The growing HIV epidemic in Central Europe: a neglected issue?

Prepare Romania: study protocol for a randomized controlled trial of an intervention to promote pre-exposure prophylaxis adherence and persistence among gay, bisexual, and other men who have sex with men

BACKGROUND

Gay, bisexual, and other men who have sex with men (GBMSM) represent a high-risk group for HIV transmission in Romania, yet they possess few resources for prevention. Despite having no formal access to pre-exposure prophylaxis (PrEP) through the health system, GBMSM in Romania demonstrate a high need for and interest in this medication. In anticipation of a national rollout of PrEP, this study tests the efficacy of a novel strategy, Prepare Romania, that combines two evidence-based PrEP promotion interventions for GBMSM living in Romania.

METHODS

This study uses a randomized controlled trial design to examine whether GBMSM living in Romania receiving Prepare Romania, a culturally adapted counseling and mobile health intervention (expected n = 60), demonstrate greater PrEP adherence and persistence than those assigned to a PrEP education control arm (expected n = 60). Participants from two main cities in Romania are prescribed PrEP and followed-up at 3 and 6 months post-randomization. PrEP adherence data are obtained through weekly self-report surveys and dried blood spot testing at follow-up visits. Potential mediators (e.g., PrEP use motivation) of intervention efficacy are also assessed. Furthermore, Prepare Romania's implementation (e.g., proportion of enrolled participants attending medical visits, intervention experience) will be examined through interviews with participants, study implementers, and healthcare officials.

DISCUSSION

The knowledge gained from this study will be utilized for further refinement and scale-up of Prepare Romania for a future multi-city effectiveness trial. By studying the efficacy of tools to support PrEP adherence and persistence, this research has the potential to lay the groundwork for PrEP rollout in Romania and similar contexts. Trial registration This study was registered on ClinicalTrials.gov, identifier NCT05323123 , on March 25, 2022.

An mHealth Intervention for Gay and Bisexual Men's Mental, Behavioral, and Sexual Health in a High-Stigma, Low-Resource Context (Project Comunică): Protocol for a Randomized Controlled Trial

BACKGROUND

The World Health Organization reported that 80% of new HIV diagnoses in Europe in 2014 occurred in Central and Eastern Europe. Romania has a particularly high HIV incidence, AIDS prevalence, and number of related deaths. HIV incidence in Romania is largely attributed to sexual contact among gay and bisexual men. However, homophobic stigma in Romania serves as a risk factor for HIV infection for gay and bisexual men. The Comunică intervention aims to provide a much-needed HIV risk reduction strategy, and it entails the delivery of motivational interviewing and cognitive behavioral therapy skills across 8 live text-based counseling sessions on a mobile platform to gay and bisexual men at risk of HIV. The intervention is based on the information-motivation-behavior and minority stress models. There is preliminary evidence suggesting that Comunică holds promise for reducing gay and bisexual men's co-occurring sexual (eg, HIV transmission risk behavior), behavioral (eg, heavy alcohol use), and mental (eg, depression) health risks in Romania.

OBJECTIVE

This paper describes the protocol for a randomized controlled trial designed to test the efficacy of Comunică in a national trial.

METHODS

To test Comunică's efficacy, 305 gay and bisexual men were randomized to receive Comunică or a content-matched education attention control condition. The control condition consisted of 8 time-matched educational modules that present information regarding gay and bisexual men's identity development, information about HIV transmission and prevention, the importance of HIV and sexually transmitted infection testing and treatment, heavy alcohol use and its associations with HIV transmission risk behavior, sexual health communication, finding social support, and creating sexual health goals. Participants undergo rapid HIV and syphilis testing and 3-site chlamydia and gonorrhea testing at baseline and the 12-month follow-up. Outcomes are measured before the intervention (baseline) and at the 4-, 8-, and 12-month follow-ups.

RESULTS

The study was funded in September 2018, and data collection began in May 2019. The last participant follow-up was in January 2024. Currently, the data analyst is cleaning data sets in preparation for data analyses, which are scheduled to begin in April 2024. Data analysis meetings are scheduled regularly to establish timelines and examine the results as analyses are gradually being conducted. Upon completion, a list of manuscripts will be reviewed and prioritized, and the team will begin preparing them for publication.

CONCLUSIONS

This study is the first to test the efficacy of an intervention with the potential to simultaneously support the sexual, behavioral, and mental health of gay and bisexual men in Central and Eastern Europe using motivational interviewing support and sensitivity to the high-stigma context of the region. If efficacious, Comunică presents a scalable platform to provide support to gay and bisexual men living in Romania and similar high-stigma, low-resource countries.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03912753; https://clinicaltrials.gov/study/NCT03912753.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52853.

Addressing HIV stigma in healthcare, community, and legislative settings in Central and Eastern Europe

INTRODUCTION

Surging HIV prevalence across countries of Central and Eastern Europe (CEE) is largely a result of poor HIV care engagement and a lack of comprehensive support for key populations. This is fostered by widespread stigma across healthcare, community, and legislative settings.

DISCUSSION

Throughout CEE, HIV stigma and intersectional stigma are serious obstacles to providing adequate medical care to people living with HIV. Anticipated and enacted (experienced) stigma from healthcare professionals, and fears of breaches in confidentiality, deter individuals from having an HIV test and engaging in HIV care. Furthermore, negative connotations surrounding HIV infection can lead to discrimination from family, friends, colleagues, and the public, leading to internalized stigma and depression. Key populations that have higher HIV prevalence, such as men who have sex with men, people who inject drugs, transgender individuals, and sex workers, experience additional stigma and discrimination based on their behaviour and identities. This contributes to the concentrated HIV epidemics seen in these populations in many CEE countries. The stigma is exacerbated by punitive legislation that criminalizes HIV transmission and penalizes sexual orientation, drug use, gender identities, and sex work. Despite high levels of HIV stigma and intersectional stigma, there are many evidence-based interventions that have reduced stigma in other parts of the world. Here, we discuss the interventions that are currently being enacted in various countries of CEE, and we suggest additional effective, evidence-based interventions that will tackle stigma and lead to increased HIV care engagement and higher rates of viral suppression. We cover the promotion of the undetectable = untransmittable (U = U) message, stigma-reduction education and training for healthcare professionals, patient-centric approaches for testing and treatment, and advocacy for non-discriminatory legislation, policies, and practices. We also consider targeted stigma-reduction interventions that acknowledge the wider challenges faced by marginalized populations.

CONCLUSIONS

HIV stigma and intersectional stigma in CEE drive poor engagement with HIV testing services and care. Widespread adoption of evidence-based interventions to tackle stigma highlighted in this review will improve the quality of life of people living with HIV, improve HIV care engagement, and ultimately slow the surging HIV prevalence and concentrated epidemics occurring throughout CEE.

Modeling the future of HIV in Turkey: Cost-effectiveness analysis of improving testing and diagnosis

AIMS

This study aimed to determine HIV incidence and prevalence in Turkey and to estimate the cost-effectiveness of improving testing and diagnosis in the next 20 years.

BACKGROUND

HIV incidence in Turkey has been rapidly increasing in the last decade with a particularly high rate of infection for younger populations, which underscores the urgent need for a robust prevention program and improved testing capacity for HIV.

METHODS

We developed a dynamic compartmental model of HIV transmission and progression among the Turkish population aged 15-64 and assessed the effect of improving testing and diagnosis. The model generated the number of new HIV cases by transmission risk and CD4 level, HIV diagnoses, HIV prevalence, continuum of care, the number of HIV-related deaths, and the expected number of infections prevented from 2020 to 2040. We also explored the cost impact of HIV and the cost-effectiveness of improving testing and diagnosis.

RESULTS

Under the base case scenario, the model estimated an HIV incidence of 13,462 cases in 2020, with 63% undiagnosed. The number of infections was estimated to increase by 27% by 2040, with HIV incidence in 2040 reaching 376,889 and HIV prevalence 2,414,965 cases. Improving testing and diagnosis to 50%, 70%, and 90%, would prevent 782,789, 2,059,399, and 2,336,564 infections-32%, 85%, and 97% reduction in 20 years, respectively. Improved testing and diagnosis would reduce spending between $1.8 and $8.8 billion.

CONCLUSIONS

In the case of no improvement in the current continuum of care, HIV incidence and prevalence will significantly increase over the next 20 years, placing a significant burden on the Turkish healthcare system. However, improving testing and diagnosis could substantially reduce the number of infections, ameliorating the public health and disease burden aspects.

A randomized controlled trial of an mHealth intervention for gay and bisexual men's mental, behavioral, and sexual health in a high-stigma, low-resource context: Project Comunică protocol

Background

The World Health Organization (WHO) reported that 80% of new HIV diagnoses in 2014 in Europe occurred in Central and Eastern Europe (CEE). Romania has particularly high HIV incidence, AIDS prevalence, and AIDS-related deaths. HIV incidence today in Romania is largely attributed to sexual contact among gay and bisexual men (GBM). However, homophobic stigma in Romania keeps GBM out of reach of the scant available prevention services and serves as a risk factor for HIV. The Comunică intervention delivers motivational interviewing and cognitive-behavioral therapy skills across eight live text-based counseling sessions. Preliminary evidence suggests that Comunică possesses promise for reducing GBM's co-occurring mental (e.g., depression), behavioral (e.g., heavy alcohol use), and sexual (e.g., HIV-transmission-risk behavior) health risks in Romania and perhaps other similar high-stigma national contexts. This paper describes a randomized controlled trial (RCT) designed to test the efficacy of Comunică.

Methods

To test Comunică's efficacy, 305 GBM were randomized to receive Comunică or a content-matched education attention control condition. The control condition consists of eight time-matched educational modules that present information regarding GBM identity development, information about HIV transmission and prevention, the importance of HIV/STI testing and treatment, heavy alcohol use and its associations with HIV-transmission-risk behavior, sexual health communication, finding social support, and creating sexual health goals. Outcomes are measured pre-intervention (baseline), and at 4-, 8-, and 12-month follow-ups. The primary outcome is frequency of condomless anal sex acts with HIV-positive or unknown-status partners outside of the context of one's own adherent PrEP use or primary partner's adherent PrEP use or undetectable viral load in the past 30 days at each follow-up. Secondary outcomes include depression, anxiety, suicidal thoughts, heavy alcohol use, and HIV/STI testing; motivational and stigma-related mechanisms of intervention efficacy will also be examined.

Discussion

If found to be efficacious, Comunică presents a scalable platform to provide mental, behavioral, and sexual health support to GBM living in Romania and similar high-stigma, low-resource areas within the CEE region and beyond.

Trial registration

Registered April 11, 2019 to ClinicalTrials.gov Identifier: NCT03912753.

Recent advances in CD8+ T cell-based immune therapies for HIV cure

Achieving a cure for HIV infection is a global priority. There is substantial evidence supporting a central role for CD8⁺ T cells in the natural control of HIV, suggesting the rationale that these cells may be exploited to achieve remission or cure of this infection. In this work, we review the major challenges for achieving an HIV cure, the models of HIV remission, and the mechanisms of HIV control mediated by CD8⁺ T cells. In addition, we discuss strategies based on this cell population that could be used in the search for an HIV cure. Finally, we analyze the current challenges and perspectives to translate this basic knowledge toward scalable HIV cure strategies.

HIV-1 subtype B spread through cross-border clusters in the Balkans: a molecular analysis in view of incidence trends

OBJECTIVES

To analyze phylogenetic relations and assess the role of cross-border clusters in the spread of HIV-1 subtype B across the Balkans, given the general trends of new HIV diagnoses in seven Balkan countries.

DESIGN

Retrospective phylogenetic and trend analysis.

METHODS

In-depth phylogenetic, phylodynamic and phylogeographic analysis performed on 2415 HIV-1 subtype B sequences from 1999 to 2019 using maximal likelihood and Bayesian methods. The joinpoint regression analysis of new HIV diagnoses by country and modes of transmission using 2004-2019 ECDC data.

RESULTS

Ninety-three HIV-1 Subtype B transmission clusters (68% of studied sequences) were detected of which four cross-border clusters (11% of studied sequences). Phylodynamic analysis showed activity of cross-border clusters up until the mid-2000s, with a subsequent stationary growth phase. Phylogeography analyses revealed reciprocal spread patterns between Serbia, Slovenia and Montenegro and several introductions to Romania from these countries and Croatia. The joinpoint analysis revealed a reduction in new HIV diagnoses in Romania, Greece and Slovenia, whereas an increase in Serbia, Bulgaria, Croatia and Montenegro, predominantly among MSM.

CONCLUSION

Differing trends of new HIV diagnoses in the Balkans mirror differences in preventive policies implemented in participating countries. Regional spread of HIV within the countries of former Yugoslavia has continued to play an important role even after country break-up, whereas the spread of subtype B through multiple introductions to Romania suggested the changing pattern of travel and migration linked to European integration of Balkan countries in the early 2000s.

Awareness of HIV pre-exposure prophylaxis among men who have sex with men using apps for sexual encounters in Turkiye

Background

New HIV diagnoses are rising in Turkiye. Men who have sex with men (MSM) are estimated to be the main driver of the epidemic. Pre-exposure prophylaxis (PrEP) was proven to be effective in reducing new HIV diagnoses and PrEP recently became available in Turkiye.

Objective

To assess awareness of and willingness to use PrEP and the level of off-licence use among MSM.

Methods

An anonymous self-completed questionnaire was sent out over the Hornet Gay Social Network from December 2019 to February 2020, available in Turkish and Arabic. It included 20 questions on HIV and STI testing, PrEP awareness, PrEP use, willingness to use, chemsex and sexual happiness level.

Results

Overall 4761 respondents who responded to more than 1/3 of the questions were eligible for analyses; 5.5% was Arabic speaking. The mean age was 30.5 years, 31.4% had never tested for HIV, 40.5% knew what PrEP was, the most common source of knowledge was the internet (44.5%), 2.5% (120) had used PrEP in the last 12 months and 1.7% (83) was current users. PrEP users had accessed drugs over the internet (47.6%), pharmacy (23%), and friends (13.8%). Almost 40% were willing to use PrEP in the following 6 months. Younger and Arabic speaking respondents had lower rates of HIV testing ( p = .001) and lower awareness for PrEP than comparators ( p = .004).

Conclusion

Awareness and willingness to use PrEP is high among MSM in Turkiye. The recent availability of PrEP in the country is a big step forward in terms of prevention.

Global, regional, and national sex-specific burden and control of the HIV epidemic, 1990-2019, for 204 countries and territories: the Global Burden of Diseases Study 2019

BACKGROUND

The sustainable development goals (SDGs) aim to end HIV/AIDS as a public health threat by 2030. Understanding the current state of the HIV epidemic and its change over time is essential to this effort. This study assesses the current sex-specific HIV burden in 204 countries and territories and measures progress in the control of the epidemic.

METHODS

To estimate age-specific and sex-specific trends in 48 of 204 countries, we extended the Estimation and Projection Package Age-Sex Model to also implement the spectrum paediatric model. We used this model in cases where age and sex specific HIV-seroprevalence surveys and antenatal care-clinic sentinel surveillance data were available. For the remaining 156 of 204 locations, we developed a cohort-incidence bias adjustment to derive incidence as a function of cause-of-death data from vital registration systems. The incidence was input to a custom Spectrum model. To assess progress, we measured the percentage change in incident cases and deaths between 2010 and 2019 (threshold >75% decline), the ratio of incident cases to number of people living with HIV (incidence-to-prevalence ratio threshold <0·03), and the ratio of incident cases to deaths (incidence-to-mortality ratio threshold <1·0).

FINDINGS

In 2019, there were 36·8 million (95% uncertainty interval [UI] 35·1-38·9) people living with HIV worldwide. There were 0·84 males (95% UI 0·78-0·91) per female living with HIV in 2019, 0·99 male infections (0·91-1·10) for every female infection, and 1·02 male deaths (0·95-1·10) per female death. Global progress in incident cases and deaths between 2010 and 2019 was driven by sub-Saharan Africa (with a 28·52% decrease in incident cases, 95% UI 19·58-35·43, and a 39·66% decrease in deaths, 36·49-42·36). Elsewhere, the incidence remained stable or increased, whereas deaths generally decreased. In 2019, the global incidence-to-prevalence ratio was 0·05 (95% UI 0·05-0·06) and the global incidence-to-mortality ratio was 1·94 (1·76-2·12). No regions met suggested thresholds for progress.

INTERPRETATION

Sub-Saharan Africa had both the highest HIV burden and the greatest progress between 1990 and 2019. The number of incident cases and deaths in males and females approached parity in 2019, although there remained more females with HIV than males with HIV. Globally, the HIV epidemic is far from the UNAIDS benchmarks on progress metrics.

FUNDING

The Bill & Melinda Gates Foundation, the National Institute of Mental Health of the US National Institutes of Health (NIH), and the National Institute on Aging of the NIH.

AIDS-related deaths in Turkey between 2009 and 2018

The prevalence of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is increasing day by day in the region, including Turkey. The study aimed to examine AIDS-related deaths in Turkey between 2009 and 2018 according to the national death registration system records. In this descriptive study, data on AIDS-related deaths were obtained from the Turkish Statistical Institute. The data consist of the cause of death codes, year of death, age and gender. Findings were presented using numbers and percentages. Seven hundred twenty-one AIDS-related deaths were reported in Turkey between 2009 and 2018. AIDS-related deaths in Turkey increased more than twice at the end of 10 years. The male/female death ratio is 4.5. Deaths under the age of 15 were 4.2% in total; however, they were increased to 10.2% in 2018. AIDS-related deaths are decreasing in the world but increasing in Turkey. The data from the Ministry of Health do not match the data of the national death registration system. Establishing a strong and accurate HIV/AIDS reporting system and identifying the causes and risk groups of this increase in AIDS-related deaths are critical.

Temporal Trends in the Epidemiology of HIV in Turkey

OBJECTIVE

The aim of this study was to analyze the temporal trends of HIV epidemiology in Turkey from 2011 to 2016.

METHODS

Thirty-four teams from 28 centers at 17 different cities participated in this retrospective study. Participating centers were asked to complete a structured form containing questions about epidemiologic, demographic and clinical characteristics of patients presented with new HIV diagnosis between 2011 and 2016. Demographic data from all centers (complete or partial) were included in the analyses. For the cascade of care analysis, 15 centers that provided full data from 2011 to 2016 were included. Overall and annual distributions of the data were calculated as percentages and the Chi square test was used to determine temporal changes.

RESULTS

A total of 2,953 patients between 2011 and 2016 were included. Overall male to female ratio was 5:1 with a significant increase in the number of male cases from 2011 to 2016 (p<0.001). The highest prevalence was among those aged 25-34 years followed by the 35-44 age bracket. The most common reason for HIV testing was illness (35%). While the frequency of sex among men who have sex with men increased from 16% to 30.6% (p<0.001) over the study period, heterosexual intercourse (53%) was found to be the most common transmission route. Overall, 29% of the cases presented with a CD4 count of >500 cells/mm3 while 46.7% presented with a CD4 T cell count of <350 cells/mm3. Among newly diagnosed cases, 79% were retained in care, and all such cases initiated ART with 73% achieving viral suppression after six months of antiretroviral therapy.

CONCLUSION

The epidemiologic profile of HIV infected individuals is changing rapidly in Turkey with an increasing trend in the number of newly diagnosed people disclosing themselves as MSM. New diagnoses were mostly at a young age. The late diagnosis was found to be a challenging issue. Despite the unavailability of data for the first 90, Turkey is close to the last two steps of 90-90-90 targets.

Lived experiences of people living with HIV: a descriptive qualitative analysis of their perceptions of themselves, their social spheres, healthcare professionals and the challenges they face daily

BACKGROUND

Human immunodeficiency virus (HIV) infection rates have been gradually increasing in Istanbul, Turkey. Many people living with HIV (PLWH) here encounter difficulties, for example, in adapting to the chronic disease and obtaining continuous access to healthcare services. In this study, we aimed to explore the challenges PLWH face in their daily lives and understand their perceptions of themselves, healthcare professionals and services, and their social spheres via their expressed lived experiences in the healthcare setting.

METHOD

Individual semi-structured in-depth interviews were conducted face-to-face with 20 PLWH in Istanbul. All the interviews were voice-recorded and transcribed verbatim except one, upon participant request, for which the interviewer took notes. These logs and the interviewer's notes were analyzed thematically using the inductive content analysis method.

RESULTS

The themes concerned experiences in three distinct contexts: 1) Interactions with healthcare providers; 2) Participants' responses to their HIV diagnosis; and 3) Interactions with their social networks. Firstly, the results highlighted that the participants perceived that healthcare professionals did not inform them about the diagnosis properly, failed to protect patients' confidentiality and exhibited discriminative behaviors towards them. Secondly, after the diagnosis the participants had difficulty in coping with their unsettled emotional state. While many ceased sexual activities and isolated themselves, some sought support. Lastly, living with HIV affected their relationships with their families and friends either positively or negatively. Moreover, they had to face the difficulties concerning spouse/partner notification issues about which many needed professional support.

CONCLUSION

Healthcare professionals' discriminative or inappropriate attitudes and customs in healthcare institutions are perceived to impair PLWH's utilization of healthcare services. Structural factors such as social pressure, societal ignorance about HIV, limited access to HIV prevention, and regulatory barriers might contribute to these challenges. The results suggest that it is necessary to raise healthcare professionals' and society's awareness about HIV and develop national policies to establish a well-functioning referral system and appropriate spouse/partner notification services.

Programmatic mapping and size estimation of female sex workers, transgender sex workers and men who have sex with men in İstanbul and Ankara, Turkey

OBJECTIVES

Despite a growing HIV threat, there is no definition and characterisation of key populations (KPs), who could be the major drivers of the epidemic in Turkey. We used programmatic mapping to identify locations where KPs congregate, estimate their numbers and understand their operational dynamics to develop appropriate HIV programme implementation strategies.

METHODS

Female and transgender sex workers (FSWs and TGSWs), and men who have sex with men (MSM) were studied in İstanbul and Ankara. Within each district, hot spots were identified by interviewing key informants and a crude spot list in each district was developed. The spot validation process was led by KP members who facilitated spot access and interviews of KPs associated with that spot. Final estimates were derived by aggregating the estimated number of KPs at all spots, which was adjusted for the proportion of KPs who visit multiple spots, and for the proportion of KPs who do not visit spots.

RESULTS

FSWs were the largest KP identified in İstanbul with an estimate of 30 447 (5.8/1000 women), followed by 15 780 TGSWs (2.9/1000 men) and 11 656 MSM (2.1/1000). The corresponding numbers in Ankara were 9945 FSWs (5.2/1000 women), 1770 TGSWs (1/1000 men) and 5018 MSM (2.5/1000 men). Each KP had unique typologies based on the way they find and interact with sex partners. MSM were mostly hidden and a higher proportion operated through internet and phone-based applications. Night time was the peak time with Friday, Saturday and Sunday being the peak days of activity in both İstanbul and Ankara.

CONCLUSIONS

This study has highlighted the presence of a substantial number of FSWs, TGSW and MSM in İstanbul and Ankara. The information obtained from this study can be used to set priorities for resource allocation and provide HIV prevention services where coverage could be the highest.

The Trend of HIV/AIDS Incidence and Risks Associated with Age, Period, and Birth Cohort in Four Central African Countries

The HIV/AIDS incidence rates have decreased in African countries although the rates are still high in Sub-Saharan Africa. Our study aimed to examine the long-term trend of the overall HIV/AIDS incidence rates in four countries of the central region of Africa, using data from the Global Burden of Diseases (GBD) 2019 study. The Age–Period–Cohort statistical model analysis was used to measure the trends of HIV/AIDS incidence rates in each of the four countries. HIV/AIDS incidence rates decreased slowly in Cameroon (CAM), Chad, and Central African Republic (CAR), but considerably in the Democratic Republic of the Congo (DRC) from 1990–2019. HIV/AIDS incidence rates in the four countries were at their peaks in the age group of 25–29 years. According to the age relative risks, individuals aged between 15 and 49 years old are at high risk of HIV/AIDS incidence in the four countries. The period and cohort relative risks have decreased in all four countries. Although CAM recorded an increase of 59.6% in the period relative risks (RRs) between 1990 and 1999, HIV/AIDS incidence has decreased dramatically in all four countries, especially after 2000. The decrease of the period RRs (relative risk) by nearly 20.6-folds and the decrease of the cohort RRs from 147.65 to almost 0.0034 in the DRC made it the country with the most significant decrease of the period and cohort RRs compared to the rest. HIV/AIDS incidence rates are decreasing in each of the four countries. Our study findings could provide solid ground for policymakers to promptly decrease HIV/AIDS incidence by strengthening the prevention policies to eliminate the public health threat of HIV/AIDS by 2030 as one of the targets of the Sustainable Development Goals (SDGs).

Estimating the burden of HIV late presentation and its attributable morbidity and mortality across Europe 2010-2016

BACKGROUND

Late presentation (LP), defined as a CD4 count < 350/mm3 or an AIDS-event at HIV-diagnosis, remains a significant problem across Europe. Linking cohort and surveillance data, we assessed the country-specific burden of LP during 2010-2016 and the occurrence of new AIDS events or deaths within 12 months of HIV-diagnosis believed to be attributable to LP.

METHODS

Country-specific percentages of LP and AIDS-events/death rates (assessed with Poisson regression) observed in The Collaboration of Observational HIV Epidemiological Research Europe (COHERE) and EuroSIDA cohorts, were applied to new HIV-diagnoses reported to the European Centre for Disease Prevention and Control. The estimated number of LP in the whole population was then calculated, as was the number of excess AIDS-events/deaths in the first 12 months following HIV-diagnosis assumed to be attributable to LP (difference in estimated events between LP and non-LP).

RESULTS

Thirty-nine thousand two hundred four persons were included from the COHERE and EuroSIDA cohorts, of whom 18,967 (48.4%; 95% Confidence Interval [CI] 47.9-48.9) were classified as LP, ranging from 36.9% in Estonia (95%CI 25.2-48.7) and Ukraine (95%CI 30.0-43.8) to 64.2% in Poland (95%CI 57.2-71.3). We estimated a total of > 320,000 LP and 12,050 new AIDS-events/deaths attributable to LP during 2010-2016, with the highest estimated numbers of LP and excess AIDS-events/deaths in Eastern Europe. Country-level estimates of excess events ranged from 17 AIDS-events/deaths (95%CI 0-533) in Denmark to 10,357 (95%CI 7768-147,448) in Russia.

CONCLUSIONS

Across countries in Europe, the burden of LP was high, with the highest estimated number of LP and excess AIDS-events/deaths being in Eastern Europe. Effective strategies are needed to reduce LP and the attributable morbidity and mortality that could be potentially avoided.

Patients' perspectives of tuberculosis treatment challenges and barriers to treatment adherence in Ukraine: a qualitative study

OBJECTIVES

To understand the challenges faced by patients with tuberculosis (TB) and factors that influence TB treatment adherence in Ukraine.

DESIGN

Qualitative study.

SETTING

TB treatment facilities in Kyiv Oblast, Ukraine.

PARTICIPANTS

Sixty adults who had undergone treatment for drug-sensitive TB between June 2012 and August 2015.

METHODS

We conducted semistructured, in-depth, individual interviews among a purposively selected clinical sample of patients previously treated for drug-sensitive TB. Interview content encompassed WHO's framework for barriers to adherence to long-term therapies and included questions about patient preferences and motivators concerning treatment adherence. We examined treatment experience across strata defined by previously identified risk correlates of non-adherence.

RESULTS

Among 60 participants, 19 (32.8%) were HIV positive, 12 (20.3%) had substance use disorder and 9 (15.0%) had not completed TB treatment. Respondents discussed the psychological distress associated with hospital-based TB care, as well as perceived unsupportive, antagonistic interactions with TB providers as major challenges to treatment adherence. An additional barrier to successful treatment completion included the financial toll of lost income during TB treatment, which was exacerbated by the additional costs of ancillary medications and transportation to ambulatory TB clinics. The high pill burden of TB treatment also undermined adherence. These challenges were endorsed among participants with and without major risk factors for non-adherence.

CONCLUSIONS

Our findings highlight important barriers to TB treatment adherence in this study population and suggest specific interventions that may be beneficial in mitigating high rates of poor treatment outcomes for TB in Ukraine.

The Challenges of Transition From Donor-Funded Programs: Results From a Theory-Driven Multi-Country Comparative Case Study of Programs in Eastern Europe and Central Asia Supported by the Global Fund

INTRODUCTION

In the era of declining development assistance for health, transitioning externally funded programs to governments becomes a priority for donors. However, the process requires a careful approach not only to preserve the public health gains that have already been achieved but also to expand on them. In the Eastern Europe and Central Asia region, countries are expected to graduate from support from the Global Fund to Fight AIDS, Tuberculosis and Malaria in or before 2025. We aim to describe transition risks and identify possible means to address them.

METHODS

Using a theory-based conceptual framework-Transition Preparedness Assessment of Tuberculosis and HIV/AIDS programs-we investigated transition-related challenges through a health systems lens in 10 countries of the Eastern Europe and Central Asia region during 2015-2017. Study findings were derived from systematic collection of quantitative data on socioeconomic indicators and disease epidemics as well as qualitative data from in-depth interviews with 264 stakeholders. These findings were then compared with other donor transition experiences documented elsewhere.

RESULTS

We found numerous common transition challenges, such as poor monitoring of a country's macroeconomic performance along with weakness in estimating financial needs for successful transition; limited political will of governments to replace donor-funded programs; punitive legislation criminalizing certain behaviors and constraining the government's ability to allocate funds and contract civil society organizations essential to providing services for key populations; limited coordination function of governments and weak decision-making power of coordinating mechanisms obscuring the latter's future role; and inadequate function of national procurement and supply chain management systems undermining an uninterrupted supply of quality-assured drugs and commodities. These challenges are compounded by the risks related to health workforce management leading to specialist shortages and/or inadequately skilled and qualified professionals and by limited funding for critical surveillance activities.

CONCLUSION

The complex and multidimensional transition process requires a multipronged approach through well-planned collective and coordinated responses from global, bilateral, and national partners in coming years. Other similar transition processes may provide guidance. Although no "one-size-fits-all" approach exists, previous experiences highlight a need for both early planning and monitoring of the transition along several key dimensions. Issues that could threaten the maintenance of health gains include ongoing stigma against key populations; continued heavy reliance on external funding in some countries, especially for preventive services; the institutional viability of the country coordinating mechanisms; and emerging difficulties with procurement of quality drugs at reasonable prices.

Prevalence and risk factors for child mental disorders in a population-based cohort of HIV-exposed and unexposed African children aged 7-11 years

Despite being home to a large population of vulnerable children there is a dearth of population-based evidence on childhood mental disorders in sub-Saharan Africa. Parent and child mental health are rarely measured concurrently, despite potential for confounding with other risk factors, including parental HIV. Using the parent-report Child Behaviour Checklist (CBCL) we assessed children's mental health in a population-based cohort of 1536 HIV-negative children (31% HIV-exposed, 18% HIV-affected, 51% HIV-unexposed) aged 7-11 years. CBCL was scored using CBCL Rating-to-Score software. A binary indicator was determined using the clinical threshold ≥ 65. We modelled mental disorders using logistic regression, including covariates associated with the mother, child, household, and parenting. Structural equation modelling techniques also derived continuous latent variables representing the underlying mental health and parent-relationship constructs. Prevalence of conduct disorders (11.8%) was high, regardless of HIV exposure, while HIV-affected children had increased odds of affective disorders. Maternal depression increased odds of externalising disorders; maternal anxiety was associated with affective and anxiety disorders. Mother-child relationship dysfunction increased odds of all disorders, including: affective [aOR = 5.1 (2.6-9.9)]; oppositional [aOR = 7.9 (4.0-15.5)]; conduct [aOR = 4.3 (2.6-7.2)] disorders. Food insecurity and male gender increased odds of somatic disorders; breastfeeding halved odds of conduct disorders. In the latent model, associations were substantially stronger for the mother-child relationship and externalising disorders (Oppositional 0.464 p < 0.001; Conduct 0.474 p = <0.001). Conduct disorders were high for all children regardless of HIV exposure. The mother-child relationship was strongly related to all child disorders, suggesting potential for concurrent interventions targeting child behaviours and the parent-child or mother-child relationship.

Female Gender and HIV Transmission Risk Behaviors Among People Living with HIV Who Have Ever Used Injection Drugs in St. Petersburg, Russia

Among persons who inject drugs, women have a higher HIV prevalence (than men) in many settings. Understanding how gender affects risk for infection among HIV-negative, and transmission among HIV-positive people who currently or previously injected drugs is key to designing effective prevention and treatment programs. We analyzed data from 291 persons living with HIV who had ever injected drugs. Participants were drawn from the Russia Alcohol Research Collaboration on HIV/AIDS cohort (2012-2015) to examine associations between female gender and HIV transmission risk. Primary outcomes were sharing drug injecting equipment (e.g., needle/syringes) and condomless sex. Secondary outcomes were alcohol use before sharing drug injecting equipment; before condomless sex; and both sharing drug injecting equipment and condomless sex. Logistic regression models assessed associations between gender and outcomes, controlling for demographics, partner HIV status and use of antiretroviral treatment. Female gender was not significantly associated with sharing drug injecting equipment [aOR = 1.45, 95% confidence interval (CI) 0.85-2.46, p value = 0.18] but was associated with condomless sex (aOR = 1.91, 95% CI 1.12-3.23, p = 0.02) in adjusted models. Female gender was not significantly associated with any secondary outcomes. Better understanding of risky sex and drug use behaviors among people who currently or previously injected drugs can support the design of effective gender-tailored HIV prevention interventions.

HIV care in Central and Eastern Europe: How close are we to the target?

OBJECTIVES

The aim of this survey was to describe the current status of HIV care in the countries of Central and Eastern Europe and to investigate how close the region is to achieving the UNAIDS 2020 target of 90-90-90.

METHODS

In 2014, data were collected from 24 Central and Eastern European countries using a 38-item questionnaire.

RESULTS

All countries reported mandatory screening of blood and organ donors for HIV. Other groups subjected to targeted screening included people who inject drugs (PWID) (15/24, 62.5%), men who have sex with men (MSM) (14/24, 58.3%), and sex workers (12/24, 50.0%). Only 14 of the 24 countries (58.3%) screened pregnant women. The percentages of late presentation and advanced disease were 40.3% (range 14-80%) and 25.4% (range 9-50%), respectively. There was no difference between countries categorized by income or by region in terms of the percentages of persons presenting late or with advanced disease. The availability of newer antiretroviral drugs (rilpivirine, etravirine, darunavir, maraviroc, raltegravir, dolutegravir) tended to be significantly better with a higher country income status. Ten countries reported initiating antiretroviral therapy (ART) regardless of CD4+ T cell count (41.7%), five countries (20.8%) used the threshold of <500 cells/μl, and nine countries (37.5%) used the threshold of <350cells/μl. Initiation of ART regardless of the CD4+ T cell count was significantly more common among high-income countries than among upper-middle-income and lower-middle-income countries (100% vs. 27.3% and 0%, respectively; p=0.001). Drugs were provided free of charge in all countries and mostly provided by governments. There were significant discrepancies between countries regarding the follow-up of people living with HIV.

CONCLUSIONS

There are major disparities in the provision of HIV care among sub-regions in Europe, which should be addressed. More attention in terms of funding, knowledge and experience sharing, and capacity building is required for the resource-limited settings of Central and Eastern Europe. The exact needs should be defined and services scaled up in order to achieve a standard level of care and provide an adequate and sustainable response to the HIV epidemic in this region.

HIV prevalence among men who have sex with men in Istanbul

OBJECTIVES

The re-emergence of the HIV epidemic among men who have sex with men (MSM) represents a serious health issue. This study aimed to assess the HIV prevalence among MSM in a very low prevalence population of a large city.

METHODS

A public campaign to raise awareness of HIV infection and to provide access to anonymous testing was conducted in places frequented by MSM and through a mobile phone application. No identity information was requested from individuals contacting the call centre, and anonymous and free HIV testing was offered proactively. Those who agreed to have a test were provided a code number, which was used in blood sampling procedures.

RESULTS

Of 1200 subjects who contacted the call centre, 197 consented to undergo HIV testing and visited the laboratory to give a blood sample. Twenty-five subjects were found to have a reactive ELISA result on two different occasions plus a positive Western blot test result. Thus, the HIV prevalence in this group of MSM was 12.7%.

CONCLUSIONS

MSM remain a high risk group for HIV infection in a low prevalence setting, and thus represent a key target population for diagnostic and therapeutic interventions.