model where the within-human and within-mosquito submodels are unidirectionally coupled to the human-to-mosquito and mosquito-to-human submodels. A fast and slow time scale analysis is performed on this system. The result is a simple multiscale model which describes the mechanics of malaria transmission in terms of the major components of the complete malaria parasite life-cycle. This multiscale modelling approach may be found useful in guiding malaria control and elimination.

'Just another vial…': a qualitative study to explore the acceptability and feasibility of routine blood-borne virus testing in an emergency department setting in the UK

OBJECTIVES

Increased test uptake for HIV and viral hepatitis is fast becoming a health priority at both national and global levels. Late diagnosis of these infections remains a critical public health concern in the UK. Recommendations have been issued to expand blood-borne virus (BBV) testing in alternative settings. Emergency departments (EDs) offer a potentially important point of testing. This paper presents findings from a qualitative study which aimed to explore the acceptability and feasibility of a routine opt-out combined BBV testing intervention implemented at an inner London ED.

METHODS

We conducted 22 semistructured interviews with patients and service providers in the ED over a 4-month period during the intervention pilot. A grounded analytical approach was employed to conduct thematic analysis of qualitative study data.

RESULTS

Core interrelating thematic areas, identified and analytically developed in relation to test intervention implementation and experience, included the following: the remaking of routine test procedure; notions of responsibility in relation to status knowledge and test engagement; the opportunity and constraints of the ED as a site for testing; and the renegotiation of testing cultures within and beyond the clinic space.

CONCLUSION

Study findings demonstrate how relational and spatial dynamics specific to the ED setting shape test meaning and engagement. We found acceptability of the test practice was articulated through narratives of situated responsibility, with the value of the test offset by perceptions of health need and justification of the test expense. Participant accounts indicate that the nontargeted approach of the test affords a productive disruption to 'at-risk' identities, yet they also reveal limits to the test intervention's 'normalising' effect. Evaluation of the intervention must attend to the situated dynamics of the test practice if opportunities of an opt-out BBV test procedure are to be fully realised. Findings also highlight the critical need to further evaluate post-test intervention practices and experiences.

FROM INDIVIDUAL HEALTH TO COMMUNITY HEALTH: TOWARDS MULTISCALE MODELING OF DIRECTLY TRANSMITTED INFECTIOUS DISEASE SYSTEMS

In this paper, we present a new method for developing a class of nested multiscale models for directly transmitted infectious disease systems that integrates within-host scale and between-host scale using community pathogen load (CPL) as a new public health measure of a community’s level of infectiousness and as an indicator of the effectiveness of health interventions. The approach develops a multiscale modeling science base for directly transmitted infectious disease systems (where the inside-host environment’s biological entities such as cells, tissues, organs, body fluids, whole body are the reservoir of infective pathogen in the community) that is comparable to an existing multiscale modeling science base for environmentally transmitted infectious diseases (where the outside-host geographical environment’s physical entities such as soil, air, formites/contact surfaces, food and water are the reservoir of infective pathogen in the community) where pathogen load in the environment is explicitly incorporated into the model. This is achieved by assuming that infected hosts in the community are homogeneous and unevenly distributed microbial habitats. We illustrate the utility of this multiscale modeling methodology by evaluating the comparative effectiveness of HIV/AIDS preventive and treatment interventions as a case study.

Performance of a Novel Low-Cost, Instrument-Free Plasma Separation Device for HIV Viral Load Quantification and Determination of Treatment Failure in People Living with HIV in Malaysia: a Diagnostic Accuracy Study

HIV viral load (VL) testing is the recommended method for monitoring the response of people living with HIV and receiving antiretroviral therapy (ART). The availability of standard plasma VL testing in low- and middle-income countries (LMICs), and access to this testing, are limited by the need to use fresh plasma. Good specimen collection methods for HIV VL testing that are applicable to resource-constrained settings are needed. We assessed the diagnostic performance of the filtered dried plasma spot (FDPS), created using the newly developed, instrument-free VLPlasma device, in identifying treatment failure at a VL threshold of 1,000 copies/ml in fresh plasma. Performance was compared with that of the conventional dried blood spot (DBS). Venous blood samples from 201 people living with HIV and attending an infectious disease clinic in Malaysia were collected, and HIV VL was quantified using fresh plasma (the reference standard), FDPS, and DBS specimens. VL testing was done using the Roche Cobas AmpliPrep/Cobas TaqMan v2.0 assay. At a threshold of 1,000 copies/ml, the diagnostic performance of the FDPS was superior (sensitivity, 100% [95% confidence interval {CI}, 89.1 to 100%]; specificity, 100% [95% CI, 97.8 to 100%]) to that of the DBS (sensitivity, 100% [95% CI, 89.4 to 100%]; specificity, 36.8% [95% CI, 29.4 to 44.7%]) (P < 0.001). A stronger correlation was observed between the FDPS VL and the plasma VL (r = 0.94; P < 0.001) than between the DBS VL and the plasma VL (r = 0.85; P < 0.001). The mean difference in VL measures between the FDPS and plasma (plasma VL minus FDPS VL) was 0.127 log₁₀ copies/ml (standard deviation [SD], 0.32), in contrast to -0.95 log₁₀ copies/ml (SD, 0.84) between the DBS and plasma. HIV VL measurement using the FDPS outperformed that with the DBS in identifying treatment failure at a threshold of 1,000 copies/ml and compared well with the quantification of VL in plasma. The FDPS can be an attractive alternative to fresh plasma for improving access to HIV VL monitoring among people living with HIV on ART in LMICs.

The importance of local epidemic conditions in monitoring progress towards HIV epidemic control in Kenya: a modelling study

INTRODUCTION

Setting and monitoring progress towards targets for HIV control is critical in ensuring responsive programmes. Here, we explore how to apply targets for reduction in HIV incidence to local settings and which indicators give the strongest signal of a change in incidence in the population and are therefore most important to monitor.

METHODS

We use location-specific HIV transmission models, tailored to the epidemics in the counties and major cities in Kenya, to project a wide range of plausible future epidemic trajectories through varying behaviours, treatment coverage and prevention interventions. We look at the change in incidence across modelled scenarios in each location between 2015 and 2030 to inform local target setting. We also simulate the measurement of a library of potential indicators and assess which are most strongly associated with a change in incidence.

RESULTS

Considerable variation was observed in the trajectory of the local epidemics under the plausible scenarios defined (only 10 of 48 locations saw a median reduction in incidence of greater than or equal to an 80% target by 2030). Indicators that provide strong signals in certain epidemic types may not perform consistently well in settings with different epidemiological features. Predicting changes in incidence is more challenging in advanced generalized epidemics compared to concentrated epidemics where changes in high-risk sub-populations track more closely to the population as a whole. Many indicators demonstrate only limited association with incidence (such as "condom use" or "pre-exposure prophylaxis coverage"). This is because many other factors (low effectiveness, impact of other interventions, countervailing changes in risk behaviours, etc.) can confound the relationship between interventions and their ultimate long-term impact, especially for an intervention with low expected coverage. The population prevalence of viral suppression shows the most consistent associations with long-term changes in incidence even in the largest generalized epidemics.

CONCLUSIONS

Target setting should be appropriate for the local epidemic and what can feasibly be achieved. There is no one universally reliable indicator to predict future HIV incidence across settings. Thus, the signature of epidemic control must contain indications of success across a wide range of interventions and outcomes.

Trends in human immunodeficiency virus diagnoses among men who have sex with men in North America, Western Europe, and Australia, 2000-2014

PURPOSE

The aim of the article was to investigate recent trends in human immunodeficiency virus (HIV) diagnosis rates among men who have sex with men (MSM) in high-income countries in North America, Western Europe, and Australia.

METHODS

Data on annual rates of HIV diagnoses among MSM aged 15 to 65 years from 2000 to 2014 were collected from 13 high-income countries. Joinpoint regression software was used to empirically determine country-specific trend periods. Trends in HIV diagnosis rates and in the proportion of diagnoses occurring in young MSM aged 15 to 24 years were analyzed using Poisson regression and log-binomial regression, respectively.

RESULTS

Six countries experienced an increasing trend from 2000 to 2007-08 followed by either a stable or declining trend through 2014. Five countries had recently increasing trends, and two countries had one stable trend from 2000 to 2014. All 13 countries experienced increases in the proportion of diagnoses occurring in young MSM.

CONCLUSIONS

Since 2008, half of the 13 high-income countries examined experienced stable or decreasing trends. Still, some countries continue to experience increasing HIV trends, and young MSM are increasingly represented among new diagnoses. Efforts to support early sexual health promotion, reduce barriers to pre-exposure prophylaxis, and improve care engagement for young MSM are critical to addressing current HIV trends.

Modelling the dynamics of population viral load measures under HIV treatment as prevention

In 2011 the Centers for Disease Control and Prevention (CDC) published guidelines for the use of population viral load (PVL), community viral load (CVL) and monitored viral load (MVL), defined as the average viral load (VL) of all HIV infected individuals in a population, of all diagnosed individuals, and of all individuals on antiretroviral treatment (ART), respectively. Since then, CVL has been used to assess the effectiveness of ART on HIV transmission and as a proxy for HIV incidence. The first objective of this study was to investigate how aggregate VL measures change with the HIV epidemic phase and the drivers behind these changes using a mathematical transmission model. Secondly, we aimed to give some insight into how well CVL correlates with HIV incidence during the course of the epidemic and roll out of ART. We developed a compartmental model for disease progression and HIV transmission with disease stages that differ in viral loads for epidemiological scenarios relevant to a concentrated epidemic in a population of men who have sex with men (MSM) in Western Europe (WE) and to a generalized epidemic in a heterosexual population in Sub-Saharan Africa (SSA). The model predicts that PVL and CVL change with the epidemic phase, while MVL stays constant. These dynamics are linked to the dynamics of infected subgroups (undiagnosed, diagnosed untreated and treated) in different disease stages (primary, chronic and AIDS). In particular, CVL decreases through all epidemic stages: before ART, since chronic population builds up faster than AIDS population and after ART, due to the build-up of treated population with low VL. The trends in CVL and incidence can be both opposing and coinciding depending on the epidemic phase. Before ART is scaled up to sufficiently high levels, incidence increases while CVL decreases. After this point, CVL is a useful indicator of changes in HIV incidence. The model predicts that during the ART scale-up HIV transmission is driven by undiagnosed and diagnosed untreated individuals, and that new infections decline due to the increase in the number of treated. Although CVL is not able to capture the contribution of undiagnosed population to HIV transmission, it declines due to the increase of people on ART too. In the scenarios described by our model, the present epidemic phase corresponds to declining trends in CVL and incidence.

Community-based HIV prevalence in KwaZulu-Natal, South Africa: results of a cross-sectional household survey

BACKGROUND

In high HIV burden settings, maximising the coverage of prevention strategies is crucial to achieving epidemic control. However, little is known about the reach and effect of these strategies in some communities.

METHODS

We did a cross-sectional community survey in the adjacent Greater Edendale and Vulindlela areas in the uMgungundlovu district, KwaZulu-Natal, South Africa. Using a multistage cluster sampling method, we randomly selected enumeration areas, households, and individuals. One household member (aged 15-49 years) selected at random was invited for survey participation. After obtaining consent, questionnaires were administered to obtain sociodemographic, psychosocial, and behavioural information, and exposure to HIV prevention and treatment programmes. Clinical samples were collected for laboratory measurements. Statistical analyses were done accounting for multilevel sampling and weighted to represent the population. A multivariable logistic regression model assessed factors associated with HIV infection.

FINDINGS

Between June 11, 2014, and June 22, 2015, we enrolled 9812 individuals. The population-weighted HIV prevalence was 36·3% (95% CI 34·8-37·8, 3969 of 9812); 44·1% (42·3-45·9, 2955 of 6265) in women and 28·0% (25·9-30·1, 1014 of 3547) in men (p<0·0001). HIV prevalence in women aged 15-24 years was 22·3% (20·2-24·4, 567 of 2224) compared with 7·6% (6·0-9·3, 124 of 1472; p<0·0001) in men of the same age. Prevalence peaked at 66·4% (61·7-71·2, 517 of 760) in women aged 35-39 years and 59·6% (53·0-66·3, 183 of 320) in men aged 40-44 years. Consistent condom use in the last 12 months was 26·5% (24·1-28·8, 593 of 2356) in men and 22·7% (20·9-24·4, 994 of 4350) in women (p=0·0033); 35·7% (33·4-37·9, 1695 of 5447) of women's male partners and 31·9% (29·5-34·3, 1102 of 3547) of men were medically circumcised (p<0·0001), and 45·6% (42·9-48·2, 1251 of 2955) of women and 36·7% (32·3-41·2, 341 of 1014) of men reported antiretroviral therapy (ART) use (p=0·0003). HIV viral suppression was achieved in 54·8% (52·0-57·5, 1574 of 2955) of women and 41·9% (37·1-46·7, 401 of 1014) of men (p<0·0001), and 87·2% (84·6-89·8, 1086 of 1251) of women and 83·9% (78·5-89·3, 284 of 341; p=0·3670) of men on ART. Age, incomplete secondary schooling, being single, having more than one lifetime sex partner (women), sexually transmitted infections, and not being medically circumcised were associated with HIV-positive status.

INTERPRETATION

The HIV burden in specific age groups, the suboptimal differential coverage, and uptake of HIV prevention strategies justifies a location-based approach to surveillance with finer disaggregation by age and sex. Intensified and customised approaches to seek, identify, and link individuals to HIV services are crucial to achieving epidemic control in this community.

FUNDING

The President's Emergency Plan for AIDS Relief through the Centers for Disease Control and Prevention.

Effect of population viral load on prospective HIV incidence in a hyperendemic rural African community

Monitoring HIV population viral load (PVL) has been advocated as an important means of inferring HIV transmission potential and predicting the future rate of new HIV infections (HIV incidence) in a particular community. However, the relationship between PVL measures and directly measured HIV incidence has not been quantified in any setting and, most importantly, in a hyperendemic sub-Saharan African setting. We assessed this relationship using one of Africa's largest population-based prospective population cohorts in rural KwaZulu-Natal, South Africa in which we followed 8732 HIV-uninfected participants between 2011 and 2015. Despite clear evidence of spatial clustering of high viral loads in some communities, our results demonstrate that PVL metrics derived from aggregation of viral load data only from the HIV-positive members of a particular community did not predict HIV incidence in this typical hyperendemic, rural African population. Only once we used modified PVL measures, which combined viral load information with the underlying spatial variation in the proportion of the population infected (HIV prevalence), did we find a consistently strong relationship with future risk of HIV acquisition. For example, every 1% increase in the overall proportion of a population having detectable virus (PDV _P ) was independently associated with a 6.3% increase in an individual's risk of HIV acquisition (P = 0.001). In hyperendemic African populations, these modified PVL indices could play a key role in targeting and monitoring interventions in the most vulnerable communities where the future rate of new HIV infections is likely to be highest.

Treatment with direct-acting antivirals in a multicenter cohort of HCV-infected inmates in Italy

BACKGROUND

People who are incarcerated have a significantly higher prevalence of HCV infection than the general population. Given their high-risk behavior, they represent a reservoir of HCV infection for the whole community.

METHODS

We evaluated all HCV-infected people who were incarcerated in 25 Italian prisons starting direct-acting antivirals (DAAs) treatment between May 2015 and October 2016. We collected information on demographic characteristics, liver disease, HCV-related aspects, anti-HCV treatment, HIV or HBV co-infection.

RESULTS

We enrolled 142 incarcerated people treated with DAAs. They were mostly Italians (93.7%) and males (98.6%). Median age was 50 years and 108/142 (76.1%) were cirrhotic patients. Prevalent genotypes were 1a (35.9%) and 3 (35.9%). Two patients were HBV co-infected, twenty-one patients (14.8%) were HIV co-infected and almost all (95.2%) received antiretroviral therapy. 118/142 (83.1%) DAAs-based regimens included sofosbuvir. Treatment completion rate was 94.4%. There were eight (5.6%) discontinuations, one (0.7%) due to an adverse reaction, one due to death (0.7%) and six (5.6%) due to release from prison. SVR12 was achieved in 90.8%. Four patients relapsed but no breakthrough occurred.

CONCLUSIONS

Our study shows that in Italian penitentiary settings DAAs treatment is feasible and effective. This intervention is crucial for reducing HCV circulation with possible benefits to the general population.

A Pilot Study to Increase the Efficiency of HIV Outreach Testing Through the Use of Timely and Geolocated HIV Viral Load Surveillance Data

BACKGROUND

Eliminating HIV transmission in a population necessitates identifying population reservoirs of HIV infection and subgroups most likely to transmit. HIV viral load is the single most important predictor of HIV transmission. The objective of this analysis was to evaluate whether a public health practice pilot project based on community viral load resulted in increases in the proportion of time spent testing in high viral load areas (process measure) and 3 outcome measures-the number and percent of overall HIV diagnoses, new diagnoses, and high viral load positives-in one mid-Atlantic US city with a severe HIV epidemic.

METHODS

The evaluation was conducted during three, 3-month periods for 3 years and included the use of community viral load, global positioning system tracking data, and statistical testing to evaluate the effectiveness of the pilot project.

RESULTS

The proportion of time spent outreach testing in high viral load areas (69%-84%, P < 0.001) and the overall number and percent of HIV positives ((60 (3%) to 127 (6%), P < 0.001) significantly increased for 3 years. The number and percent of new diagnoses (3 (0.1%) to 6 (0.2%)) and high viral load positives (5 (0.2%) to 9 (0.4%)) increased, but the numbers were too small for statistical testing.

DISCUSSION

These results suggest that using community viral load to increase the efficiency of HIV outreach testing is feasible and may be effective in identifying more HIV positives. The pilot project provides a model for other public health practice demonstration projects.

Network Viral Load: A Critical Metric for HIV Elimination

BACKGROUND

Associations have been observed between an aggregate viral load measure, the community viral load, and new HIV diagnoses. The community viral load aggregates viral loads within chosen geographic areas, restricting inferences about HIV acquisition risk to these areas. We develop a more precise metric, the network viral load (NVL), to measure the composite viral load within a risk network of a HIV-negative individual.

METHODS

We examined the relationship between NVL and HIV infection among young men who have sex with men in Chicago, United States. Networks were generated using respondent-driven sampling. NVL was defined as the prevalence of viremic individuals in one's risk network, characterized as those with a viral load ≥20 k copies per milliliter. Permutation tests were conducted to account for dependency.

RESULTS

After controlling for total connections, age, substance use during sex, syphilis diagnosis (previous 12 months), and frequency of condomless anal sex (previous 6 months), we found a positive association between NVL and HIV infection. Compared with a network with all HIV-seronegative members, the odds of HIV infection with an NVL of <10% viremia were 1.85 (95% confidence interval: 1.18 to 2.92) times higher and those with an NVL of ≥10% viremia were 2.73 (95% confidence interval: 1.54 to 4.85) times higher.

CONCLUSIONS

We found a positive association between NVL and HIV seroprevalence. Although limited in its ability to infer causality, NVL could have substantial public health implications for persons most at risk for HIV infection, given that this novel metric avoids overreliance on individual level behavior or broad community indices.

Reduction in HIV community viral loads following the implementation of a "Treatment as Prevention" strategy over 2 years at a population-level among men who have sex with men in Hangzhou, China

Background

Previous studies have shown that the increased coverage of antiretroviral therapy (ART) could reduce the community viral load (CVL) and reduce the occurrence of new HIV infections. However, the impact on the reduction of HIV transmission among men who have sex with men (MSM) is much less certain. The frequency of HIV infections in MSM have been rapidly increasing in recent years in Hangzhou, China. The “Treatment as Prevention” strategy was implemented at a population-level for HIV-infected MSM from January 2014 to June 2016 in Hangzhou; it aimed to increase the ART coverage, reduce the CVL, and reduce HIV transmission.

Methods

We investigated a subset of MSM diagnosed with HIV pre- and post-implementation of the strategy, using random sampling methods. Viral load (VL) testing was performed for all enrolled individuals; the lower limits of detection were 20 and 50 copies/mL. The data on infections were collected from the national epidemiology database of Hangzhou. Logistic regression analyses were conducted to identify factors associated with the differences in social demographic characteristics and available VL data.

Results

The ART coverage increased from 60.7% (839/1383) during the pre-implementation period to 92.3% (2183/2365) during the post-implementation period in Hangzhou. A total of 940 HIV-infected MSM were selected for inclusion in this study: 490 (52.1%) and 450 (47.9%) MSM in the pre- and post-implementation periods, respectively. In total, 89.5% (841/940) of patients had data available on VL rates. The mean CVL was 579 copies/mL pre-implementation and this decreased to 33 copies/mL post-implementation (Kruskal-Wallis < 0.001). The mean CVL decreased for all variables investigated post-implementation of the treatment strategy (P < 0.05). The undetectable VL (≤400 copies/mL) rate pre-implementation period was 50.0% which increased to 84.7% post-implementation (P < 0.001). The mean CVL at the county level significantly decreased in each county post-implementation (Kruskal-Wallis < 0.05).

Conclusion

Our study confirmed a population-level association between increased ART coverage and decreased mean CVL; overall 84.7% of HIV infected MSM had an undetectable VL and were no longer infectious.

The validity of self-reported antiretroviral use in persons living with HIV: a population-based study

OBJECTIVE

To assess the validity of self-reported antiretroviral therapy use (ART) using population-based cohort data.

METHODS

Self-reported ART use and nonuse was compared with a validated laboratory assay in 557 HIV-positive participants in the Rakai Community Cohort Study surveyed between September and December 2011 in Rakai, Uganda. The study population included participants from seven communities, including one fishing community with high HIV prevalence (∼41%). ART use was assayed using liquid chromatography-tandem mass spectrometry, which detects 20 antiretroviral drugs. HIV viral load measurements were also obtained. Individuals with at least two antiretroviral drugs detected were considered to be using ART.

RESULTS

One hundred and fifty-three (27%) participants self-reported ART use of whom 148 (97%) had at least two antiretroviral drugs detected. There were at least two antiretroviral drugs detected in 11% (n = 44/404) of individuals with no self-reported ART use. Overall, the specificity of self-reported ART use was 99% (95% CI 97-100%) and the sensitivity was 77% (70-83%). Positive and negative predictive values were 97% (95% CI 93-99%) and 89% (95% CI 86-92%), respectively. Nondisclosure of ART use was significantly more common in younger persons (<30 years) and among those in trading occupations.

CONCLUSION

Self-reported ART use has high specificity and moderate sensitivity providing reasonable, but conservative estimates of population-based ART use. There is more under-reporting of ART use among younger persons and traders suggesting a need for more research on barriers to self-reporting of ART use in these sub-groups.

Measures of human immunodeficiency virus (HIV) community viral load and HIV incidence among people who inject drugs

PURPOSE

To evaluate the measures of community human immunodeficiency virus (HIV) viral load (VL) and the association with HIV incidence among people who inject drugs (PWID).

METHODS

Data were from 1986 to 1999 Urban Health Study conducted among PWID in the San Francisco Bay Area. Extant measures of community VL use mean VL among HIV + study participants, not accounting for the proportion of HIV- individuals. We compared the strength of the associations between HIV incidence and the traditionally measured mean community VL and a new prevalence-adjusted community VL, calculated by dividing the sum of VL among HIV + participants by the total participants irrespective of HIV status.

RESULTS

Mean community VL was not correlated with HIV incidence in this sample of PWID (rs = 0.32, P = .28). However, prevalence-adjusted community VL was strongly correlated with HIV incidence (rs = 0.69, P = .009). Nested complimentary log-log linear models indicated that increases in community VL and prevalence-adjusted community VL were both associated with HIV incidence, but prevalence-adjusted community VL was a more sensitive measure (hazard ratio = 1.28, P = .038 and hazard ratio = 3.29, P < .001, respectively).

CONCLUSIONS

The effect of community VL on HIV incidence may be stronger than previously reported. Future studies of community VL surveillance should consider accounting for the prevalence of HIV using a prevalence-adjusted community VL measure.

Treatment of HIV for the Prevention of Transmission in Discordant Couples and at the Population Level

The scientific breakthrough proving that antiretroviral therapy (ART) can halt heterosexual HIV transmission came in the form of a landmark clinical trial conducted among serodiscordant couples. Study findings immediately informed global recommendations for the use of treatment as prevention in serodiscordant couples. The extent to which these findings are generalizable to other key populations or to groups exposed to HIV through nonsexual transmission routes (i.e., anal intercourse or unsafe injection of drugs) has since driven a large body of research. This review explores the history of HIV research in serodiscordant couples, the implications for management of couples, subsequent research on treatment as prevention in other key populations, and challenges in community implementation of these strategies.

Engagement in HIV care and its correlates among people who inject drugs in St Petersburg, Russian Federation and Kohtla-Järve, Estonia

BACKGROUND AND AIMS

HIV infection and mortality in Eastern Europe are driven by unsafe injection drug use. We sought to compare engagement in care from HIV testing through receipt of antiretroviral treatment among HIV-positive people who inject drugs (PWID) in St Petersburg, Russian Federation (RF) and Kohtla-Järve, Estonia and identify factors associated significantly with failure to progress at each stage of the HIV treatment cascade.

DESIGN

Cross-sectional biobehavioral surveys of PWID with an analysis stratified by location-two Russian-speaking regions with similar HIV epidemic histories and current prevalence.

SETTING

Field-based surveys conducted in St Petersburg, RF and Kohtla-Järve, Estonia.

PARTICIPANTS

We recruited 452 HIV-positive PWID in St Petersburg (November 2012 to June 2013) and 370 HIV-positive PWID in Kohtla-Järve (June-August 2012) using respondent-driven sampling.

MEASUREMENTS

Participants were tested for antibodies to HIV, and administered a questionnaire focusing on participants' medical care histories. Engagement in care was categorized as a cascade of five transitional steps through six stages, ranging from HIV testing to current receipt of antiretroviral medications.

FINDINGS

Progress along the cascade was greater in Kohtla Järve (32.7% were receiving antiretroviral medications) than in St Petersburg (9.7%). In both locations, we found the steps with high failure rates were the transitions from being aware of one's HIV diagnosis to being in regular care and initiation of highly active antiretroviral therapy (HAART). Factors associated significantly with transition failure in both locations and across steps included high alcohol consumption, variables associated with drug choice and injection frequency and lack of basic medical insurance.

CONCLUSION

The two steps in treatment cascade for HIV-positive PWID in St Petersburg, RF and Kohtla-Järve, Estonia requiring greatest improvement are retention in regular care and initiation of HAART. Both individual behavioral and structural factors are associated with failure to transition along the cascade.

Brief Report: HIV Prevalence and the Prevalence of Unsuppressed HIV in New York City, 2010-2014

BACKGROUND

The widespread use of antiretroviral treatment made HIV prevalence no longer a good measure of population-level transmission risk. The objective of this analysis was to use the prevalence of unsuppressed HIV to describe population-level HIV transmission risk.

METHODS

Using New York City (NYC) HIV surveillance data, we reported HIV prevalence and the prevalence of unsuppressed HIV, defined as the number of persons living with HIV with an unsuppressed viral load divided by population size.

RESULTS

The estimated number of persons living with HIV in NYC increased from 79,100 [95% confidence interval (CI): 78,200 to 80,000] in 2010 to 81,700 (95% CI: 80,500 to 82,900) in 2014. HIV prevalence (≥18 years old) remained unchanged at 1.22% (95% CI: 1.21% to 1.24%) in 2010 and 1.22% (95% CI: 1.20% to 1.24%) in 2014. The prevalence of unsuppressed HIV (≥18 years old) steadily decreased from 0.49% (95% CI: 0.48% to 0.51%) in 2010 to 0.34% (95% CI: 0.32% to 0.36%) in 2014. Men had both higher HIV prevalence (1.86% vs. 0.65% in 2014) and higher prevalence of unsuppressed HIV (0.51% vs. 0.18% in 2014) than women. In 2014, the black-white ratio of prevalence of unsuppressed HIV was 5.8 among men and 26.3 among women, and the Hispanic-white ratio was 2.7 among men and 10.0 among women.

CONCLUSIONS

The prevalence of unsuppressed HIV has been steadily decreasing in NYC. As antiretroviral treatment continues to expand, programs should consider using the prevalence of unsuppressed HIV to measure population-level transmission risk.

Comparing viral load metrics and evaluating their use for HIV surveillance

OBJECTIVES

To investigate the value of in-care viral load (ICVL) and other viral load (VL) metrics for HIV surveillance by comparing time trends and associations with numbers of new HIV diagnoses.

METHODS

Data from 20,740 HIV patients registered in the Dutch ATHENA-cohort between 2002 and 2013 were used. We compared: six ICVL metrics (i.e. mean of the mean/first/last/highest log VL, median of the median log VL, first log VL for newly diagnosed combined with mean log VL for all others), log VL at diagnosis, proportion of patients with transmission risk (>400 copies/ml) or suppressed VL (≤200 copies/ml). Subgroup differences were assessed using Kruskal-Wallis and chi-square tests. Negative binomial regression was used for studying associations between VL metrics and numbers of new diagnoses 1-4 years later.

RESULTS

Most ICVL metrics showed similar decreasing trends over time. Differences in covariables were found for all VL metrics. Mean ICVL showed the strongest association with new diagnoses: a decrease of one log unit in mean ICVL was associated with a 21% decrease in new diagnoses two years later.

CONCLUSIONS

VL metrics may be of value for enhancing HIV surveillance by identifying subgroup differences in impact of treatment on viral suppression, and by predicting numbers of new diagnoses in subsequent years.

Reduced community viral load does not coincide with a reduction in the rate of new HIV diagnoses and recent infections: data from a region of southern Italy

OBJECTIVES

We assessed whether changes in community viral load (CVL) over time were associated with the rate of new HIV diagnoses (NDs).

METHODS

HIV-1-positive individuals referred to our institute and permanently residing in our province were considered for inclusion in the study. A total of 861 HIV-infected adults with at least one HIV RNA measurement (12 530 measurements in total) between 2008 and 2014 were included. Viraemia copy-years were calculated from all HIV RNA values for each patient using the trapezoidal rule; multiple CVL indicators were considered. Total NDs and recent infections (< 1 year) were analysed separately. The association between NDs and CVL was tested by means of mixed Poisson models, with CVL as a fixed effect and year as a random effect.

RESULTS

The incidence of NDs was 2.28 per 100 000 residents in 2008 and 2.52 per 100 000 residents in 2014. Total numbers of NDs and recent infections did not vary significantly over time (P for trend 0.879 and 0.39, respectively). Mean HIV RNA decreased from 31 095.8 HIV-1 RNA copies/mL in 2008 to 21 231.5 copies/mL in 2014 (P < 0.001); a downward trend was always observed regardless of the CVL indicator considered. Depending on the indicator, there were some differences in CVL by patient characteristics. The most substantial contributors to CVL appeared to be male individuals, men who have sex with men (MSM), non-Italians, and untreated subjects (all P < 0.05). The relative risk of ND increased among Italians and MSM with an increasing proportion of subjects having an undetectable HIV RNA, and decreased in the same population with increasing levels of CVL.

CONCLUSIONS

In our setting, CVL represented a good marker of access to care and treatment; however, reduced CVL did not coincide with a reduction in the rate of NDs.

Population levels and geographical distribution of HIV RNA in rural Ugandan and Kenyan communities, including serodiscordant couples: a cross-sectional analysis

BACKGROUND

As sub-Saharan Africa transitions to a new era of universal antiretroviral therapy (ART), up-to-date assessments of population-level HIV RNA suppression are needed to inform interventions to optimise ART delivery. We sought to measure population viral load metrics to assess viral suppression and characterise demographic groups and geographical locations with high-level detectable viraemia in east Africa.

METHODS

The Sustainable East Africa Research in Community Health (SEARCH) study is a cluster-randomised controlled trial of an HIV test-and-treat strategy in 32 rural communities in Uganda and Kenya, selected on the basis of rural setting, having an approximate population of 10 000 people, and being within the catchment area of a President's Emergency Plan for AIDS Relief-supported HIV clinic. During the baseline population assessment in the SEARCH study, we did baseline HIV testing and HIV RNA measurement. We analysed stable adult (aged ≥15 years) community residents. We defined viral suppression as a viral load of less than 500 copies per mL. To assess geographical sources of transmission risk, we established the proportion of all adults (both HIV positive and HIV negative) with a detectable viral load (local prevalence of viraemia). We defined transmission risk hotspots as geopolitical subunits within communities with an at least 5% local prevalence of viraemia. We also assessed serodiscordant couples, measuring the proportion of HIV-positive partners with detectable viraemia. The SEARCH study is registered with ClinicalTrials.gov, number NCT01864603.

FINDINGS

Between April 2, 2013, and June 8, 2014, of 303 461 stable residents, we enumerated 274 040 (90·3%), of whom 132 030 (48·2%) were adults. Of these, 117 711 (89·2%) had their HIV status established, of whom 11 964 (10·2%) were HIV positive. Of these, we measured viral load in 8828 (73·8%) people. Viral suppression occurred in 3427 (81·6%) of 4202 HIV-positive adults on ART and 4490 (50·9%) of 8828 HIV-positive adults. Regional viral suppression among HIV-positive adults occurred in 881 (48·2%) of 1827 people in west Uganda, 516 (45·0%) of 1147 in east Uganda, and 3093 (52·8%) of 5854 in Kenya. Transmission risk hotspots occurred in three of 21 parishes in west Uganda and none in east Uganda and in 24 of 26 Kenya geopolitical subunits. In Uganda, 492 (2·9%) of 16 874 couples were serodiscordant: in 287 (58·3%) of these couples, the HIV-positive partner was viraemic (and in 69 [14·0%], viral load was >100 000 copies per mL). In Kenya, 859 (10·0%) of 8616 couples were serodiscordant: in 445 (53·0%) of these couples, the HIV-positive partner was viraemic (and in 129 [15%], viral load was >100 000 copies per mL).

INTERPRETATION

Before the start of the SEARCH trial, 51% of east African HIV-positive adults had viral suppression, reflecting ART scale-up efforts to date. Geographical hotspots of potential HIV transmission risk and detectable viraemia among serodiscordant couples warrant intensified interventions.

FUNDING

National Institute of Allergy and Infectious Diseases (National Institutes of Health) and the President's Emergency Plan for AIDS Relief.