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Owino L, Johnson-Peretz J, Lee J, Getahun M, Coppock-Pector D, Maeri I, Onyango A, Cohen CR, Bukusi EA, Kabami J, Ayieko J, Petersen M, Kamya MR, Charlebois E, Havlir D, Camlin CS. Exploring HIV risk perception mechanisms among youth in a test-and-treat trial in Kenya and Uganda. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002922. [PMID: 38696376 PMCID: PMC11065277 DOI: 10.1371/journal.pgph.0002922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/24/2024] [Indexed: 05/04/2024]
Abstract
Understanding risk perception and risk-taking among youth can inform targeted prevention efforts. Using a health beliefs model-informed framework, we analysed 8 semi-structured, gender-specific focus group discussions with 93 youth 15-24 years old (48% male, 52% female), drawn from the SEARCH trial in rural Kenya and Uganda in 2017-2018, coinciding with the widespread introduction of PrEP. Highly connected social networks and widespread uptake of antiretrovirals shaped youth HIV risk perception. Amid conflicting information about HIV prevention methods, youth felt exposed to multiple HIV risk factors like the high prevalence of HIV, belief that people with HIV(PWH) purposefully infect others, dislike of condoms, and doubts about PrEP efficacy. Young women also reported minimal sexual autonomy in the context of economic disadvantages, the ubiquity of intergenerational and transactional sex, and peer pressure from other women to have many boyfriends. Young men likewise reported vulnerability to intergenerational sex, but also adopted a sexual conquest mentality. Comprehensive sexuality education and economic empowerment, through credible and trusted sources, may moderate risk-taking. Messaging should leverage youth's social networks to spread fact-based, gender- and age-appropriate information. PrEP should be offered alongside other reproductive health services to address both pregnancy concerns and reduce HIV risk.
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Affiliation(s)
- Lawrence Owino
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Jason Johnson-Peretz
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Joi Lee
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Dana Coppock-Pector
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Irene Maeri
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | | | - Craig R. Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | | | - Jane Kabami
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - James Ayieko
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Maya Petersen
- Divisions of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Edwin Charlebois
- Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, California, United States of America
| | - Diane Havlir
- HIV, Infectious Disease and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Carol S. Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
- Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, California, United States of America
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Buttenheim A, Thirumurthy H. Mobile delivery of COVID-19 vaccines improved uptake in rural Sierra Leone. Nature 2024; 627:497-499. [PMID: 38480939 DOI: 10.1038/d41586-023-03186-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
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3
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Mody A, Sohn AH, Iwuji C, Tan RKJ, Venter F, Geng EH. HIV epidemiology, prevention, treatment, and implementation strategies for public health. Lancet 2024; 403:471-492. [PMID: 38043552 DOI: 10.1016/s0140-6736(23)01381-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/28/2023] [Accepted: 06/29/2023] [Indexed: 12/05/2023]
Abstract
The global HIV response has made tremendous progress but is entering a new phase with additional challenges. Scientific innovations have led to multiple safe, effective, and durable options for treatment and prevention, and long-acting formulations for 2-monthly and 6-monthly dosing are becoming available with even longer dosing intervals possible on the horizon. The scientific agenda for HIV cure and remission strategies is moving forward but faces uncertain thresholds for success and acceptability. Nonetheless, innovations in prevention and treatment have often failed to reach large segments of the global population (eg, key and marginalised populations), and these major disparities in access and uptake at multiple levels have caused progress to fall short of their potential to affect public health. Moving forward, sharper epidemiologic tools based on longitudinal, person-centred data are needed to more accurately characterise remaining gaps and guide continued progress against the HIV epidemic. We should also increase prioritisation of strategies that address socio-behavioural challenges and can lead to effective and equitable implementation of existing interventions with high levels of quality that better match individual needs. We review HIV epidemiologic trends; advances in HIV prevention, treatment, and care delivery; and discuss emerging challenges for ending the HIV epidemic over the next decade that are relevant for general practitioners and others involved in HIV care.
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Affiliation(s)
- Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA.
| | - Annette H Sohn
- TREAT Asia, amfAR, The Foundation for AIDS Research, Bangkok, Thailand
| | - Collins Iwuji
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK; Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Rayner K J Tan
- University of North Carolina Project-China, Guangzhou, China; Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Francois Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Elvin H Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
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Puryear SB, Ayieko J, Hahn JA, Mucunguzi A, Owaraganise A, Schwab J, Balzer LB, Kwarisiima D, Charlebois ED, Cohen CR, Bukusi EA, Petersen ML, Havlir DV, Kamya MR, Chamie G. Universal HIV Testing and Treatment With Patient-Centered Care Improves ART Uptake and Viral Suppression Among Adults Reporting Hazardous Alcohol Use in Uganda and Kenya. J Acquir Immune Defic Syndr 2023; 94:37-45. [PMID: 37220015 PMCID: PMC10524467 DOI: 10.1097/qai.0000000000003226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 04/28/2023] [Indexed: 05/25/2023]
Abstract
OBJECTIVES Determine whether patient-centered, streamlined HIV care achieves higher antiretroviral therapy (ART) uptake and viral suppression than the standard treatment model for people with HIV (PWH) reporting hazardous alcohol use. DESIGN Community cluster-randomized trial. METHODS The Sustainable East Africa Research in Community Health trial (NCT01864603) compared an intervention of annual population HIV testing, universal ART, and patient-centered care with a control of baseline population testing with ART by country standard in 32 Kenyan and Ugandan communities. Adults (15 years or older) completed a baseline Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) and were classified as no/nonhazardous (AUDIT-C 0-2 women/0-3 men) or hazardous alcohol use (≥3 women/≥4 men). We compared year 3 ART uptake and viral suppression of PWH reporting hazardous use between intervention and control arms. We compared alcohol use as a predictor of year 3 ART uptake and viral suppression among PWH, by arm. RESULTS Of 11,070 PWH with AUDIT-C measured, 1723 (16%) reported any alcohol use and 893 (8%) reported hazardous use. Among PWH reporting hazardous use, the intervention arm had higher ART uptake (96%) and suppression (87%) compared with control (74%, adjusted risk ratio [aRR] = 1.28, 95% CI: 1.19 to 1.38; and 72%, aRR = 1.20, 95% CI: 1.10 to 1.31, respectively). Within arm, hazardous alcohol use predicted lower ART uptake in control (aRR = 0.86, 95% CI: 0.78 to 0.96), but not intervention (aRR = 1.02, 95% CI: 1.00 to 1.04); use was not predictive of suppression in either arm. CONCLUSIONS The Sustainable East Africa Research in Community Health intervention improved ART uptake and viral suppression among PWH reporting hazardous alcohol use and eliminated gaps in ART uptake between PWH with hazardous and no/nonhazardous use. Patient-centered HIV care may decrease barriers to HIV care for PWH with hazardous alcohol use.
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Affiliation(s)
- Sarah B Puryear
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, CA
| | - James Ayieko
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Judith A Hahn
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, CA
| | | | | | - Joshua Schwab
- Division of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA
| | - Laura B Balzer
- Division of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA
| | | | - Edwin D Charlebois
- Division of Prevention Sciences, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA; and
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Maya L Petersen
- Division of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA
| | - Diane V Havlir
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, CA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | - Gabriel Chamie
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, CA
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Okorie CN, Gutin SA, Getahun M, Lebu SA, Okiring J, Neilands TB, Ssali S, Cohen CR, Maeri I, Eyul P, Bukusi EA, Charlebois ED, Camlin CS. Sex specific differences in HIV status disclosure and care engagement among people living with HIV in rural communities in Kenya and Uganda. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0000556. [PMID: 37027350 PMCID: PMC10081749 DOI: 10.1371/journal.pgph.0000556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 02/28/2023] [Indexed: 04/08/2023]
Abstract
Non-disclosure of human immunodeficiency virus (HIV) status can hinder optimal health outcomes for people living with HIV (PLHIV). We sought to explore experiences with and correlates of disclosure among PLHIV participating in a study of population mobility. Survey data were collected from 1081 PLHIV from 2015-16 in 12 communities in Kenya and Uganda participating in a test-and-treat trial (SEARCH, NCT#01864603). Pooled and sex-stratified multiple logistic regression models examined associations of disclosure with risk behaviors controlling for covariates and community clustering. At baseline, 91.0% (n = 984) of PLHIV had disclosed their serostatus. Amongst those who had never disclosed, 31% feared abandonment (47.4% men vs. 15.0% women; p = 0.005). Non-disclosure was associated with no condom use in the past 6 months (aOR = 2.44; 95%CI, 1.40-4.25) and with lower odds of receiving care (aOR = 0.8; 95%CI, 0.04-0.17). Unmarried versus married men had higher odds of non- disclosure (aOR = 4.65, 95%CI, 1.32-16.35) and no condom use in the past 6 months (aOR = 4.80, 95%CI, 1.74-13.20), as well as lower odds of receiving HIV care (aOR = 0.15; 95%CI, 0.04-50 0.49). Unmarried versus married women had higher odds of non-disclosure (aOR = 3.14, 95%CI, 1.47-6.73) and lower odds of receiving HIV care if they had never disclosed (aOR = 0.05, 95%CI, 0.02-0.14). Findings highlight gender differences in barriers to HIV disclosure, use of condoms, and engagement in HIV care. Interventions focused on differing disclosure support needs for women and men are needed and may help facilitate better care engagement for men and women and improve condom use in men.
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Affiliation(s)
- Chinomnso N. Okorie
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California, United States of America
| | - Sarah A. Gutin
- Department of Medicine, Division of Prevention Science, University of California, San Francisco, California, United States of America
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California, United States of America
| | - Sarah A. Lebu
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California, United States of America
| | - Jaffer Okiring
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Torsten B. Neilands
- Department of Medicine, Division of Prevention Science, University of California, San Francisco, California, United States of America
| | - Sarah Ssali
- School of Women and Gender Studies, Makerere University, Kampala, Uganda
| | - Craig R. Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California, United States of America
| | - Irene Maeri
- Kenya Medical Research Institute, Centre for Microbiology Research, Nairobi, Kenya
| | - Patrick Eyul
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Elizabeth A. Bukusi
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California, United States of America
- Kenya Medical Research Institute, Centre for Microbiology Research, Nairobi, Kenya
| | - Edwin D. Charlebois
- Department of Medicine, Division of Prevention Science, University of California, San Francisco, California, United States of America
| | - Carol S. Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California, United States of America
- Department of Medicine, Division of Prevention Science, University of California, San Francisco, California, United States of America
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Khader Y, Tsao WW, Lin KC, Fang YY, Lin KY, Li CL. Risk and Protective Profile of Men Who Have Sex With Men Using Mobile Voluntary HIV Counseling and Testing: Latent Class Analysis. JMIR Public Health Surveill 2023; 9:e43394. [PMID: 36795477 PMCID: PMC9982722 DOI: 10.2196/43394] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 01/06/2023] [Accepted: 01/11/2023] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Mobile voluntary counseling and testing (VCT) for HIV has been carried out to improve the targeting of at-risk populations and HIV case detection for men who have sex with men (MSM). However, the HIV-positive detection rate using this screening strategy has declined in recent years. This may imply unknown changes in risk-taking and protective features jointly influencing the testing results. These changing patterns in this key population remain unexplored. OBJECTIVE The aim of this study was to identify the nuanced group classification of MSM who underwent mobile VCT using latent class analysis (LCA), and to compare the difference in characteristics and testing results between subgroups. METHODS A cross-sectional research design and purposive sampling were applied between May 21, 2019, and December 31, 2019. Participants were recruited by a well-trained research assistant through social networking platforms, including the most popular instant messenger app Line, geosocial network apps dedicated to MSM, and online communities. Mobile VCT was provided to participants at an assigned time and place. Demographic characteristics and risk-taking and protective features of the MSM were collected via online questionnaires. LCA was used to identify discrete subgroups based on four risk-taking indicators-multiple sexual partners (MSP), unprotected anal intercourse (UAI), recreational drug use within the past 3 months, and history of sexually transmitted diseases-and three protective indicators-experience of postexposure prophylaxis, preexposure prophylaxis use, and regular HIV testing. RESULTS Overall, 1018 participants (mean age 30.17, SD 7.29 years) were included. A three-class model provided the best fit. Classes 1, 2, and 3 corresponded to the highest risk (n=175, 17.19%), highest protection (n=121, 11.89%), and low risk and low protection (n=722, 70.92%), respectively. Compared to those of class 3, class 1 participants were more likely to have MSP and UAI within the past 3 months, to be ≥40 years of age (odds ratio [OR] 2.197, 95% CI 1.357-3.558; P=.001), to have HIV-positive results (OR 6.47, 95% CI 2.272-18.482; P<.001), and a CD4 count ≤349/μL (OR 17.50, 95% CI 1.223-250.357; P=.04). Class 2 participants were more likely to adopt biomedical preventions and have marital experience (OR 2.55, 95% CI 1.033-6.277; P=.04). CONCLUSIONS LCA helped derive a classification of risk-taking and protection subgroups among MSM who underwent mobile VCT. These results may inform policies for simplifying the prescreening assessment and more precisely recognizing those who have higher probabilities of risk-taking features but remain undiagnosed targets, including MSM engaging in MSP and UAI within the past 3 months and those ≥40 years old. These results could be applied to tailor HIV prevention and testing programs.
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Affiliation(s)
| | - Wei-Wen Tsao
- School of Nursing, College of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Kuan-Chia Lin
- Community Medicine Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Medical Affairs, Cheng Shin General Hospital, Taipei, Taiwan
| | - Yuan-Yuan Fang
- Department of Post Baccalaureate Nursing, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Kuan-Yin Lin
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chia-Lin Li
- Research and Development Committee, Taiwan AIDS Nurse Association, Taipei, Taiwan.,Center for Neuropsychiatric Research, National Health Research Institutes, Taipei, Taiwan
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Mwangwa F, Charlebois ED, Ayieko J, Olio W, Black D, Peng J, Kwarisiima D, Kabami J, Balzer LB, Petersen ML, Kapogiannis B, Kamya MR, Havlir DV, Ruel TD. Two or more significant life-events in 6-months are associated with lower rates of HIV treatment and virologic suppression among youth with HIV in Uganda and Kenya. AIDS Care 2023; 35:95-105. [PMID: 35578398 PMCID: PMC9666617 DOI: 10.1080/09540121.2022.2052260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 03/01/2022] [Indexed: 10/18/2022]
Abstract
Youth living with HIV in sub-Saharan Africa have poor HIV care outcomes. We determined the association of recent significant life-events with HIV antiretroviral treatment (ART) initiation and HIV viral suppression in youth aged 15-24 years living with HIV in rural Kenya and Uganda. This was a cross-sectional analysis of 995 youth enrolled in the SEARCH Youth study. At baseline, providers assessed recent (within 6 months) life-events, defined as changes in schooling/employment, residence, partnerships, sickness, incarceration status, family strife or death, and birth/pregnancy, self-reported alcohol use, being a parent, and HIV-status disclosure. We examined the frequencies of events and their association with ART status and HIV viral suppression (<400 copies/ul). Recent significant life-events were prevalent (57.7%). Having >2 significant life-events (aOR = 0.61, 95% CI:0.45-0.85) and consuming alcohol (aOR = 0.61, 95% CI:0.43-0.87) were associated with a lower odds of HIV viral suppression, while disclosure of HIV-status to partner (aOR = 2.39, 95% CI:1.6-3.5) or to family (aOR = 1.86, 95% CI:1.3-2.7), being a parent (aOR = 1.8, 95% CI:1.2-2.5), and being single (aOR = 1.6, 95% CI:1.3-2.1) had a higher odds. This suggest that two or more recent life-events and alcohol use are key barriers to ART initiation and achievement of viral suppression among youth living with HIV in rural East Africa.Trial registration: ClinicalTrials.gov identifier: NCT03848728..
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Affiliation(s)
| | - Edwin D. Charlebois
- University of California, San Francisco, San Francisco, California, United States of America
| | - James Ayieko
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Winter Olio
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Douglas Black
- University of California, San Francisco, San Francisco, California, United States of America
| | - James Peng
- University of California, San Francisco, San Francisco, California, United States of America
| | | | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Laura B. Balzer
- University of Massachusetts, Amherst, Massachusetts, United States of America
| | - Maya L. Petersen
- University of California, Berkeley School of Public Health, Berkeley, California, United States of America
| | - Bill Kapogiannis
- Eunice Kennedy Shriver National Institute of Child Health and Human Development at the National Institutes of Health, Bethesda, Maryland, United States of America
| | - Moses R. Kamya
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane V. Havlir
- University of California, San Francisco, San Francisco, California, United States of America
| | - Theodore D. Ruel
- University of California, San Francisco, San Francisco, California, United States of America
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8
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Groves AK, Stankard P, Bowler SL, Jamil MS, Gebrekristos LT, Smith PD, Quinn C, Ba NS, Chidarikire T, Nguyen VTT, Baggaley R, Johnson C. A systematic review and meta-analysis of the evidence for community-based HIV testing on men's engagement in the HIV care cascade. Int J STD AIDS 2022; 33:1090-1105. [PMID: 35786140 PMCID: PMC9660288 DOI: 10.1177/09564624221111277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/29/2022] [Accepted: 06/13/2022] [Indexed: 12/04/2022]
Abstract
OBJECTIVE Men with HIV are less likely than women to know their status, be on antiretroviral therapy, and be virally suppressed. This review examined men's community-based HIV testing services (CB-HTS) outcomes. DESIGN Systematic review and meta-analysis. METHODS We searched seven databases and conference abstracts through July 2018. We estimated pooled proportions and/or risk ratios (for meta-analyses) for each outcome using random effects models. RESULTS 188 studies met inclusion criteria. Common testing models included targeted outreach (e.g. mobile testing), home-based testing, and testing at stand-alone community sites. Across 25 studies reporting uptake, 81% (CI: 75-86%) of men offered testing accepted it. Uptake was higher among men reached through CB-HTS than facility-based HTS (RR = 1.39; CI: 1.13-1.71). Over 69% (CI: 64-71%) of those tested through CB-HTS were men, across 184 studies. Across studies reporting new HIV-positivity among men (n = 18), 96% were newly diagnosed (CI: 77-100%). Across studies reporting linkage to HIV care (n = 8), 70% (CI: 36-103%) of men were linked to care. Across 57 studies reporting sex-disaggregated data for CB-HTS conducted among key populations, men's uptake was high (80%; CI: 70-88%) and nearly all were newly diagnosed and linked to care (95%; CI: 94-100%; and 94%; CI: 88-100%, respectively). CONCLUSION CB-HTS is an important strategy for reaching undiagnosed men with HIV from the general population and key population groups, particularly using targeted outreach models. When compared to facility-based HIV testing services, men tested through CB-HTS are more likely to uptake testing, and nearly all men who tested positive through CB-HTS were newly diagnosed. Linkage to care may be a challenge following CB-HTS, and greater efforts and research are needed to effectively implement testing strategies that facilitate rapid ART initiation and linkage to prevention services.
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Affiliation(s)
- Allison K Groves
- Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | | | - Sarah L Bowler
- Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Muhammad S Jamil
- Department of HIV/AIDS, World Health
Organization, Geneva, Switzerland
| | | | - Patrick D Smith
- Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Caitlin Quinn
- Department of HIV/AIDS, World Health
Organization, Geneva, Switzerland
| | - Ndoungou Salla Ba
- Department of HIV/AIDS, World Health
Organization, Geneva, Switzerland
| | - Thato Chidarikire
- HIV Prevention Programmes, National Department of
Health, Johannesburg, South Africa
| | | | - Rachel Baggaley
- Department of HIV/AIDS, World Health
Organization, Geneva, Switzerland
| | - Cheryl Johnson
- Department of HIV/AIDS, World Health
Organization, Geneva, Switzerland
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9
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Camlin CS, Getahun M, Koss CA, Owino L, Akatukwasa C, Itiakorit H, Onyango A, Bakanoma R, Atwine F, Maeri I, Ayieko J, Atukunda M, Owaraganise A, Mwangwa F, Sang N, Kabami J, Kaplan RL, Chamie G, Petersen ML, Cohen CR, Bukusi EA, Kamya MR, Havlir DV, Charlebois ED. Providers' Attitudes and Experiences with Pre-Exposure Prophylaxis Implementation in a Population-Based Study in Kenya and Uganda. AIDS Patient Care STDS 2022; 36:396-404. [PMID: 36201226 PMCID: PMC9595612 DOI: 10.1089/apc.2022.0084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Pre-exposure prophylaxis (PrEP) implementation is underway across sub-Saharan Africa. However, little is known about health care providers' experiences with PrEP provision in generalized epidemic settings, particularly outside of selected risk groups. In this study (NCT01864603), universal access to PrEP was offered to adolescents and adults at elevated risk during population-level HIV testing in rural Kenya and Uganda. Providers received training on PrEP prescribing and support from local senior clinicians. We conducted in-depth interviews with providers (n = 19) in four communities in Kenya and Uganda to explore the attitudes and experiences with implementation. Transcripts were coded and analyzed using interpretivist methods. Providers had heterogenous attitudes toward PrEP in its early implementation: some expressed enthusiasm, while others feared being blamed for "failures" (HIV seroconversions) if participants were nonadherent, or that offering PrEP would increase "immorality." Providers supported PrEP usage among HIV-serodifferent couples, whose mutual support for daily pill-taking facilitated harmony and protection from HIV. Providers reported challenges with counseling on "seasons of risk," and safely stopping and restarting PrEP. They felt uptake was hampered for women by difficulties negotiating with partners, and for youth by parental consent requirements. They believed PrEP continuation was hindered by transportation costs, stigma, pill burden, and side effects, and was facilitated by counseling, proactive management of side effects, and home/community-based provision. Providers are critical "implementation actors" in interventions to promote adoption of new technologies such as PrEP. Dedicated training and ongoing support for providers may facilitate successful scale-up.
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Affiliation(s)
- Carol S. Camlin
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco (UCSF), San Francisco, California, USA
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Monica Getahun
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Catherine A. Koss
- Division of HIV, Infectious Diseases & Global Medicine, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Lawrence Owino
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | | | | | | | - Robert Bakanoma
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Fredrick Atwine
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Irene Maeri
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - James Ayieko
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | | | | | - Florence Mwangwa
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Norton Sang
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Jane Kabami
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Rachel L. Kaplan
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Gabriel Chamie
- Division of HIV, Infectious Diseases & Global Medicine, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Maya L. Petersen
- Divisions of Biostatistics & Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Craig R. Cohen
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco (UCSF), San Francisco, California, USA
| | | | - Moses R. Kamya
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases & Global Medicine, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Edwin D. Charlebois
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco (UCSF), San Francisco, California, USA
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10
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Ostermann J, Njau B, Hobbie AM, Mtuy TB, Masnick M, Brown DS, Mühlbacher AC, Thielman NM. Divergent preferences for enhanced HIV testing options among high-risk populations in northern Tanzania: a short report. AIDS Care 2022:1-9. [PMID: 36063533 PMCID: PMC9985668 DOI: 10.1080/09540121.2022.2119471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
To achieve the UNAIDS target of diagnosing 95% of all persons living with HIV, enhanced HIV testing services with greater attractional value need to be developed and implemented. We conducted a discrete choice experiment (DCE) to quantify preferences for enhanced HIV testing features across two high-risk populations in the Kilimanjaro Region in northern Tanzania. We designed and fielded a survey with 12 choice tasks to systematically recruited female barworkers and male mountain porters. Key enhanced features included: testing availability on every day of the week, an oral test, integration of a general health check or an examination for sexually transmitted infections (STI) with HIV testing, and provider-assisted confidential partner notification in the event of a positive HIV test result. Across 300 barworkers and 440 porters surveyed, mixed logit analyses of 17,760 choices indicated strong preferences for everyday testing availability, health checks, and STI examinations. Most participants were averse to oral testing and confidential partner notification by providers. Substantial preference heterogeneity was observed within each risk group. Enhancing HIV testing services to include options for everyday testing, general health checks, and STI examinations may increase the appeal of HIV testing offers to high-risk populations.Trial registration: ClinicalTrials.gov identifier: NCT02714140.
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Affiliation(s)
- Jan Ostermann
- Department of Health Services Policy & Management, University of South Carolina, Columbia, SC,USA,South Carolina Smart State Center for Healthcare Quality, University of South Carolina, Columbia, SC, USA,Duke Global Health Institute, Duke University, Durham, NC, USA,Center for Health Policy & Inequalities Research, Duke University, Durham, NC, USA
| | - Bernard Njau
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Amy M. Hobbie
- Center for Health Policy & Inequalities Research, Duke University, Durham, NC, USA
| | - Tara B. Mtuy
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania,Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Derek S. Brown
- Center for Health Policy & Inequalities Research, Duke University, Durham, NC, USA,Brown School, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Axel C. Mühlbacher
- Center for Health Policy & Inequalities Research, Duke University, Durham, NC, USA,Institut Gesundheitsökonomie und Medizinmanagement, Hochschule Neubrandenburg, Neubrandenburg, Germany,Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Nathan M. Thielman
- Duke Global Health Institute, Duke University, Durham, NC, USA,Center for Health Policy & Inequalities Research, Duke University, Durham, NC, USA,Nathan M. Thielman, Duke University, Box 90519, Durham, NC 27708, Tel: +1 919 668 7173,
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11
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Mugenyi L, Nanfuka M, Byawaka J, Agaba C, Mijumbi A, Kagimu D, Mugisha K, Shabbar J, Etukoit M. Effect of universal test and treat on retention and mortality among people living with HIV-infection in Uganda: An interrupted time series analysis. PLoS One 2022; 17:e0268226. [PMID: 35580126 PMCID: PMC9113587 DOI: 10.1371/journal.pone.0268226] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/25/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Few studies have analysed the effect of HIV universal test and treat (UTT) on retention and mortality among people living with HIV (PLHIV) in routine care. We examined six-month retention and mortality at 11 health facilities (HFs) run by a large NGO, The AIDS Support Organisation (TASO), before and after UTT.
Methods
We used a quasi-experimental study using patient data extracted from 11 TASO HFs. Two periods, one before UTT (2015–2016) and the other during UTT (2017–2018) were compared. The primary outcome was six-month retention defined as the proportion of PLHIV who were alive and in care at six months from enrolment. The secondary outcome was six-month mortality defined as the proportion of PLHIV who died within six months from enrolment. We performed an interrupted time series analysis using graphical aids to study trends in six-month retention and mortality and a segmented regression to evaluate the effect of UTT. We used a generalized linear mixed model (GLMM) and generalized estimating equations (GEE) to account for facility-level clustering.
Results
Of the 20,171 PLHIV registered between 2015 and 2018 and included in the analysis, 12,757 (63.2%) were enrolled during the UTT period. 5256/7414 (70.9%) of the pre-UTT period compared to 12239/12757 (95.9%) of the UTT were initiated on ART treatment with 6 months from enrolment. The median time from enrolment to initiating ART was 14 (interquartile range (IQR): 0–31) days for the pre-UTT compared to 0 (IQR: 0–0) days for the UTT period. The median age at enrolment was 32.5 years for the pre-UTT and 35.0 years for the UTT period. Overall, the six-month retention just after scale-up of UTT, increased by 9.2 percentage points (p = 0.002) from the baseline value of 82.6% (95% CI: 77.6%-87.5%) but it eventually decreased at a rate 1.0 percentage point (p = 0.014) for cohorts recruited each month after UTT. The baseline six-month mortality was 3.3% (95% CI: 2.4%-4.2%) and this decreased by 1.6 percentage points (p = 0.003) immediately after UTT. The six-month mortality continued decreasing at a rate of 0.1 percentage points (p = 0.002) for cohorts enrolled each month after UTT. Retention differed between some health facilities with Rukungiri HF having the highest and Soroti the lowest retention. Retention was slightly higher among males and younger people. Mortality was highest among people aged 50 years and more. The effect of UTT on retention and mortality was similar across sex and age groups.
Conclusion
Overall, UTT significantly led to an immediate increase in retention and decrease in mortality among PLHIV enrolled in HIV care from 11 HFs run by TASO in Uganda. However, retention (and mortality) significantly decreased for cohorts enrolled each month after UTT. Retention was highest in Rukungiri and lowest in Soroti HFs and slightly higher in males and younger people. Mortality was highest in older patients and lowest in adolescents. We recommend for innovative interventions to improve the overall retention particularly in facilities reporting low retention in order to achieve the UNAIDS 2030 target of 95-95-95.
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Affiliation(s)
- Levicatus Mugenyi
- The AIDS Support Organization, Kampala, Uganda
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine, Entebbe Unit, Entebbe, Uganda
- * E-mail:
| | | | | | | | | | | | | | - Jaffer Shabbar
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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12
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Sundararajan R, Ponticiello M, Nansera D, Jeremiah K, Muyindike W. Interventions to Increase HIV Testing Uptake in Global Settings. Curr HIV/AIDS Rep 2022; 19:184-193. [PMID: 35441985 PMCID: PMC9110462 DOI: 10.1007/s11904-022-00602-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 12/16/2022]
Abstract
Purpose of Review HIV testing is the critical first step to direct people living with HIV (PLWH) to treatment. However, progress is still being made towards the UNAIDS benchmark of 95% of PLWH knowing their status by 2030. Here, we discuss recent interventions to improve HIV testing uptake in global settings. Recent Findings Successful facility-based HIV testing interventions involve couples and index testing, partner notification, and offering of incentives. Community-based interventions such as home-based self-testing, mobile outreach, and hybrid approaches have improved HIV testing in low-resource settings and among priority populations. Partnerships with trusted community leaders have also increased testing among populations disproportionally impacted by HIV. Summary Recent HIV testing interventions span a breadth of facility- and community-based approaches. Continued research is needed to engage men in sub-Saharan Africa, people who inject drugs, and people who avoid biomedical care. Interventions should consider supporting linkage to care for newly diagnosed PLWH.
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Affiliation(s)
- Radhika Sundararajan
- Department of Emergency Medicine, Weill Cornell Medicine, 525 East 68th Street, M-130, New York, NY, 10065, USA. .,Weill Cornell Center for Global Health, New York, NY, USA.
| | - Matthew Ponticiello
- Department of Emergency Medicine, Weill Cornell Medicine, 525 East 68th Street, M-130, New York, NY, 10065, USA
| | - Denis Nansera
- Mbarara Regional Referral Hospital, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Winnie Muyindike
- Mbarara Regional Referral Hospital, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda
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13
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Phiri MM, Schaap A, Simwinga M, Hensen B, Floyd S, Mulubwa C, Simuyaba M, Chiti B, Bond V, Shanaube K, Fidler S, Hayes R, Ayles H. Closing the gap: did delivery approaches complementary to home-based testing reach men with HIV testing services during and after the HPTN 071 (PopART) trial in Zambia? J Int AIDS Soc 2022; 25:e25855. [PMID: 35001530 PMCID: PMC8743361 DOI: 10.1002/jia2.25855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 11/26/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The HPTN 071 (PopART) trial demonstrated that universal HIV testing-and-treatment reduced community-level HIV incidence. Door-to-door delivery of HIV testing services (HTS) was one of the main components of the intervention. From an early stage, men were less likely to know their HIV status than women, primarily because they were not home during service delivery. To reach more men, different strategies were implemented during the trial. We present the relative contribution of these strategies to coverage of HTS and the impact of community hubs implemented after completion of the trial among men. METHODS Between 2013 and 2017, three intervention rounds (IRs) of door-to-door HTS delivery were conducted in eight PopART communities in Zambia. Additional strategies implemented in parallel, included: community-wide "Man-up" campaigns (IR1), smaller HTS campaigns at work/social places (IR2) and revisits to households with the option of HIV self-testing (HIVST) (IR3). In 2018, community "hubs" offering HTS were implemented for 7 months in all eight communities. Population enumeration data for each round of HTS provided the denominator, allowing for calculation of the proportion of men tested as a result of each strategy during different time periods. RESULTS By the end of the three IRs, 65-75% of men were reached with HTS, primarily through door-to-door service delivery. In IR1 and IR2, "Man-up" and work/social place campaigns accounted for ∼1 percentage point each and in IR3, revisits with the option of self-testing for ∼15 percentage points of this total coverage per IR. The yield of newly diagnosed HIV-positive men ranged from 2.2% for HIVST revisits to 9.9% in work/social places. At community hubs, the majority of visitors accepting services were men (62.8%). In total, we estimated that ∼36% (2.2% tested HIV positive) of men resident but not found at their household during IR3 of PopART accessed HTS provided at the hubs after trial completion. CONCLUSIONS Achieving high coverage of HTS among men requires universal, home-based service delivery combined with an option of HIVST and delivery of HTS through community-based hubs. When men are reached, they are willing to test for HIV. Reaching men thus requires implementers to adapt their HTS delivery strategies to meet men's needs. CLINICAL TRIAL NUMBER NCT01900977.
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Affiliation(s)
| | - Ab Schaap
- ZambartLusakaZambia
- Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | | | - Bernadette Hensen
- Clinical Research DepartmentLondon School of Hygiene and Tropical MedicineLondonUK
| | - Sian Floyd
- Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | | | | | | | - Virginia Bond
- ZambartLusakaZambia
- Department of Global HealthLondon School of Hygiene and Tropical MedicineLondonUK
| | | | - Sarah Fidler
- Imperial College and Imperial College NIHR BRCLondonUK
| | - Richard Hayes
- Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Helen Ayles
- ZambartLusakaZambia
- Clinical Research DepartmentLondon School of Hygiene and Tropical MedicineLondonUK
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14
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Effect of universal HIV testing and treatment on socioeconomic wellbeing in rural Kenya and Uganda: a cluster-randomised controlled trial. Lancet Glob Health 2022; 10:e96-e104. [DOI: 10.1016/s2214-109x(21)00458-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/20/2021] [Accepted: 09/15/2021] [Indexed: 12/24/2022]
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15
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'It is not fashionable to suffer nowadays': Community motivations to repeatedly participate in outreach HIV testing indicate UHC potential in Tanzania. PLoS One 2021; 16:e0261408. [PMID: 34937061 PMCID: PMC8694479 DOI: 10.1371/journal.pone.0261408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 12/01/2021] [Indexed: 11/19/2022] Open
Abstract
Objective This study examined people’s motivations for (repeatedly) utilizing HIV testing services during community-based testing events in urban and rural Shinyanga, Tanzania and potential implications for Universal Health Coverage (UHC). Methods As part of a broader multidisciplinary study on the implementation of a HIV Test and Treat model in Shinyanga Region, Tanzania, this ethnographic study focused on community-based testing campaigns organised by the implementing partner. Between April 2018 and December 2019, we conducted structured observations (24), short questionnaires (42) and in-depth interviews with HIV-positive (23) and HIV-negative clients (8). Observations focused on motivations for (re-)testing, and the counselling and testing process. Thematic analysis based on inductive and deductive coding was completed using NVivo software. Results Regular HIV testing was encouraged by counsellors. Most participants in testing campaigns were HIV-negative; 51.1% had tested more than once over their lifetimes. Testing campaigns provided an accessible way to learn one’s HIV status. Motivations for repeat testing included: monitoring personal health to achieve (temporary) reassurance, having low levels of trust toward sexual partners, feeling at risk, seeking proof of (ill)-health, and acting responsibly. Repeat testers also associated testing with a desire to start treatment early to preserve a healthy-looking body, should they prove HIV positive. Conclusions Community-based testing campaigns serve three valuable functions related to HIV prevention and treatment: 1) enable community members to check their HIV status regularly as part of a personalized prevention strategy that reinforces responsible behaviour; 2) identify recently sero-converted clients who would not otherwise be targeted; and 3) engage community with general prevention and care messaging and services. This model could be expanded to include routine management of other (chronic) diseases and provide an entry for scaling up UHC.
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16
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Jewell BL, BALZER LB, CLARK TD, CHARLEBOIS ED, KWARISIIMA D, KAMYA MR, HAVLIR DV, PETERSEN ML, BERSHTEYN A. Predicting HIV Incidence in the SEARCH Trial: A Mathematical Modeling Study. J Acquir Immune Defic Syndr 2021; 87:1024-1031. [PMID: 33770065 PMCID: PMC8217115 DOI: 10.1097/qai.0000000000002684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/16/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The SEARCH study provided community-based HIV and multidisease testing and antiretroviral therapy (ART) to 32 communities in East Africa and reported no statistically significant difference in 3-year HIV incidence. We used mathematical modeling to estimate the effect of control arm viral suppression and community mixing on SEARCH trial outcomes. SETTING Uganda and Kenya. METHODS Using the individual-based HIV modeling software EMOD-HIV, we configured a new model of SEARCH communities. The model was parameterized using demographic, HIV prevalence, male circumcision, and viral suppression data and calibrated to HIV prevalence, ART coverage, and population size. Using assumptions about ART scale-up in the control arm, degree of community mixing, and effect of baseline testing, we estimated comparative HIV incidence under multiple scenarios. RESULTS Before the trial results, we predicted that SEARCH would report a 4%-40% reduction between arms, depending on control arm ART linkage rates and community mixing. With universal baseline testing followed by rapidly expanded ART eligibility and uptake, modeled effect sizes were smaller than the study was powered to detect. Using interim viral suppression data, we estimated 3-year cumulative incidence would have been reduced by up to 27% in the control arm and 43% in the intervention arm compared with a counterfactual without universal baseline testing. CONCLUSIONS Our model suggests that the active control arm substantially reduced expected effect size and power of the SEARCH study. However, compared with a counterfactual "true control" without increased ART linkage because of baseline testing, SEARCH reduced HIV incidence by up to 43%.
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Affiliation(s)
- Britta L. Jewell
- University of California, Berkeley, Berkeley, USA
- Institute for Disease Modeling, Bellevue, USA
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17
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Farhoudi B, Ghalekhani N, Afsar Kazerooni P, Namdari Tabar H, Tayeri K, Gouya MM, SeyedAlinaghi S, Haghdoost AA, Mirzazadeh A, Sharifi H. Cascade of care in people living with HIV in Iran in 2019; how far to reach UNAIDS/WHO targets. AIDS Care 2021; 34:590-596. [PMID: 34180724 DOI: 10.1080/09540121.2021.1944603] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Systematic HIV program evaluation requires looking at all steps of the HIV cascade of care, from diagnosis to treatment outcomes. Our study was carried out to assess the treatment cascade of people living with HIV (PLWH) in Iran in 2019. We used data from the HIV Case Registry System of Iran through December 2019. We estimated the number of PLWH in 2019 by using Spectrum, and then the proportion of them being diagnosed, linked to care, received antiretroviral treatment and suppressed viral load. We estimated that there are 59,314 (UI: 32,685-125,636) PLWH in Iran, of whom 22,054 people (37% of PLWH) were diagnosed. At the end of 2019, of whom, 14,685 (25% of PLWH) people received antiretroviral therapy. Also, of whom 6338 (11% of PLWH) people had viral load suppression by 2019. Our results showed that about one-third of total PLWH were diagnosed, while this defect is somewhat less in children than adults. To reach the 90.90.90 targets Iran needs to developed the current national HIV care guidelines, which recommend best strategies to scale up the case finding and linkage to care among undiagnosed people specifically those who infected by sexual contact in general and key populations as well.
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Affiliation(s)
- Behnam Farhoudi
- Social Determinant of Health research Center, Amiralmomenin Hospital, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
| | - Nima Ghalekhani
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Parvin Afsar Kazerooni
- HIV/AIDS Control Office, Center for Communicable Disease, Ministry of Health, Tehran, Iran
| | - Hengameh Namdari Tabar
- HIV/AIDS Control Office, Center for Communicable Disease, Ministry of Health, Tehran, Iran
| | - Katayoun Tayeri
- HIV/AIDS Control Office, Center for Communicable Disease, Ministry of Health, Tehran, Iran
| | | | - SeyedAhmad SeyedAlinaghi
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Akbar Haghdoost
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Ali Mirzazadeh
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Hamid Sharifi
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
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18
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Abstract
BACKGROUND Social isolation among HIV-positive persons might be an important barrier to care. Using data from the SEARCH Study in rural Kenya and Uganda, we constructed 32 community-wide, sociocentric networks and evaluated whether less socially connected HIV-positive persons were less likely to know their status, have initiated treatment, and be virally suppressed. METHODS Between 2013 and 2014, 168,720 adult residents in the SEARCH Study were census-enumerated, offered HIV testing, and asked to name social contacts. Social networks were constructed by matching named contacts to other residents. We characterized the resulting networks and estimated risk ratios (aRR) associated with poor HIV care outcomes, adjusting for sociodemographic factors and clustering by community with generalized estimating equations. RESULTS The sociocentric networks contained 170,028 residents (nodes) and 362,965 social connections (edges). Among 11,239 HIV-positive persons who named ≥1 contact, 30.9% were previously undiagnosed, 43.7% had not initiated treatment, and 49.4% had viral nonsuppression. Lower social connectedness, measured by the number of persons naming an HIV-positive individual as a contact (in-degree), was associated with poorer outcomes in Uganda, but not Kenya. Specifically, HIV-positive persons in the lowest connectedness tercile were less likely to be previously diagnosed (Uganda-West aRR: 0.89 [95% confidence interval (CI): 0.83, 0.96]; Uganda-East aRR: 0.85 [95% CI: 0.76, 0.96]); on treatment (Uganda-West aRR: 0.88 [95% CI: 0.80, 0.98]; Uganda-East aRR: 0.81 [0.72, 0.92]), and suppressed (Uganda-West aRR: 0.84 [95% CI: 0.73, 0.96]; Uganda-East aRR: 0.74 [95% CI: 0.58, 0.94]) than those in the highest connectedness tercile. CONCLUSIONS HIV-positive persons named as a contact by fewer people may be at higher risk for poor HIV care outcomes, suggesting opportunities for targeted interventions.
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19
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Kavanagh NM, Schaffer EM, Ndyabakira A, Marson K, Havlir DV, Kamya MR, Kwarisiima D, Chamie G, Thirumurthy H. Planning prompts to promote uptake of HIV services among men: a randomised trial in rural Uganda. BMJ Glob Health 2021; 5:bmjgh-2020-003390. [PMID: 33257417 PMCID: PMC7705572 DOI: 10.1136/bmjgh-2020-003390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 10/20/2020] [Accepted: 10/25/2020] [Indexed: 12/04/2022] Open
Abstract
Introduction Interventions informed by behavioural economics, such as planning prompts, have the potential to increase HIV testing at minimal or no cost. Planning prompts have not been previously evaluated for HIV testing uptake. We conducted a randomised clinical trial to evaluate the effectiveness of low-cost planning prompts to promote HIV testing among men. Methods We randomised adult men in rural Ugandan parishes to receive a calendar planning prompt that gave them the opportunity to make a plan to get tested for HIV at health campaigns held in their communities. Participants received either a calendar showing the dates when the community health campaign would be held (control group) or a calendar showing the dates and prompting them to select a date and time when they planned to attend (planning prompt group). Participants were not required to select a date and time or to share their selection with study staff. The primary outcome was HIV testing uptake at the community health campaign. Results Among 2362 participants, 1796 (76%) participants tested for HIV. Men who received a planning prompt were 2.2 percentage points more likely to test than the control group, although the difference was not statistically significant (77.1% vs 74.9%; 95% CI –1.2 to 5.7 percentage points, p=0.20). The planning prompt was more effective among men enrolled ≤40 days before the campaigns (3.6 percentage-point increase in testing; 95% CI –2.9 to 10.1, p=0.27) than among men enrolled >40 days before the campaigns (1.8 percentage-point increase; 95% CI –2.3 to 5.8, p=0.39), although the effects within the subgroups were not significant. Conclusion These findings suggest that planning prompts may be an effective behavioural intervention to promote HIV testing at minimal or no cost. Large-scale studies should further assess the impact and cost-effectiveness of such interventions.
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Affiliation(s)
- Nolan M Kavanagh
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Elisabeth M Schaffer
- Data Science to Patient Value, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Alex Ndyabakira
- Infectious Diseases Research Collaboration, Kampala, Central Region, Uganda
| | - Kara Marson
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, California, USA
| | - Diane V Havlir
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, California, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Central Region, Uganda.,Department of Medicine, Makerere University, Kampala, Kampala, Uganda
| | - Dalsone Kwarisiima
- Infectious Diseases Research Collaboration, Kampala, Central Region, Uganda
| | - Gabriel Chamie
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, California, USA
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA .,Center for Health Incentives and Behavioral Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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20
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Akatukwasa C, Getahun M, El Ayadi AM, Namanya J, Maeri I, Itiakorit H, Owino L, Sanyu N, Kabami J, Ssemmondo E, Sang N, Kwarisiima D, Petersen ML, Charlebois ED, Chamie G, Clark TD, Cohen CR, Kamya MR, Bukusi EA, Havlir DV, Camlin CS. Dimensions of HIV-related stigma in rural communities in Kenya and Uganda at the start of a large HIV 'test and treat' trial. PLoS One 2021; 16:e0249462. [PMID: 33999961 PMCID: PMC8128261 DOI: 10.1371/journal.pone.0249462] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 03/18/2021] [Indexed: 11/19/2022] Open
Abstract
HIV-related stigma is a frequently cited barrier to HIV testing and care engagement. A nuanced understanding of HIV-related stigma is critical for developing stigma-reduction interventions to optimize HIV-related outcomes. This qualitative study documented HIV-related stigma across eight communities in east Africa during the baseline year of a large HIV test-and-treat trial (SEARCH, NCT: 01864603), prior to implementation of widespread community HIV testing campaigns and efforts to link individuals with HIV to care and treatment. Findings revealed experiences of enacted, internalized and anticipated stigma that were highly gendered, and more pronounced in communities with lower HIV prevalence; women, overwhelmingly, both held and were targets of stigmatizing attitudes about HIV. Past experiences with enacted stigma included acts of segregation, verbal discrimination, physical violence, humiliation and rejection. Narratives among women, in particular, revealed acute internalized stigma including feelings of worthlessness, shame, embarrassment, and these resulted in anxiety and depression, including suicidality among a small number of women. Anticipated stigma included fears of marital dissolution, verbal and physical abuse, gossip and public ridicule. Anticipated stigma was especially salient for women who held internalized stigma and who had experienced enacted stigma from their partners. Anticipated stigma led to care avoidance, care-seeking at remote facilities, and hiding of HIV medications. Interventions aimed at reducing individual and community-level forms of stigma may be needed to improve the lives of PLHIV and fully realize the promise of test-and-treat strategies.
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Affiliation(s)
| | - Monica Getahun
- Department of Obstetrics, Bixby Center for Global Reproductive Health, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States of America
| | - Alison M. El Ayadi
- Department of Obstetrics, Bixby Center for Global Reproductive Health, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States of America
| | - Judith Namanya
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Irene Maeri
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Lawrence Owino
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Naomi Sanyu
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Norton Sang
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Maya L. Petersen
- Divisions of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA, United States of America
| | - Edwin D. Charlebois
- Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, CA, United States of America
| | - Gabriel Chamie
- Division of HIV, Infectious Disease and Global Medicine, Department of Medicine, University of California, San Francisco, CA, United States of America
| | - Tamara D. Clark
- Division of HIV, Infectious Disease and Global Medicine, Department of Medicine, University of California, San Francisco, CA, United States of America
| | - Craig R. Cohen
- Department of Obstetrics, Bixby Center for Global Reproductive Health, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States of America
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Elizabeth A. Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Diane V. Havlir
- Division of HIV, Infectious Disease and Global Medicine, Department of Medicine, University of California, San Francisco, CA, United States of America
| | - Carol S. Camlin
- Department of Obstetrics, Bixby Center for Global Reproductive Health, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States of America
- Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, CA, United States of America
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Abstract
OBJECTIVE Sub-Saharan Africa faces twin epidemics of HIV and noncommunicable diseases including hypertension. Integrating hypertension care into chronic HIV care is a global priority, but cost estimates are lacking. In the SEARCH Study, we performed population-level HIV/hypertension testing, and offered integrated streamlined chronic care. Here, we estimate costs for integrated hypertension/HIV care for HIV-positive individuals, and costs for hypertension care for HIV-negative individuals in the same clinics. DESIGN Microcosting analysis of healthcare expenditures within Ugandan HIV clinics. METHODS SEARCH (NCT: 01864603) conducted community health campaigns for diagnosis and linkage to care for both HIV and hypertension. HIV-positive patients received hypertension/HIV care jointly including blood pressure monitoring and medications; HIV-negative patients received hypertension care at the same clinics. Within 10 Ugandan study communities during 2015-2016, we estimated incremental annual per-patient hypertension care costs using micro-costing techniques, time-and-motion personnel studies, and administrative/clinical records review. RESULTS Overall, 70 HIV-positive and 2355 HIV-negative participants received hypertension care. For HIV-positive participants, average incremental cost of hypertension care was $6.29 per person per year, a 2.1% marginal increase over prior estimates for HIV care alone. For HIV-negative participants, hypertension care cost $11.39 per person per year, a 3.8% marginal increase over HIV care costs. Key costs for HIV-positive patients included hypertension medications ($6.19 per patient per year; 98% of total) and laboratory testing ($0.10 per patient per year; 2%). Key costs for HIV-negative patients included medications ($5.09 per patient per year; 45%) and clinic staff salaries ($3.66 per patient per year; 32%). CONCLUSION For only 2-4% estimated additional costs, hypertension care was added to HIV care, and also expanded to all HIV-negative patients in prototypic Ugandan clinics, demonstrating substantial synergy. Our results should encourage accelerated scale-up of hypertension care into existing clinics.
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Financial incentives and deposit contracts to promote HIV retesting in Uganda: A randomized trial. PLoS Med 2021; 18:e1003630. [PMID: 33945526 PMCID: PMC8131095 DOI: 10.1371/journal.pmed.1003630] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 05/18/2021] [Accepted: 04/15/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Frequent retesting for HIV among persons at increased risk of HIV infection is critical to early HIV diagnosis of persons and delivery of combination HIV prevention services. There are few evidence-based interventions for promoting frequent retesting for HIV. We sought to determine the effectiveness of financial incentives and deposit contracts in promoting quarterly HIV retesting among adults at increased risk of HIV. METHODS AND FINDINGS In peri-urban Ugandan communities from October to December 2018, we randomized HIV-negative adults with self-reported risk to 1 of 3 strategies to promote HIV retesting: (1) no incentive; (2) cash incentives (US$7) for retesting at 3 and 6 months (total US$14); or (3) deposit contracts: participants could voluntarily deposit US$6 at baseline and at 3 months that would be returned with interest (total US$7) upon retesting at 3 and 6 months (total US$14) or lost if participants failed to retest. The primary outcome was retesting for HIV at both 3 and 6 months. Of 1,482 persons screened for study eligibility following community-based recruitment, 524 participants were randomized to either no incentive (N = 180), incentives (N = 172), or deposit contracts (N = 172): median age was 25 years (IQR: 22 to 30), 44% were women, and median weekly income was US$13.60 (IQR: US$8.16 to US$21.76). Among participants randomized to deposit contracts, 24/172 (14%) made a baseline deposit, and 2/172 (1%) made a 3-month deposit. In intent-to-treat analyses, HIV retesting at both 3 and 6 months was significantly higher in the incentive arm (89/172 [52%]) than either the control arm (33/180 [18%], odds ratio (OR) 4.8, 95% CI: 3.0 to 7.7, p < 0.001) or the deposit contract arm (28/172 [16%], OR 5.5, 95% CI: 3.3 to 9.1, p < 0.001). Among those in the deposit contract arm who made a baseline deposit, 20/24 (83%) retested at 3 months; 11/24 (46%) retested at both 3 and 6 months. Among 282 participants who retested for HIV during the trial, three (1%; 95%CI: 0.2 to 3%) seroconverted: one in the incentive group and two in the control group. Study limitations include measurement of retesting at the clinic where baseline enrollment occurred, only offering clinic-based (rather than community-based) HIV retesting and lack of measurement of retesting after completion of the trial to evaluate sustained retesting behavior. CONCLUSIONS Offering financial incentives to high-risk adults in Uganda resulted in significantly higher HIV retesting. Deposit contracts had low uptake and overall did not increase retesting. As part of efforts to increase early diagnosis of HIV among high-risk populations, strategic use of incentives to promote retesting should receive greater consideration by HIV programs. TRIAL REGISTRATION clinicaltrials.gov: NCT02890459.
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Chamie G, Napierala S, Agot K, Thirumurthy H. HIV testing approaches to reach the first UNAIDS 95% target in sub-Saharan Africa. Lancet HIV 2021; 8:e225-e236. [PMID: 33794183 DOI: 10.1016/s2352-3018(21)00023-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/20/2021] [Accepted: 01/26/2021] [Indexed: 02/06/2023]
Abstract
HIV testing is a crucial first step to accessing HIV prevention and treatment services and to achieving the UNAIDS target of 95% of people living with HIV being aware of their status by 2030. Combined implementation of facility-based and community-based approaches has helped to achieve high levels of HIV testing coverage in many countries including those in sub-Saharan Africa. Approaches such as index testing and self-testing help to reach individuals at higher risk of acquiring HIV, men, and those less likely to use health facilities or community-based services. However, as the proportion of people living with HIV who are aware of their HIV status has risen, the challenge of reaching those who remain undiagnosed or those who are at high risk of acquiring HIV has grown. Demand generation and novel testing approaches will be necessary to reach undiagnosed people living with HIV and to promote frequent retesting among key and priority populations.
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Affiliation(s)
- Gabriel Chamie
- Division of HIV, Infectious Diseases & Global Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Sue Napierala
- RTI International, Women's Global Health Imperative, Berkeley, CA, USA
| | - Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
| | - Harsha Thirumurthy
- Perelman School of Medicine and Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
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Kamya MR, Petersen ML, Kabami J, Ayieko J, Kwariisima D, Sang N, Clark TD, Schwab J, Charlebois ED, Cohen CR, Bukusi EA, Peng J, Jain V, Chen YH, Chamie G, Balzer LB, Havlir DV. SEARCH Human Immunodeficiency Virus (HIV) Streamlined Treatment Intervention Reduces Mortality at a Population Level in Men With Low CD4 Counts. Clin Infect Dis 2021; 73:e1938-e1945. [PMID: 33783495 DOI: 10.1093/cid/ciaa1782] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We tested the hypothesis that patient-centered, streamlined human immunodeficiency virus (HIV) care would achieve lower mortality than the standard treatment model for persons with HIV and CD4 ≤ 350/uL in the setting of population-wide HIV testing. METHODS In the SEARCH (Sustainable East Africa Research in Community Health) Study (NCT01864603), 32 communities in rural Uganda and Kenya were randomized to country-guided antiretroviral therapy (ART) versus streamlined ART care that included rapid ART start, visit spacing, flexible clinic hours, and welcoming environment. We assessed persons with HIV and CD4 ≤ 350/uL, ART eligible in both arms, and estimated the effect of streamlined care on ART initiation and mortality at 3 years. Comparisons between study arms used a cluster-level analysis with survival estimates from Kaplan-Meier; estimates of ART start among ART-naive persons treated death as a competing risk. RESULTS Among 13 266 adults with HIV, 2973 (22.4%) had CD4 ≤ 350/uL. Of these, 33% were new diagnoses, and 10% were diagnosed but ART-naive. Men with HIV were almost twice as likely as women with HIV to have CD4 ≤ 350/uL and be untreated (15% vs 8%, respectively). Streamlined care reduced mortality by 28% versus control (risk ratio [RR] = 0.72; 95% confidence interval [CI]: .56, .93; P = .02). Despite eligibility in both arms, persons with CD4 ≤ 350/uL started ART faster under streamlined care versus control (76% vs 43% by 12 months, respectively; P < .001). Mortality was reduced substantially more among men (RR = 0.61; 95% CI: .43, .86; P = .01) than among women (RR = 0.90; 95% CI: .62, 1.32; P = .58). CONCLUSIONS After population-based HIV testing, streamlined care reduced population-level mortality among persons with HIV and CD4 ≤ 350/uL, particularly among men. Streamlined HIV care models may play a key role in global efforts to reduce AIDS deaths.
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Affiliation(s)
- Moses R Kamya
- Makerere University, Kampala, Uganda.,Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Maya L Petersen
- University of California Berkeley, Berkeley, California, USA
| | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | | | - Tamara D Clark
- University of California San Francisco, San Francisco, California, USA
| | - Joshua Schwab
- University of California Berkeley, Berkeley, California, USA
| | | | - Craig R Cohen
- University of California San Francisco, San Francisco, California, USA
| | | | - James Peng
- University of California San Francisco, San Francisco, California, USA
| | - Vivek Jain
- University of California San Francisco, San Francisco, California, USA
| | - Yea-Hung Chen
- University of California San Francisco, San Francisco, California, USA
| | - Gabriel Chamie
- University of California San Francisco, San Francisco, California, USA
| | - Laura B Balzer
- University of Massachusetts Amherst, Amherst, Massachusetts, USA
| | - Diane V Havlir
- University of California San Francisco, San Francisco, California, USA
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Chiou PY, Ko NY, Chien CY. Mobile HIV Testing Through Social Networking Platforms: Comparative Study. J Med Internet Res 2021; 23:e25031. [PMID: 33769298 PMCID: PMC8035663 DOI: 10.2196/25031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/20/2021] [Accepted: 01/31/2021] [Indexed: 11/24/2022] Open
Abstract
Background Improving HIV screening in key populations is a crucial strategy to achieve the goal of eliminating AIDS in 2030. Social networking platforms can be used to recruit high risk-taking men who have sex with men (MSM) to promote the delivery of voluntary counseling and testing (VCT) as mobile HIV testing. Therefore, client recruitment and availability of mobile HIV testing through social networking platforms requires further evaluation. Objective The aim of this study is to compare the effects of targeting high risk-taking MSM and HIV case finding between two mobile HIV testing recruitment approaches: through the traditional website-based approach and through social networking platforms. Methods A comparative study design and propensity score matching was applied. The traditional VCT model, that is, the control group, recruited MSM through a website, and a trained research assistant visited the walk-in testing station at a gay village on Friday and Saturday nights. The social networking VCT model, the experimental group, recruited MSM from social networking platforms by periodically reloading into and conducting web-based discussions on dating apps and Facebook. The participants then referred to others in their social networks via a popular messenger app in Taiwan. The test was conducted at a designated time and place during weekdays by a trained research assistant. Across both modes of contact, before the mobile HIV testing, participants needed to provide demographic characteristics and respond to a questionnaire about HIV risk-taking behaviors. Results We recruited 831 MSM over 6 months, with a completion rate of 8.56% (616/7200) in the traditional VCT model and 20.71% (215/1038) in the social networking VCT model. After propensity score matching, there were 215 MSM in each group (mean age 29.97, SD 7.61 years). The social networking model was more likely to reach MSM with HIV risk-taking behaviors, that is, those seeking sexual activity through social media, having multiple sexual partners and unprotected anal intercourse, having experience of recreational drug use, and never having or not regularly having an HIV test, compared with the traditional model. HIV positive rates (incidence rate ratio 3.40, 95% CI 1.089-10.584; P=.03) and clinic referral rates (incidence rate ratio 0.03, 95% CI 0.001-0.585; P=.006) were significantly higher among those in the social networking VCT model than in the traditional VCT model. Conclusions Through effective recruitment strategies on social networking platforms, the social networking VCT mode can be smoothly promoted, as compared with the traditional VCT model, to target high risk-taking MSM and increase testing outcomes.
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Affiliation(s)
- Piao-Yi Chiou
- Department of Nursing, National Taiwan University Hospital, Taipei City, Taiwan.,School of Nursing, College of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Nai-Ying Ko
- Department of Nursing, College of Medicine, National Cheng Kung, Tainan, Taiwan
| | - Chien-Yu Chien
- School of Nursing, College of Medicine, National Taiwan University, Taipei City, Taiwan
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26
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Abstract
BACKGROUND Population-level estimates of disease prevalence and control are needed to assess prevention and treatment strategies. However, available data often suffer from differential missingness. For example, population-level HIV viral suppression is the proportion of all HIV-positive persons with suppressed viral replication. Individuals with measured HIV status, and among HIV-positive individuals those with measured viral suppression, likely differ from those without such measurements. METHODS We discuss three sets of assumptions to identify population-level suppression in the intervention arm of the SEARCH Study (NCT01864603), a community randomized trial in rural Kenya and Uganda (2013-2017). Using data on nearly 100,000 participants, we compare estimates from (1) an unadjusted approach assuming data are missing-completely-at-random (MCAR); (2) stratification on age group, sex, and community; and (3) targeted maximum likelihood estimation to adjust for a larger set of baseline and time-updated variables. RESULTS Despite high measurement coverage, estimates of population-level viral suppression varied by identification assumption. Unadjusted estimates were most optimistic: 50% (95% confidence interval [CI] = 46%, 54%) of HIV-positive persons suppressed at baseline, 80% (95% CI = 78%, 82%) at year 1, 85% (95% CI = 83%, 86%) at year 2, and 85% (95% CI = 83%, 87%) at year 3. Stratifying on baseline predictors yielded slightly lower estimates, and full adjustment reduced estimates meaningfully: 42% (95% CI = 37%, 46%) of HIV-positive persons suppressed at baseline, 71% (95% CI = 69%, 73%) at year 1, 76% (95% CI = 74%, 78%) at year 2, and 79% (95% CI = 77%, 81%) at year 3. CONCLUSIONS Estimation of population-level disease burden and control requires appropriate adjustment for missing data. Even in large studies with limited missingness, estimates relying on the MCAR assumption or baseline stratification should be interpreted cautiously.
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Heri AB, Cavallaro FL, Ahmed N, Musheke MM, Matsui M. Changes over time in HIV testing and counselling uptake and associated factors among youth in Zambia: a cross-sectional analysis of demographic and health surveys from 2007 to 2018. BMC Public Health 2021; 21:456. [PMID: 33676482 PMCID: PMC7937241 DOI: 10.1186/s12889-021-10472-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 02/19/2021] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Zambia is among the countries with the highest HIV burden and where youth remain disproportionally affected. Access to HIV testing and counselling (HTC) is a crucial step to ensure the reduction of HIV transmission. This study examines the changes that occurred between 2007 and 2018 in access to HTC, inequities in testing uptake, and determinants of HTC uptake among youth. METHODS We carried out repeated cross-sectional analyses using three Zambian Demographic and Health Surveys (2007, 2013-14, and 2018). We calculated the percentage of women and men ages 15-24 years old who were tested for HIV in the last 12 months. We analysed inequity in HTC coverage using indicators of absolute inequality. We performed bivariate and multivariate logistic regression analyses to identify predictors of HTC uptake in the last 12 months. RESULTS HIV testing uptake increased between 2007 and 2018, from 45 to 92% among pregnant women, 10 to 58% among non-pregnant women, and from 10 to 49% among men. By 2018 roughly 60% of youth tested in the past 12 months used a government health centre. Mobile clinics were the second most common source reaching up to 32% among adolescent boys by 2018. Multivariate analysis conducted among men and non-pregnant women showed higher odds of testing among 20-24 year-olds than adolescents (aOR = 1.55 [95%CI:1.30-1.84], among men; and aOR = 1.74 [1.40-2.15] among women). Among men, being circumcised (aOR = 1.57 [1.32-1.88]) and in a union (aOR = 2.44 [1.83-3.25]) were associated with increased odds of testing. For women greater odds of testing were associated with higher levels of education (aOR = 6.97 [2.82-17.19]). Education-based inequity was considerably widened among women than men by 2018. CONCLUSION HTC uptake among Zambian youth improved considerably by 2018 and reached 65 and 49% tested in the last 12 months for women and men, respectively. However, achieving the goal of 95% envisioned by 2020 will require sustaining the success gained through government health centres, and scaling up the community-led approaches that have proven acceptable and effective in reaching young men and adolescent girls who are less easy to reach through the government facilities.
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Affiliation(s)
- Aimé Bitakuya Heri
- Department of Global Health, Nagasaki University School of Tropical Medicine and Global Health, Sakamoto 1-12-4, Nagasaki, 852-8523, Japan
| | - Francesca L Cavallaro
- Institute of Child Health, University College London, 30 Guilford St, Holborn, London, WC1N 1EH, UK
| | - Nurilign Ahmed
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Maurice Mubuyaeta Musheke
- Centre for Infectious Disease Research in Zambia, Plot # 34620, Off Alick Nkhata Road, Lusaka, Zambia
| | - Mitsuaki Matsui
- Department of Global Health, Nagasaki University School of Tropical Medicine and Global Health, Sakamoto 1-12-4, Nagasaki, 852-8523, Japan.
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Nyabuti MN, Petersen ML, Bukusi EA, Kamya MR, Mwangwa F, Kabami J, Sang N, Charlebois ED, Balzer LB, Schwab JD, Camlin CS, Black D, Clark TD, Chamie G, Havlir DV, Ayieko J. Characteristics of HIV seroconverters in the setting of universal test and treat: Results from the SEARCH trial in rural Uganda and Kenya. PLoS One 2021; 16:e0243167. [PMID: 33544717 PMCID: PMC7864429 DOI: 10.1371/journal.pone.0243167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 11/14/2020] [Indexed: 12/05/2022] Open
Abstract
Background Additional progress towards HIV epidemic control requires understanding who remains at risk of HIV infection in the context of high uptake of universal testing and treatment (UTT). We sought to characterize seroconverters and risk factors in the SEARCH UTT trial (NCT01864603), which achieved high uptake of universal HIV testing and ART coverage in 32 communities of adults (≥15 years) in rural Uganda and Kenya. Methods In a pooled cohort of 117,114 individuals with baseline HIV negative test results, we described those who seroconverted within 3 years, calculated gender-specific HIV incidence rates, evaluated adjusted risk ratios (aRR) for seroconversion using multivariable targeted maximum likelihood estimation, and assessed potential infection sources based on self-report. Results Of 704 seroconverters, 63% were women. Young (15–24 years) men comprised a larger proportion of seroconverters in Western Uganda (18%) than Eastern Uganda (6%) or Kenya (10%). After adjustment for other risk factors, men who were mobile [≥1 month of prior year living outside community] (aRR:1.68; 95%CI:1.09,2.60) or who HIV tested at home vs. health fair (aRR:2.44; 95%CI:1.89,3.23) were more likely to seroconvert. Women who were aged ≤24 years (aRR:1.91; 95%CI:1.27,2.90), mobile (aRR:1.49; 95%CI:1.04,2.11), or reported a prior HIV test (aRR:1.34; 95%CI:1.06,1.70), or alcohol use (aRR:2.07; 95%CI:1.34,3.22) were more likely to seroconvert. Among survey responders (N = 607, 86%), suspected infection source was more likely for women than men to be ≥10 years older (28% versus 8%) or a spouse (51% vs. 31%) and less likely to be transactional sex (10% versus 16%). Conclusion In the context of universal testing and treatment, additional strategies tailored to regional variability are needed to address HIV infection risks of young women, alcohol users, mobile populations, and those engaged in transactional sex to further reduce HIV incidence rates.
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Affiliation(s)
| | - Maya L. Petersen
- Division of Biostatistics and Epidemiology, School of Public Health, University of California Berkeley, Berkeley, California, United States of America
| | | | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda, Makerere University College of Health Sciences, Kampala, Uganda
| | - Florence Mwangwa
- Infectious Diseases Research Collaboration, Kampala, Uganda, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda, Makerere University College of Health Sciences, Kampala, Uganda
| | - Norton Sang
- Kenya Medical Research Institute, Kisumu, Kenya
| | - Edwin D. Charlebois
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, California, United States of America
| | - Laura B. Balzer
- Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, Massachusetts, United States of America
| | - Joshua D. Schwab
- Division of Biostatistics and Epidemiology, School of Public Health, University of California Berkeley, Berkeley, California, United States of America
| | - Carol S. Camlin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Douglas Black
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Tamara D. Clark
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Gabriel Chamie
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, California, United States of America
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Koss CA, Havlir DV, Ayieko J, Kwarisiima D, Kabami J, Chamie G, Atukunda M, Mwinike Y, Mwangwa F, Owaraganise A, Peng J, Olilo W, Snyman K, Awuonda B, Clark TD, Black D, Nugent J, Brown LB, Marquez C, Okochi H, Zhang K, Camlin CS, Jain V, Gandhi M, Cohen CR, Bukusi EA, Charlebois ED, Petersen ML, Kamya MR, Balzer LB. HIV incidence after pre-exposure prophylaxis initiation among women and men at elevated HIV risk: A population-based study in rural Kenya and Uganda. PLoS Med 2021; 18:e1003492. [PMID: 33561143 PMCID: PMC7872279 DOI: 10.1371/journal.pmed.1003492] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 01/04/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Oral pre-exposure prophylaxis (PrEP) is highly effective for HIV prevention, but data are limited on HIV incidence among PrEP users in generalized epidemic settings, particularly outside of selected risk groups. We performed a population-based PrEP study in rural Kenya and Uganda and sought to evaluate both changes in HIV incidence and clinical and virologic outcomes following seroconversion on PrEP. METHODS AND FINDINGS During population-level HIV testing of individuals ≥15 years in 16 communities in the Sustainable East Africa Research in Community Health (SEARCH) study (NCT01864603), we offered universal access to PrEP with enhanced counseling for persons at elevated HIV risk (based on serodifferent partnership, machine learning-based risk score, or self-identified HIV risk). We offered rapid or same-day PrEP initiation and flexible service delivery with follow-up visits at facilities or community-based sites at 4, 12, and every 12 weeks up to week 144. Among participants with incident HIV infection after PrEP initiation, we offered same-day antiretroviral therapy (ART) initiation and analyzed HIV RNA, tenofovir hair concentrations, drug resistance, and viral suppression (<1,000 c/ml based on available assays) after ART start. Using Poisson regression with cluster-robust standard errors, we compared HIV incidence among PrEP initiators to incidence among propensity score-matched recent historical controls (from the year before PrEP availability) in 8 of the 16 communities, adjusted for risk group. Among 74,541 individuals who tested negative for HIV, 15,632/74,541 (21%) were assessed to be at elevated HIV risk; 5,447/15,632 (35%) initiated PrEP (49% female; 29% 15-24 years; 19% in serodifferent partnerships), of whom 79% engaged in ≥1 follow-up visit and 61% self-reported PrEP adherence at ≥1 visit. Over 7,150 person-years of follow-up, HIV incidence was 0.35 per 100 person-years (95% confidence interval [CI] 0.22-0.49) among PrEP initiators. Among matched controls, HIV incidence was 0.92 per 100 person-years (95% CI 0.49-1.41), corresponding to 74% lower incidence among PrEP initiators compared to matched controls (adjusted incidence rate ratio [aIRR] 0.26, 95% CI 0.09-0.75; p = 0.013). Among women, HIV incidence was 76% lower among PrEP initiators versus matched controls (aIRR 0.24, 95% CI 0.07-0.79; p = 0.019); among men, HIV incidence was 40% lower, but not significantly so (aIRR 0.60, 95% CI 0.12-3.05; p = 0.54). Of 25 participants with incident HIV infection (68% women), 7/25 (28%) reported taking PrEP ≤30 days before HIV diagnosis, and 24/25 (96%) started ART. Of those with repeat HIV RNA after ART start, 18/19 (95%) had <1,000 c/ml. One participant with viral non-suppression was found to have transmitted viral resistance, as well as emtricitabine resistance possibly related to PrEP use. Limitations include the lack of contemporaneous controls to assess HIV incidence without PrEP and that plasma samples were not archived to assess for baseline acute infection. CONCLUSIONS Population-level offer of PrEP with rapid start and flexible service delivery was associated with 74% lower HIV incidence among PrEP initiators compared to matched recent controls prior to PrEP availability. HIV infections were significantly lower among women who started PrEP. Universal HIV testing with linkage to treatment and prevention, including PrEP, is a promising approach to accelerate reductions in new infections in generalized epidemic settings. TRIAL REGISTRATION ClinicalTrials.gov NCT01864603.
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Affiliation(s)
- Catherine A. Koss
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - James Ayieko
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Gabriel Chamie
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | | | - Yusuf Mwinike
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | - James Peng
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Winter Olilo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Katherine Snyman
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Benard Awuonda
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Tamara D. Clark
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Douglas Black
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Joshua Nugent
- Department of Biostatistics and Epidemiology, University of Massachusetts, Amherst, Amherst, Massachusetts, United States of America
| | - Lillian B. Brown
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Carina Marquez
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Hideaki Okochi
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Kevin Zhang
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Carol S. Camlin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Vivek Jain
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Monica Gandhi
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Craig R. Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Elizabeth A. Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Edwin D. Charlebois
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Maya L. Petersen
- Graduate Group in Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Laura B. Balzer
- Department of Biostatistics and Epidemiology, University of Massachusetts, Amherst, Amherst, Massachusetts, United States of America
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Mwangwa F, Getahun M, Itiakorit H, Jain V, Ayieko J, Owino L, Akatukwasa C, Maeri I, Koss CA, Chamie G, Clark TD, Kabami J, Atukunda M, Kwarisiima D, Sang N, Bukusi EA, Kamya MR, Petersen ML, Cohen CR, Charlebois ED, Havlir DV, Camlin CS. Provider and Patient Perspectives of Rapid ART Initiation and Streamlined HIV Care: Qualitative Insights From Eastern African Communities. J Int Assoc Provid AIDS Care 2021; 20:23259582211053518. [PMID: 34841945 PMCID: PMC8641109 DOI: 10.1177/23259582211053518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 09/21/2021] [Accepted: 09/26/2021] [Indexed: 11/30/2022] Open
Abstract
The Sustainable East Africa Research in Community Health (SEARCH), a universal test and treat (UTT) trial, implemented 'Streamlined Care'-a multicomponent strategy including rapid linkage to care and antiretroviral therapy (ART) start, 3-monthly refills, viral load counseling, and accessible, patient-centered care provision. To understand patient and provider experiences of Streamlined Care to inform future care innovations, we conducted in-depth interviews with patients (n = 18) and providers (n = 28) at baseline (2014) and follow-up (2015) (n = 17 patients; n = 21 providers). Audio recordings were transcribed, translated, and deductively and inductively coded. Streamlined Care helped to decongest clinic spaces and de-stigmatize human immunodeficiency virus (HIV) care. Patients credited the individualized counselling, provider-assisted HIV status disclosure, and providers' knowledge of patient's drug schedules, availability, and phone call reminders for their care engagement. However, for some, denial (repeated testing to disprove HIV+ results), feeling healthy, limited understanding of the benefits of early ART, and anticipated side-effects, and mistrust of researchers hindered rapid ART initiation. Patients' short and long-term mobility proved challenging for both patients and providers. Providers viewed viral load counselling as a powerful tool to convince otherwise healthy and high-CD4 patients to initiate ART. Patient-centered HIV care models should build on the successes of Streamlined Care, while addressing persistent barriers.#NCT01864683-https://clinicaltrials.gov/ct2/show/NCT01864603.
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Affiliation(s)
| | | | | | - Vivek Jain
- University of California San Francisco, San Francisco, USA
| | - James Ayieko
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | - Irene Maeri
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Gabriel Chamie
- University of California San Francisco, San Francisco, USA
| | | | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | - Norton Sang
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | | | | | | | | | - Carol S. Camlin
- University of California San Francisco, San Francisco, USA
- University of California, San Francisco, San Francisco, CA, USA
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Truong HHM, Mocello AR, Ouma D, Bushman D, Kadede K, Ating'a E, Obunge D, Bukusi EA, Odhiambo F, Cohen CR. Community-based HIV testing services in an urban setting in western Kenya: a programme implementation study. Lancet HIV 2021; 8:e16-e23. [PMID: 33166505 PMCID: PMC10880946 DOI: 10.1016/s2352-3018(20)30253-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 08/12/2020] [Accepted: 08/24/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Some countries are struggling to reach the UNAIDS target of 90% of all individuals with HIV knowing their HIV status, especially among men and youth. To identify individuals who are unaware of their HIV-positive status and achieve testing saturation, we implemented a hybrid HIV testing approach in an urban informal settlement in western Kenya. In this study, we aimed to describe the uptake of HIV testing and linkage to care and treatment during this programme. METHODS The Community Health Initiative involved community mapping, household census, multidisease community health campaigns, and home-based tracking in the informal settlement of Obunga in Kisumu, Kenya. 52 multidisease community health campaigns were held throughout the programme coverage area, at which HIV testing by certified testing service counsellors was one of the health services available. Individuals aged 15 years or older who were not previously identified as HIV-positive, children younger than 15 years who reported being sexually active or for whom testing was requested by a parent or guardian, and individuals who tested HIV-negative within the past 3 months but who reported a recent risk were all eligible for testing. Health and counselling services were tailored for men and youth to encourage their participation. Individuals identified during the census who did not attend a community health campaign were tracked using global positioning system data and offered home-based HIV testing services. We calculated the previously unidentified fraction, defined as the number of individuals who were newly identified as HIV-positive as a proportion of all individuals previously identified and newly identified as HIV-positive. FINDINGS Between Jan 11 and Aug 29, 2018, the Community Health Initiative programme reached 23 584 individuals, of whom 11 526 (48·9%) were men and boys and 5635 (23·9%) were aged 15-24 years. Of 12 769 individuals who were eligible for HIV testing, 12 407 (97·2%) accepted testing, including 3917 (31·6%) first-time testers. 101 individuals were newly identified as HIV-positive out of 1248 total individuals who were HIV-positive, representing an 8·1% previously unidentified fraction. The previously unidentified fraction was highest among men (9·8%) and among people aged 15-24 years (15·3%). INTERPRETATION Community-based hybrid HIV testing was successfully implemented in an urban setting. Innovative approaches that make HIV testing more accessible and acceptable, particularly to men and young people, are crucial for achieving testing and treatment saturation. Focusing on identifying individuals who are unaware of their HIV-positive status in combination with monitoring the previously unidentified fraction has the potential to achieve the UNAIDS Fast Track commitment to end AIDS by 2030. FUNDING US President's Emergency Plan for AIDS Relief through the US Centers for Disease Control and Prevention.
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Affiliation(s)
- Hong-Ha M Truong
- Department of Medicine, University of California, San Francisco, CA, USA.
| | - A Rain Mocello
- Department of Obstetrics, Gynecology, and Reproductive Services, University of California, San Francisco, CA, USA
| | - David Ouma
- Kenya Medical Research Institute, Kisumu, Kenya
| | - Dena Bushman
- Department of Medicine, University of California, San Francisco, CA, USA
| | | | | | | | | | | | - Craig R Cohen
- Department of Obstetrics, Gynecology, and Reproductive Services, University of California, San Francisco, CA, USA
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Gesesew HA, Ward P, Woldemichael K, Mwanri L. HIV Care continuum Outcomes: Can Ethiopia Meet the UNAIDS 90-90-90 Targets? Ethiop J Health Sci 2020; 30:179-188. [PMID: 32165807 PMCID: PMC7060392 DOI: 10.4314/ejhs.v30i2.5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Ethiopia has pledged to the UNAIDS 90-90-90 framework. However, the achievements of these UNAIDS targets are not assessed in Southwest Ethiopia. Using HIV care and treatment outcomes as surrogate markers, we assessed all targets. Methods Complex surrogate makers were used to assess the HIV care continuum outcomes using antiretroviral therapy data in Jimma University Teaching Hospital. Early HIV diagnosis was a surrogate marker to measure the first 90. Numbers of people on HIV treatment and who have good adherence were used to measure the second 90. To measure the third 90, we used immunological success that was measured using numbers of CD4 counts, clinical success using WHO clinical stages and treatment success using immunological and clinical successes. Results In total, 8172 patients were enrolled for HIV care from June 2003 to March 2015. For the diagnosis target, the prevalence of early HIV diagnosis among patients on ART was 35% (43% among children and 33.3% among adults). For the treatment target, 5299(65%) received ART of which 1154(22%) patients lost to follow-up or defaulted from ART treatment, and 1015(19%) patients on treatment transferred out to other sites. In addition, 17% had fair or good adherence. Finally, 81% had immunological success, 80% had clinical success and 66% treatment success. Conclusions The study revealed that Southwest Ethiopia achieved 35%, 65% and 66% of the first, second and third UNAIDS targets, a very far performance from achieving the target. These highlight further rigorous interventions to improve outcome of HIV continuum of care.
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Affiliation(s)
- Hailay Abrha Gesesew
- Public Health, Flinders University, Adelaide, Australia.,Epidemiology, Jimma University, Jimma, Ethiopia
| | - Paul Ward
- Public Health, Flinders University, Adelaide, Australia
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Balzer LB, Havlir DV, Kamya MR, Chamie G, Charlebois ED, Clark TD, Koss CA, Kwarisiima D, Ayieko J, Sang N, Kabami J, Atukunda M, Jain V, Camlin CS, Cohen CR, Bukusi EA, Van Der Laan M, Petersen ML. Machine Learning to Identify Persons at High-Risk of Human Immunodeficiency Virus Acquisition in Rural Kenya and Uganda. Clin Infect Dis 2020; 71:2326-2333. [PMID: 31697383 PMCID: PMC7904068 DOI: 10.1093/cid/ciz1096] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 11/05/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND In generalized epidemic settings, strategies are needed to prioritize individuals at higher risk of human immunodeficiency virus (HIV) acquisition for prevention services. We used population-level HIV testing data from rural Kenya and Uganda to construct HIV risk scores and assessed their ability to identify seroconversions. METHODS During 2013-2017, >75% of residents in 16 communities in the SEARCH study were tested annually for HIV. In this population, we evaluated 3 strategies for using demographic factors to predict the 1-year risk of HIV seroconversion: membership in ≥1 known "risk group" (eg, having a spouse living with HIV), a "model-based" risk score constructed with logistic regression, and a "machine learning" risk score constructed with the Super Learner algorithm. We hypothesized machine learning would identify high-risk individuals more efficiently (fewer persons targeted for a fixed sensitivity) and with higher sensitivity (for a fixed number targeted) than either other approach. RESULTS A total of 75 558 persons contributed 166 723 person-years of follow-up; 519 seroconverted. Machine learning improved efficiency. To achieve a fixed sensitivity of 50%, the risk-group strategy targeted 42% of the population, the model-based strategy targeted 27%, and machine learning targeted 18%. Machine learning also improved sensitivity. With an upper limit of 45% targeted, the risk-group strategy correctly classified 58% of seroconversions, the model-based strategy 68%, and machine learning 78%. CONCLUSIONS Machine learning improved classification of individuals at risk of HIV acquisition compared with a model-based approach or reliance on known risk groups and could inform targeting of prevention strategies in generalized epidemic settings. CLINICAL TRIALS REGISTRATION NCT01864603.
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Affiliation(s)
- Laura B Balzer
- Department of Biostatistics and Epidemiology, University of Massachusetts, Amherst, Massachusetts, USA
| | - Diane V Havlir
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Gabriel Chamie
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Edwin D Charlebois
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, California, USA
| | - Tamara D Clark
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Catherine A Koss
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | | | - James Ayieko
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Norton Sang
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Vivek Jain
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Carol S Camlin
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Elizabeth A Bukusi
- Kenya Medical Research Institute, Nairobi, Kenya
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Mark Van Der Laan
- Division of Epidemiology and Biostatistics, University of California, Berkeley, California, USA
| | - Maya L Petersen
- Division of Epidemiology and Biostatistics, University of California, Berkeley, California, USA
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Camlin CS, Charlebois ED, Getahun M, Akatukwasa C, Atwine F, Itiakorit H, Bakanoma R, Maeri I, Owino L, Onyango A, Chamie G, Clark TD, Cohen CR, Kwarisiima D, Kabami J, Sang N, Kamya MR, Bukusi EA, Petersen ML, V Havlir D. Pathways for reduction of HIV-related stigma: a model derived from longitudinal qualitative research in Kenya and Uganda. J Int AIDS Soc 2020; 23:e25647. [PMID: 33283986 PMCID: PMC7720278 DOI: 10.1002/jia2.25647] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION The rollout of antiretroviral therapy (ART) has been associated with reductions in HIV-related stigma, but pathways through which this reduction occurs are poorly understood. In the newer context of universal test and treat (UTT) interventions, where rapid diffusion of ART uptake takes place, there is an opportunity to understand the processes through which HIV-related stigma can decline, and how UTT strategies may precipitate more rapid and widespread changes in stigma. This qualitative study sought to evaluate how a UTT intervention influenced changes in beliefs, attitudes and behaviours related to HIV. METHODS Longitudinal qualitative in-depth semi-structured interview data were collected within a community-cluster randomized UTT trial, the Sustainable East Africa Research in Community Health (SEARCH) study, annually over three rounds (2014 to 2016) from two cohorts of adults (n = 32 community leaders, and n = 112 community members) in eight rural communities in Uganda and Kenya. Data were inductively analysed to develop new theory for understanding the pathways of stigma decline. RESULTS We present an emergent theoretical model of pathways through which HIV-related stigma may decline: internalized stigma may be reduced by two processes accelerated through the uptake and successful usage of ART: first, a reduced fear of dying and increased optimism for prolonged and healthy years of life; second, a restoration of perceived social value and fulfilment of subjective role expectations via restored physical strength and productivity. Anticipated stigma may be reduced in response to widespread engagement in HIV testing, leading to an increasing number of HIV status disclosures in a community, "normalizing" disclosure and reducing fears. Improvements in the perceived quality of HIV care lead to people living with HIV (PLHIV) seeking care in nearby facilities, seeing other known community members living with HIV, reducing isolation and facilitating opportunities for social support and "solidarity." Finally, enacted stigma may be reduced in response to the community viewing the healthy bodies of PLHIV successfully engaged in treatment, which lessens the fears that trigger enacted stigma; it becomes no longer socially normative to stigmatize PLHIV. This process may be reinforced through public health messaging and anti-discrimination laws. CONCLUSIONS Declines in HIV-related stigma appear to underway and explained by social processes accelerated by UTT efforts. Widespread implementation of UTT shows promise for reducing multiple dimensions of stigma, which is critical for improving health outcomes among PLHIV.
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Affiliation(s)
- Carol S Camlin
- Department of ObstetricsGynecology & Reproductive SciencesUniversity of California San FranciscoSan FranciscoCAUSA
- Department of MedicineCenter for AIDS Prevention StudiesUniversity of California San FranciscoSan FranciscoCAUSA
| | - Edwin D Charlebois
- Department of MedicineCenter for AIDS Prevention StudiesUniversity of California San FranciscoSan FranciscoCAUSA
| | - Monica Getahun
- Department of ObstetricsGynecology & Reproductive SciencesUniversity of California San FranciscoSan FranciscoCAUSA
| | | | | | | | | | - Irene Maeri
- Kenya Medical Research InstituteNairobiKenya
| | | | | | - Gabriel Chamie
- Division of HIVDepartment of MedicineInfectious Diseases, and Global MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Tamara D Clark
- Division of HIVDepartment of MedicineInfectious Diseases, and Global MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Craig R Cohen
- Department of ObstetricsGynecology & Reproductive SciencesUniversity of California San FranciscoSan FranciscoCAUSA
| | | | - Jane Kabami
- Infectious Diseases Research CollaborationKampalaUganda
| | - Norton Sang
- Kenya Medical Research InstituteNairobiKenya
| | - Moses R Kamya
- Infectious Diseases Research CollaborationKampalaUganda
- School of MedicineMakerere UniversityKampalaUganda
| | | | - Maya L Petersen
- Divisions of Biostatistics and EpidemiologySchool of Public HealthUniversity of California BerkeleyBerkeleyCAUSA
| | - Diane V Havlir
- Division of HIVDepartment of MedicineInfectious Diseases, and Global MedicineUniversity of California San FranciscoSan FranciscoCAUSA
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Chamie G, Hickey MD, Kwarisiima D, Ayieko J, Kamya MR, Havlir DV. Universal HIV Testing and Treatment (UTT) Integrated with Chronic Disease Screening and Treatment: the SEARCH study. Curr HIV/AIDS Rep 2020; 17:315-323. [PMID: 32507985 DOI: 10.1007/s11904-020-00500-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW The growing burden of untreated chronic disease among persons with HIV (PWH) threatens to reverse heath gains from ART expansion. Universal test and treat (UTT)'s population-based approach provides opportunity to jointly identify and treat HIV and other chronic diseases. This review's purpose is to describe SEARCH UTT study's integrated disease strategy and related approaches in Sub-Saharan Africa. RECENT FINDINGS In SEARCH, 97% of adults were HIV tested, 85% were screened for hypertension, and 79% for diabetes at health fairs after 2 years, for an additional $1.16/person. After 3 years, population-level hypertension control was 26% higher in intervention versus control communities. Other mobile/home-based multi-disease screening approaches have proven successful, but data on multi-disease care delivery are extremely limited and show little effect on clinical outcomes. Integration of chronic disease into HIV in the UTT era is feasible and can achieve population level effects; however, optimization and implementation remain a huge unmet need.
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Affiliation(s)
- Gabriel Chamie
- Division of HIV, Infectious Diseases & Global Medicine, San Francisco General Hospital / University of California, San Francisco, UCSF Box 0874, San Francisco, CA, 94143-0874, USA.
| | - Matthew D Hickey
- Division of HIV, Infectious Diseases & Global Medicine, San Francisco General Hospital / University of California, San Francisco, UCSF Box 0874, San Francisco, CA, 94143-0874, USA
| | | | | | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda.,Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane V Havlir
- Division of HIV, Infectious Diseases & Global Medicine, San Francisco General Hospital / University of California, San Francisco, UCSF Box 0874, San Francisco, CA, 94143-0874, USA
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Brault MA, Spiegelman D, Abdool Karim SS, Vermund SH. Integrating and Interpreting Findings from the Latest Treatment as Prevention Trials. Curr HIV/AIDS Rep 2020; 17:249-258. [PMID: 32297219 DOI: 10.1007/s11904-020-00492-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW In 2018-2019, studies were published assessing the effectiveness of reducing HIV incidence by expanding HIV testing, linkage to HIV treatment, and assistance to persons living with HIV to adhere to their medications (the "90-90-90" strategy). These tests of "treatment as prevention" (TasP) had complex results. RECENT FINDINGS The TasP/ANRS 12249 study in South Africa, the SEARCH study in Kenya and Uganda, and one comparison (arms A to C) of the HPTN 071 (PopART) study in South Africa and Zambia did not demonstrate a community impact on HIV incidence. In contrast, the Botswana Ya Tsie study and the second comparison (arms B to C) of PopART indicated significant ≈ 30% reductions in HIV incidence in the intervention communities where TasP was expanded. We discuss the results of these trials and outline future research and challenges. These include the efficient expansion of widespread HIV testing, better linkage to care, and viral suppression among all persons living with HIV. A top implementation science priority for the next decade is to determine what strategies to use in specific local contexts.
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Affiliation(s)
- Marie A Brault
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA.
| | - Donna Spiegelman
- Department of Biostatistics; Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Salim S Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Sten H Vermund
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
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Amstutz A, Lejone TI, Khesa L, Muhairwe J, Bresser M, Vanobberghen F, Kopo M, Kao M, Nsakala BL, Tlali K, Klimkait T, Battegay M, Labhardt ND, Glass TR. Home-based oral self-testing for absent and declining individuals during a door-to-door HIV testing campaign in rural Lesotho (HOSENG): a cluster-randomised trial. Lancet HIV 2020; 7:e752-e761. [PMID: 33045193 DOI: 10.1016/s2352-3018(20)30233-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND In sub-Saharan Africa, home-based HIV testing is validated and accepted, but coverage is low because household members are often absent during home-based testing campaigns. We aimed to measure the effect of a secondary distribution of oral-fluid HIV self-tests on coverage during home-based testing in rural Lesotho. METHODS The Home-Based Self-Testing (HOSENG) trial was a cluster-randomised, non-blinded superiority trial in rural villages in the catchment area of 20 health facilities of two districts in Lesotho (Butha-Buthe and Mokhotlong). Eligible villages had a consenting village chief and at least one registered village health worker; eligible households had a consenting representative aged 18 years or older. The HOSENG trial provided a recruitment platform for the interlinked Village-Based Refill of Antiretroviral Therapy (VIBRA) trial. Villages were randomly assigned 1:1:1:1 with block sizes of four to one of four groups: VIBRA control and HOSENG control; VIBRA control and HOSENG intervention; VIBRA intervention and HOSENG control; and VIBRA intervention and HOSENG intervention. Randomisation was stratified by district, village size, and access to the nearest health facility. An independent statistician was responsible for the computer-generated randomisation list. In the intervention group, oral-fluid HIV self-tests were left for absent or declining household members (aged ≥12 years) during a home visit from the HIV testing campaign team. One present household member was trained on self-test use. Distributed self-tests were followed up by village health workers. In control village clusters, absent or declining household members were referred to the clinic for HIV testing. The primary outcome was HIV testing coverage among all household members aged 12 years or older within 120 days, defined as a confirmed HIV test result or known status, reported in testing registers at the health facilities or on the follow-up forms of the village health worker. Adjusted random-effects logistic regression with individuals as the unit of analysis was used. This trial is registered with ClinicalTrials.gov, NCT03598686. FINDINGS Between July 26, 2018, and Dec 12, 2018, 3091 consenting households with 7816 household members aged 12 years or older were enrolled and randomly assigned (intervention: 57 village clusters, 1620 households, 4174 household members; control: 49 village clusters, 1471 households, 3642 household members). In the control group, 38 (3%) of 1455 initially absent or declining household members tested at a clinic within 120 days. In the intervention group, 841 (53%) of 1601 initially absent or declining household members had a confirmed status within 120 days; 12 (1%) of 841 tested at the clinic and 829 (99%) used their self-test kit. This resulted in a testing coverage of 2201 (60%) of 3642 in the control group versus 3386 (81%) of 4174 in the intervention group (odds ratio 3·00 [95% CI 2·52-3·59]; p<0·0001). INTERPRETATION Secondary distribution of oral-fluid HIV self-tests during home-based testing increases testing coverage substantially and thus presents a promising add-on during testing campaigns. FUNDING Swiss National Science Foundation.
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Affiliation(s)
- Alain Amstutz
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland; Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | | | - Lefu Khesa
- SolidarMed, Partnerships for Health, Maseru, Lesotho
| | | | - Moniek Bresser
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Fiona Vanobberghen
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Mathebe Kopo
- SolidarMed, Partnerships for Health, Maseru, Lesotho
| | - Mpho Kao
- SolidarMed, Partnerships for Health, Maseru, Lesotho
| | | | - Katleho Tlali
- SolidarMed, Partnerships for Health, Maseru, Lesotho
| | - Thomas Klimkait
- University of Basel, Basel, Switzerland; Molecular Virology, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Manuel Battegay
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Niklaus Daniel Labhardt
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland; Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
| | - Tracy Renée Glass
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
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Grimsrud A, Wilkinson L, Eshun-Wilson I, Holmes C, Sikazwe I, Katz IT. Understanding Engagement in HIV Programmes: How Health Services Can Adapt to Ensure No One Is Left Behind. Curr HIV/AIDS Rep 2020; 17:458-466. [PMID: 32844274 PMCID: PMC7497373 DOI: 10.1007/s11904-020-00522-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Despite the significant progress in the HIV response, gaps remain in ensuring engagement in care to support life-long medication adherence and viral suppression. This review sought to describe the different points in the HIV care cascade where people living with HIV were not engaging and highlight promising interventions. RECENT FINDINGS There are opportunities to improve engagement both between testing and treatment and to support re-engagement in care for those in a treatment interruption. The gap between testing and treatment includes people who know their HIV status and people who do not know their status. People in a treatment interruption include those who interrupt immediately following initiation, early on in their treatment (first 6 months) and late (after 6 months or more on ART). For each of these groups, specific interventions are required to support improved engagement. There are diverse needs and specific populations of people living with HIV who are not engaged in care, and differentiated service delivery interventions are required to meet their needs and expectations. For the HIV response to realise the 2030 targets, engagement will need to be supported by quality care and patient choice combined with empowered patients who are treatment literate and have been supported to improve self-management.
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Affiliation(s)
- Anna Grimsrud
- International AIDS Society, 3 Doris Road, Claremont, Cape Town, 7708 South Africa
- Desmond Tutu HIV Centre, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925 South Africa
| | - Lynne Wilkinson
- International AIDS Society, 3 Doris Road, Claremont, Cape Town, 7708 South Africa
- Department of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Charles Holmes
- Center for Innovation in Global Health, Georgetown University, Washington, DC USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Ingrid T. Katz
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
- Harvard Medical School, Boston, MA USA
- Massachusetts General Hospital Center for Global Health, Boston, MA USA
- Harvard Global Health Institute, Cambridge, MA USA
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Iwuji C, Chimukuche RS, Zuma T, Plazy M, Larmarange J, Orne-Gliemann J, Siedner M, Shahmanesh M, Seeley J. Test but not treat: Community members' experiences with barriers and facilitators to universal antiretroviral therapy uptake in rural KwaZulu-Natal, South Africa. PLoS One 2020; 15:e0239513. [PMID: 32970730 PMCID: PMC7514038 DOI: 10.1371/journal.pone.0239513] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 09/08/2020] [Indexed: 01/20/2023] Open
Abstract
Introduction Antiretroviral therapy (ART) has revolutionised the care of HIV-positive individuals resulting in marked decreases in morbidity and mortality, and markedly reduced transmission to sexual partners. However, these benefits can only be realised if individuals are aware of their HIV-positive status, initiated and retained on suppressive lifelong ART. Framed using the socio-ecological model, the present study explores factors contributing to poor ART uptake among community members despite high acceptance of HIV-testing within a Treatment as Prevention (TasP) trial. In this paper we identify barriers and facilitators to treatment across different levels of the socio-ecological framework covering individual, community and health system components. Methods This research was embedded within a cluster-randomised trial (ClinicalTrials.gov, number NCT01509508) of HIV treatment as Prevention in rural KwaZulu-Natal, South Africa. Data were collected between January 2013 and July 2014 from resident community members. Ten participants contributed to repeat in-depth interviews whilst 42 participants took part in repeat focus group discussions. Data from individual interviews and focus group discussions were triangulated using community walks to give insights into community members’ perception of the barriers and facilitators of ART uptake. We used thematic analysis guided by a socio-ecological framework to analyse participants’ narratives from both individual interviews and focus group discussions. Results Barriers and facilitators operating at the individual, community and health system levels influence ART uptake. Stigma was an over-arching barrier, across all three levels and expressed variably as fear of HIV disclosure, concerns about segregated HIV clinical services and negative community religious perceptions. Other barriers were individual (substance misuse, fear of ART side effects), community (alternative health beliefs). Facilitators cited by participants included individual (expectations of improved health and longer life expectancy following ART, single tablet regimens), community (availability of ART in the community through mobile trial facilities) and health system factors (fast and efficient service provided by friendly staff). Discussion We identified multiple barriers to achieving universal ART uptake. To enhance uptake in HIV care services, and achieve the full benefits of ART requires interventions that tackle persistent HIV stigma, and offer people with HIV respectful, convenient and efficient services. These interventions require evaluation in appropriately designed studies.
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Affiliation(s)
- Collins Iwuji
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, United Kingdom
- Africa Health Research Institute, Berea, KwaZulu-Natal, South Africa
- * E-mail:
| | | | - Thembelihle Zuma
- Africa Health Research Institute, Berea, KwaZulu-Natal, South Africa
| | - Melanie Plazy
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Bordeaux, France
| | - Joseph Larmarange
- Institut de Recherche pour le Développement(IRD), Centre Population et Développement (Ceped), Paris, France
| | - Joanna Orne-Gliemann
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Bordeaux, France
| | - Mark Siedner
- Africa Health Research Institute, Berea, KwaZulu-Natal, South Africa
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Maryam Shahmanesh
- Africa Health Research Institute, Berea, KwaZulu-Natal, South Africa
- Institute for Global Health, University College London, London, United Kingdom
| | - Janet Seeley
- Africa Health Research Institute, Berea, KwaZulu-Natal, South Africa
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Population-level viral suppression among pregnant and postpartum women in a universal test and treat trial. AIDS 2020; 34:1407-1415. [PMID: 32472768 DOI: 10.1097/qad.0000000000002564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE(S) We sought to determine whether universal 'test and treat' (UTT) can achieve gains in viral suppression beyond universal antiretroviral treatment (ART) eligibility during pregnancy and postpartum, among women living with HIV. DESIGN A community cluster randomized trial. METHODS The SEARCH UTT trial compared an intervention of annual population testing and universal ART with a control of baseline population testing with ART by country standard, including ART eligibility for all pregnant/postpartum women, in 32 communities in Kenya and Uganda. When testing, women were asked about current pregnancy and live births over the prior year and, if HIV-infected, had their viral load measured. Between arms, we compared population-level viral suppression (HIV RNA <500 copies/ml) among all pregnant/postpartum HIV-infected women at study close (year 3). We also compared year-3 population-level viral suppression and predictors of viral suppression among all 15 to 45-year-old women by arm. RESULTS At baseline, 92 and 93% of 15 to 45-year-old women tested for HIV: HIV prevalence was 12.6 and 12.3%, in intervention and control communities, respectively. Among HIV-infected women self-reporting pregnancy/live birth, prevalence of viral suppression was 42 and 44% at baseline, and 81 and 76% (P = 0.02) at year 3, respectively. Among all 15 to 45-year-old HIV-infected women, year-3 population-level viral suppression was higher in intervention (77%) versus control (68%; P < 0.001). Pregnancy/live birth was a predictor of year-3 viral suppression in control (P = 0.016) but not intervention (P = 0.43). Younger age was a risk factor for nonsuppression in both arms. CONCLUSION The SEARCH intervention resulted in higher population viral suppression among pregnant/postpartum women than a control of baseline universal testing with ART eligibility for pregnant/postpartum women.
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Camlin CS, Koss CA, Getahun M, Owino L, Itiakorit H, Akatukwasa C, Maeri I, Bakanoma R, Onyango A, Atwine F, Ayieko J, Kabami J, Mwangwa F, Atukunda M, Owaraganise A, Kwarisiima D, Sang N, Bukusi EA, Kamya MR, Petersen ML, Cohen CR, Charlebois ED, Havlir DV. Understanding Demand for PrEP and Early Experiences of PrEP Use Among Young Adults in Rural Kenya and Uganda: A Qualitative Study. AIDS Behav 2020; 24:2149-2162. [PMID: 31955361 PMCID: PMC7909847 DOI: 10.1007/s10461-020-02780-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Few studies have sought to understand factors influencing uptake and continuation of pre-exposure prophylaxis (PrEP) among young adults in sub-Saharan Africa in the context of population-based delivery of open-label PrEP. To address this gap, this qualitative study was implemented within the SEARCH study (NCT#01864603) in Kenya and Uganda, which achieved near-universal HIV testing, and offered PrEP in 16 intervention communities beginning in 2016-2017. Focus group discussions (8 groups, n = 88 participants) and in-depth interviews (n = 23) with young adults who initiated or declined PrEP were conducted in five communities, to explore PrEP-related beliefs and attitudes, HIV risk perceptions, motivations for uptake and continuation, and experiences. Grounded theoretical methods were used to analyze data. Young people felt personally vulnerable to HIV, but perceived the severity of HIV to be low, due to the success of antiretroviral therapy (ART): daily pill-taking was more threatening than the disease itself. Motivations for PrEP were highly gendered: young men viewed PrEP as a vehicle for safely pursuing multiple partners, while young women saw PrEP as a means to control risks in the context of engagement in transactional sex and limited agency to negotiate condom use and partner testing. Rumors, HIV/ART-related stigma, and desire for "proof" of efficacy militated against uptake, and many women required partners' permission to take PrEP. Uptake was motivated by high perceived HIV risk, and beliefs that PrEP use supported life goals. PrEP was often discontinued due to dissolution of partnerships/changing risk, unsupportive partners/peers, or early side effects/pill burden. Despite high perceived risks and interest, PrEP was received with moral ambivalence because of its associations with HIV/ART and stigmatized behaviors. Delivery models that promote youth access, frame messaging on wellness and goals, and foster partner and peer support, may facilitate uptake among young people.
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Affiliation(s)
- Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, ANSIRH Program, University of California San Francisco, 1330 Broadway, Suite 1100, Oakland, CA, 94612, USA.
- Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, USA.
| | - Catherine A Koss
- Department of Medicine, Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, USA
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, ANSIRH Program, University of California San Francisco, 1330 Broadway, Suite 1100, Oakland, CA, 94612, USA
| | | | | | | | - Irene Maeri
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | | | - James Ayieko
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | | | | | - Norton Sang
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Maya L Petersen
- Graduate Group in Biostatistics, School of Public Health, University of California Berkeley, Berkeley, USA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, ANSIRH Program, University of California San Francisco, 1330 Broadway, Suite 1100, Oakland, CA, 94612, USA
| | - Edwin D Charlebois
- Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, USA
| | - Diane V Havlir
- Department of Medicine, Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, USA
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Nachega JB, Leisegang R, Kallay O, Mills EJ, Zumla A, Lester RT. Mobile Health Technology for Enhancing the COVID-19 Response in Africa: A Potential Game Changer? Am J Trop Med Hyg 2020; 103:3-5. [PMID: 32476643 PMCID: PMC7356462 DOI: 10.4269/ajtmh.20-0506] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 05/21/2020] [Indexed: 01/19/2023] Open
Affiliation(s)
- Jean B. Nachega
- Department of Medicine and Centre for Infectious Diseases, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Departments of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Departments of Epidemiology, Infectious Diseases and Microbiology, Center for Global Health, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Rory Leisegang
- Family Clinical Research Unit (FAMCRU), Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Pharmacometrics, Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Oscar Kallay
- School of Public Health, University of Rwanda, Kigali, Rwanda
| | - Edward J. Mills
- Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Alimuddin Zumla
- Division of Infection and Immunity, Centre for Clinical Microbiology, University College London, London, United Kingdom
- National Institute for Health Research Biomedical Research Centre, University College London Hospitals, London, United Kingdom
| | - Richard T. Lester
- Division of Infectious Diseases, Department of Medicine, University of British of Columbia, Vancouver, Canada
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Abstract
Four of the largest HIV prevention trials have been conducted in sub-Saharan Africa, enrolling hundreds of thousands of participants in catchment areas of millions of people. The trials have focused on community-level interventions to increase diagnosis and initiation of antiretroviral therapy (ART) to improve health and reduce HIV transmission. Universal test-and-treat strategies are deployed to achieve viral suppression thereby reducing risk to uninfected persons, known as treatment as prevention (TasP).
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Schaffer EM, Gonzalez JM, Wheeler SB, Kwarisiima D, Chamie G, Thirumurthy H. Promoting HIV Testing by Men: A Discrete Choice Experiment to Elicit Preferences and Predict Uptake of Community-based Testing in Uganda. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2020; 18:413-432. [PMID: 31981135 PMCID: PMC7255957 DOI: 10.1007/s40258-019-00549-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND AND OBJECTIVES HIV testing is essential to access HIV treatment and care and plays a critical role in preventing transmission. Despite this, testing coverage is low among men in sub-Saharan Africa. Community-based testing has demonstrated potential to expand male testing coverage, yet scant evidence reveals how community-based services can be designed to optimize testing uptake. We conducted a discrete choice experiment (DCE) to elicit preferences and predict uptake of community-based testing by men in Uganda. METHODS Hypothetical choices between alternative community-based testing services and the option to opt-out of testing were presented to a random, population-based sample of 203 adult male residents. The testing alternatives varied by service delivery model (community health campaign, counselor-administered home-based testing, distribution of HIV self-test kits at local pharmacies), availability of multi-disease testing, access to antiretroviral therapy (ART), and provision of a US$0.85 incentive. We estimated preferences using a random parameters logit model and explored whether preferences varied by participant characteristics through subgroup analyses. We simulated uptake when a single and when two community-based testing services are made available, using reference values of observed uptake to calibrate predictions. RESULTS The share of the adult male population predicted to test for HIV ranged from 0.15 to 0.91 when a single community-based testing service is made available and from 0.50 to 0.96 when two community-based services are provided concurrently. ART access was the strongest driver of choices (relative importance [RI] = 3.01, 95% confidence interval [CI]: 1.74-4.29), followed by the service delivery model (RI = 1.27, 95% CI 0.72-1.82) and availability of multi-disease testing (RI = 1.27, 95% CI 0.09-2.45). A US$0.85 incentive had the least yet still significant influence on choices (RI = 0.77, 95% CI 0.06-1.49). Men who perceived their risk of having HIV to be relatively elevated had higher predicted uptake of HIV self-test kits at local pharmacies, as did young adult men compared to men aged ≥ 30 years. Men who earned ≤ the daily median income had higher predicted uptake of all community-based testing services versus men who earned above the daily median income. CONCLUSION Substantial opportunity exists to optimize the delivery of HIV testing to expand uptake by men; using an innovative DCE, we deliver timely, actionable guidance for promoting community-based testing by men in Uganda. We advance the stated preference literature methodologically by describing how we constructed and evaluated a pragmatic experimental design, used interaction terms to conduct subgroup analyses, and harnessed participant-specific preference estimates to predict and calibrate testing uptake.
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Affiliation(s)
- Elisabeth M Schaffer
- Data Science to Patient Value, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | | | - Stephanie B Wheeler
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Gabriel Chamie
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Harsha Thirumurthy
- Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Marcus JL, Sewell WC, Balzer LB, Krakower DS. Artificial Intelligence and Machine Learning for HIV Prevention: Emerging Approaches to Ending the Epidemic. Curr HIV/AIDS Rep 2020; 17:171-179. [PMID: 32347446 PMCID: PMC7260108 DOI: 10.1007/s11904-020-00490-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW We review applications of artificial intelligence (AI), including machine learning (ML), in the field of HIV prevention. RECENT FINDINGS ML approaches have been used to identify potential candidates for preexposure prophylaxis (PrEP) in healthcare settings in the USA and Denmark and in a population-based research setting in Eastern Africa. Although still in the proof-of-concept stage, other applications include ML with smartphone-collected and social media data to promote real-time HIV risk reduction, virtual reality tools to facilitate HIV serodisclosure, and chatbots for HIV education. ML has also been used for causal inference in HIV prevention studies. ML has strong potential to improve delivery of PrEP, with this approach moving from development to implementation. Development and evaluation of AI and ML strategies for HIV prevention may benefit from an implementation science approach, including qualitative assessments with end users, and should be developed and evaluated with attention to equity.
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Affiliation(s)
- Julia L Marcus
- Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Dr, Ste 401, Boston, MA, 02215, USA.
| | - Whitney C Sewell
- Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Dr, Ste 401, Boston, MA, 02215, USA
| | - Laura B Balzer
- University of Massachusetts Amherst, 715 North Pleasant St, Amherst, MA, 01003, USA
| | - Douglas S Krakower
- Beth Israel Deaconess Medical Center, Division of Infectious Diseases, 110 Francis St., W/LMOB Suite GB, Boston, MA, 02215, USA
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A pilot randomized trial of incentive strategies to promote HIV retesting in rural Uganda. PLoS One 2020; 15:e0233600. [PMID: 32470089 PMCID: PMC7259772 DOI: 10.1371/journal.pone.0233600] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 05/07/2020] [Indexed: 11/24/2022] Open
Abstract
Background Retesting for HIV is critical to identifying newly-infected persons and reinforcing prevention efforts among at-risk adults. Incentives can increase one-time HIV testing, but their role in promoting retesting is unknown. We sought to test feasibility and acceptability of incentive strategies, including commitment contracts, to promote HIV retesting among at-risk adults in rural Uganda. Methods At-risk HIV-negative adults were enrolled in a pilot trial assessing feasibility and acceptability of incentive strategies to promote HIV retesting three months after enrollment. Participants were randomized (1:1:3) to: 1) no incentive; 2) standard cash incentive (~US$4); and 3) commitment contract: participants could voluntarily make a low- or high-value deposit that would be returned with added interest (totaling ~US$4 including the deposit) upon retesting or lost if participants failed to retest. Contracts sought to promote retesting by leveraging loss aversion and addressing present bias via pre-commitment. Outcomes included acceptability of trial enrollment, contract feasibility (proportion of participants making deposits), and HIV retesting uptake. Results Of 130 HIV-negative eligible adults, 123 (95%) enrolled and were randomized: 74 (60%) to commitment contracts, 25 (20%) to standard incentives, and 24 (20%) to no incentive. Of contract participants, 69 (93%) made deposits. Overall, 93 (76%) participants retested for HIV: uptake was highest in the standard incentive group (22/25 [88%]) and lowest in high-value contract (26/36 [72%]) and no incentive (17/24 [71%]) groups. Conclusion In a randomized trial of strategies to promote HIV retesting among at-risk adults in Uganda, incentive strategies, including commitment contracts, were feasible and had high acceptability. Our findings suggest use of incentives for HIV retesting merits further comparison in a larger trial. Trial registration ClinicalTrials.gov identifier: NCT:02890459
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Olilo WA, Petersen ML, Koss CA, Wafula E, Kwarisiima D, Kadede K, Clark TD, Cohen CR, Bukusi EA, Kamya MR, Charlebois ED, Havlir DV, Ayieko J. Pre-exposure Prophylaxis (PrEP) Uptake Among Older Individuals in Rural Western Kenya. J Acquir Immune Defic Syndr 2020; 82:e50-e53. [PMID: 31490343 PMCID: PMC6831040 DOI: 10.1097/qai.0000000000002150] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Winter A Olilo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | - Eric Wafula
- University of California, San Francisco, San Francisco, CA
| | | | - Kevin Kadede
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Tamara D Clark
- University of California, San Francisco, San Francisco, CA
| | - Craig R Cohen
- University of California, San Francisco, San Francisco, CA
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | - Diane V Havlir
- University of California, San Francisco, San Francisco, CA
| | - James Ayieko
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
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Okal J, Lango D, Matheka J, Obare F, Ngunu-Gituathi C, Mugambi M, Sarna A. "It is always better for a man to know his HIV status" - A qualitative study exploring the context, barriers and facilitators of HIV testing among men in Nairobi, Kenya. PLoS One 2020; 15:e0231645. [PMID: 32294124 PMCID: PMC7159816 DOI: 10.1371/journal.pone.0231645] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 03/28/2020] [Indexed: 01/20/2023] Open
Abstract
HIV testing services are an important component of HIV program and provide an entry point for clinical care for persons newly diagnosed with HIV. Although uptake of HIV testing has increased in Kenya, men are still less likely than women to get tested and access services. There is, however, limited understanding of the context, barriers and facilitators of HIV testing among men in the country. Data are from in-depth interviews with 30 men living with HIV and 8 HIV testing counsellors that were conducted to gain insights on motivations and drivers for HIV testing among men in the city of Nairobi. Men were identified retroactively by examining clinical CD4 registers on early and late diagnosis (e.g. CD4 of ≥500 cells/mm, early diagnosis and <500 cells/mm, late diagnosis). Analysis involved identifying broad themes and generating descriptive codes and categories. Timing for early testing is linked with strong social support systems and agency to test, while cost of testing, choice of facility to test and weak social support systems (especially poor inter-partner relations) resulted in late testing. Minimal discussions occurred prior to testing and whenever there was dialogue it happened with partners or other close relatives. Interrelated barriers at individual, health-care system, and interpersonal levels hindered access to testing services. Specifically, barriers to testing included perceived providers attitudes, facility location and set up, wait time/inconvenient clinic times, low perception of risk, limited HIV knowled ge, stigma, discrimination and fear of having a test. High risk perception, severe illness, awareness of partner's status, confidentiality, quality of services and supplies, flexible/extended opening hours, and pre-and post-test counselling were facilitators. Experiences between early and late testers overlapped though there were minor differences. In order to achieve the desired impact nationally and to attain the 90-90-90 targets, multiple interventions addressing both barriers and facilitators to testing are needed to increase uptake of testing and to link the positive to care.
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Affiliation(s)
- Jerry Okal
- Population Council, Nairobi, Kenya
- * E-mail:
| | | | | | | | | | - Mary Mugambi
- National HIV and STI Control Programme (NASCOP), Nairobi, Kenya
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Koss CA, Charlebois ED, Ayieko J, Kwarisiima D, Kabami J, Balzer LB, Atukunda M, Mwangwa F, Peng J, Mwinike Y, Owaraganise A, Chamie G, Jain V, Sang N, Olilo W, Brown LB, Marquez C, Zhang K, Ruel TD, Camlin CS, Rooney JF, Black D, Clark TD, Gandhi M, Cohen CR, Bukusi EA, Petersen ML, Kamya MR, Havlir DV. Uptake, engagement, and adherence to pre-exposure prophylaxis offered after population HIV testing in rural Kenya and Uganda: 72-week interim analysis of observational data from the SEARCH study. Lancet HIV 2020; 7:e249-e261. [PMID: 32087152 PMCID: PMC7208546 DOI: 10.1016/s2352-3018(19)30433-3] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/14/2019] [Accepted: 12/18/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Optimal strategies for pre-exposure prophylaxis (PrEP) engagement in generalised HIV epidemics are unknown. We aimed to assess PrEP uptake and engagement after population-level HIV testing and universal PrEP access to characterise gaps in the PrEP cascade in rural Kenya and Uganda. METHODS We did a 72-week interim analysis of observational data from the ongoing SEARCH (Sustainable East Africa Research in Community Health) study. Following community sensitisation and PrEP education, we did HIV testing and offered PrEP at health fairs and facilities in 16 rural communities in western Kenya, eastern Uganda, and western Uganda. We provided enhanced PrEP counselling to individuals 15 years and older who were assessed as having an elevated HIV risk on the basis of serodifferent partnership or empirical risk score, or who otherwise self-identified as being at high risk but were not in serodifferent partnerships or identified by the risk score. PrEP follow-up visits were done at facilities, homes, or community locations. We assessed PrEP uptake within 90 days of HIV testing, programme engagement (follow-up visit attendance at week 4, week 12, and every 12 weeks thereafter), refills, self-reported adherence up to 72 weeks, and concentrations of tenofovir in hair samples from individuals reporting HIV risk and adherence during follow-up, and analysed factors associated with uptake and adherence. This study is registered with ClinicalTrials.gov, NCT01864603. FINDINGS Between June 6, 2016, and June 23, 2017, 70 379 community residents 15 years or older who had not previously been diagnosed with HIV were tested during population-level HIV testing. Of these individuals, 69 121 tested HIV-negative, 12 935 of whom had elevated HIV risk (1353 [10%] serodifferent partnership, 6938 [54%] risk score, 4644 [36%] otherwise self-identified risk). 3489 (27%) initiated PrEP, 2865 (82%) of whom did so on the same day as HIV testing and 1733 (50%) of whom were men. PrEP uptake was lower among individuals aged 15-24 years (adjusted odds ratio 0·55, 95% CI 0·45-0·68) and mobile individuals (0·61, 0·41-0·91). At week 4, among 3466 individuals who initiated PrEP and did not withdraw or die before the first visit, 2215 (64%) were engaged in the programme, 1701 (49%) received medication refills, and 1388 (40%) self-reported adherence. At week 72, 1832 (56%) of 3274 were engaged, 1070 (33%) received a refill, and 900 (27%) self-reported adherence. Among participants reporting HIV risk at weeks 4-72, refills (89-93%) and self-reported adherence (70-76%) were high. Among sampled participants self-reporting adherence at week 24, the proportion with tenofovir concentrations in the hair reflecting at least four doses taken per week was 66%, and reflecting seven doses per week was 44%. Participants who stopped PrEP accepted HIV testing at 4274 (83%) of 5140 subsequent visits; half of these participants later restarted PrEP. 29 participants of 3489 who initiated PrEP had serious adverse events, including seven deaths. Five adverse events (all grade 3) were assessed as being possibly related to the study drug. INTERPRETATION During population-level HIV testing, inclusive risk assessment (combining serodifferent partnership, an empirical risk score, and self-identification of HIV risk) was feasible and identified individuals who could benefit from PrEP. The biggest gap in the PrEP cascade was PrEP uptake, particularly for young and mobile individuals. Participants who initiated PrEP and had perceived HIV risk during follow-up reported taking PrEP, but one-third had drug concentrations consistent with poor adherence, highlighting the need for novel approaches and long-acting formulations as PrEP roll-out expands. FUNDING National Institutes of Health, President's Emergency Plan for AIDS Relief, Bill & Melinda Gates Foundation, and Gilead Sciences.
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Affiliation(s)
- Catherine A Koss
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Edwin D Charlebois
- Division of Prevention Sciences, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - James Ayieko
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Laura B Balzer
- Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, MA, USA
| | | | | | - James Peng
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Yusuf Mwinike
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Gabriel Chamie
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Vivek Jain
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Norton Sang
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Winter Olilo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Lillian B Brown
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Carina Marquez
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Kevin Zhang
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Theodore D Ruel
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Carol S Camlin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
| | | | - Douglas Black
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Tamara D Clark
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Elizabeth A Bukusi
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA; Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Maya L Petersen
- Graduate Group in Biostatistics, School of Public Health, University of California Berkeley, Berkeley, CA, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda; School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane V Havlir
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
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Associations between alcohol use and HIV care cascade outcomes among adults undergoing population-based HIV testing in East Africa. AIDS 2020; 34:405-413. [PMID: 31725431 DOI: 10.1097/qad.0000000000002427] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To assess the impact of alcohol use on HIV care cascade outcomes. DESIGN Cross-sectional analyses. METHODS We evaluated HIV care cascade outcomes and alcohol use in adults (≥15 years) during baseline (2013--2014) population-based HIV testing in 28 Kenyan and Ugandan communities. 'Alcohol use' included any current use and was stratified by Alcohol Use Disorders Identification Test-Concise (AUDIT-C) scores: nonhazardous/low (1--3 men/1--2 women), hazardous/medium (4--5 men/3--5 women), hazardous/high (6--7), hazardous/very-high (8--12). We estimated cascade outcomes and relative risks associated with each drinking level using targeted maximum likelihood estimation, adjusting for confounding and missing measures. RESULTS Among 118 923 adults, 10 268 (9%) tested HIV-positive. Of those, 10 067 (98%) completed alcohol screening: 1626 (16%) reported drinking, representing 7% of women (467/6499) and 33% of men (1 159/3568). Drinking levels were: low (48%), medium (34%), high (11%), very high (7%). Drinkers were less likely to be previously HIV diagnosed (58% [95% CI: 55--61%]) than nondrinkers [66% (95% CI: 65-67%); RR: 0.87 (95% CI: 0.83-0.92)]. If previously diagnosed, drinkers were less likely to be on ART [77% (95% CI: 73-80%)] than nondrinkers [83% (95% CI 82-84%); RR: 0.93 (95% CI: 0.89-0.97)]. If on ART, there was no association between alcohol use and viral suppression; however, very-high-level users were less likely to be suppressed [RR: 0.80 (95% CI: 0.68-0.94)] versus nondrinkers. On a population level, viral suppression was 38% (95% CI: 36-41%) among drinkers and 44% (95% CI: 43-45%) among nondrinkers [RR: 0.87 (95% CI 0.82-0.94)], an association seen at all drinking levels. CONCLUSION Alcohol use was associated with lower viral suppression; this may be because of decreased HIV diagnosis and ART use.
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