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Bergh K, Toska E, Duby Z, Govindasamy D, Mathews C, Reddy T, Jonas K. Applying the HIV Prevention Cascade to an Evaluation of a Large-Scale Combination HIV Prevention Programme for Adolescent Girls and Young Women in South Africa. AIDS Behav 2024; 28:1137-1151. [PMID: 37462890 PMCID: PMC10940416 DOI: 10.1007/s10461-023-04130-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2023] [Indexed: 03/16/2024]
Abstract
Adolescent girls and young women (AGYW) in South Africa are at a three times higher risk of acquiring HIV than their male counterparts. The HIV prevention cascade is a tool which can be used to measure coverage of HIV prevention services, although there is limited empirical evidence to demonstrate its application in low-resourced settings. The unifying framework is a conceptualisation of the HIV prevention cascade which theorises that both motivation and access are required for an individual to effectively use an HIV prevention method. We applied this framework to data from a random sample of 127,951 beneficiaries of a combination HIV prevention programme for AGYW aged 15-24 in South Africa to measure the steps to, and identify key barriers to, effective use of male condoms and oral pre-exposure prophylaxis (PrEP) among this vulnerable population. Barriers to each step were analysed using univariate and multivariable logistic regression. Among self-reported HIV-negative AGYW who had sex in the past 6 months, effective use of condoms (15.2%), access to PrEP (39.1%) and use of PrEP (3.8%) were low. AGYW were: less likely to be motivated to use condoms if they believed that they had a faithful partner (aOR 0.44, 95% CI 0.22-0.90) or disliked condoms (aOR 0.26, 95% CI 0.11-0.57), less likely to access condoms if the place where AGYW accessed them was far away (aOR 0.25, 95% CI 0.10-0.64), more likely to effectively use condoms if they received counselling on how to use them (aOR 2.24, 95% CI 1.05-4.76), less likely to be motivated to use PrEP if they did not believe PrEP was efficacious (aOR 0.35, 95% CI 0.17-0.72), more likely to be motivated if they felt confident that they could use PrEP, and more likely to have access to PrEP if they had ever been offered PrEP (aOR 2.94, 95% CI 1.19-7.22). This combination HIV prevention programme and similar programmes should focus on risk-reduction counselling interventions for AGYW and their male partners to improve effective use of condoms and ensure easy access to condoms and PrEP by making them available in youth-friendly spaces. Our findings demonstrate that the application of HIV prevention cascades can inform AGYW HIV prevention programming in low-resourced settings.
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Affiliation(s)
- Kate Bergh
- Health Systems Research Unit, South African Medical Research Council, Francie Van Zijl Dr, Parrow Valley, Cape Town, 7501, South Africa.
- Department of Psychology, University of Cape Town, Cape Town, South Africa.
| | - Elona Toska
- Department of Sociology, Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
- Department of Social Work and Social Development, University of Cape Town, Cape Town, South Africa
| | - Zoe Duby
- Health Systems Research Unit, South African Medical Research Council, Francie Van Zijl Dr, Parrow Valley, Cape Town, 7501, South Africa
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Darshini Govindasamy
- Health Systems Research Unit, South African Medical Research Council, Francie Van Zijl Dr, Parrow Valley, Cape Town, 7501, South Africa
| | - Catherine Mathews
- Health Systems Research Unit, South African Medical Research Council, Francie Van Zijl Dr, Parrow Valley, Cape Town, 7501, South Africa
| | - Tarylee Reddy
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
| | - Kim Jonas
- Health Systems Research Unit, South African Medical Research Council, Francie Van Zijl Dr, Parrow Valley, Cape Town, 7501, South Africa
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Gumede-Moyo S, Sharma S, Gwanzura C, Nyirenda R, Mkandawire P, Chatora K, Hasen N. 'ARVs are a constant reminder of lost freedom, whereas for others, they are liberating': understanding the treatment narrative among people living with HIV (PLHIV) in Malawi and Zimbabwe-a qualitative study. BMJ Open 2024; 14:e063138. [PMID: 38418240 PMCID: PMC10910567 DOI: 10.1136/bmjopen-2022-063138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 03/23/2023] [Indexed: 03/01/2024] Open
Abstract
OBJECTIVE The aim of the research was to understand what drives and motivates young women living with HIV in their treatment journeys, as well as their key influencers. The findings will assist in appreciating their obstacles to treatment and constructing the most effective ways to convey fresh messages to them. These insights will contribute to the messaging developed for a campaign across sub-Saharan Africa, primarily Malawi and Zimbabwe. DESIGN This was a qualitative study conducted in order to build an understanding of unknown parts of the HIV treatment journey through in-depth interviews. A hybrid approach was used to conduct thematic analysis. SETTING AND PARTICIPANTS Study participants were HIV-positive women, their influencers (eg, parents/partners/siblings/aunts and uncles/religious leaders, etc) and healthcare providers from a range of regions in Zimbabwe and Malawi. RESULTS A total of 26 young people living with HIV (PLHIV), 29 healthcare providers and 24 influencers such as maternal figures in the community were interviewed. Two main broad insights were drawn, that is, key needs and wider contextual factors. The key needs of young PLHIV to stay on treatment were empathy, support and emotional connection with antiretroviral therapy (ART), while the wider contextual factors impacting their treatment journeys were structural challenges and cultural reference points. Fear of shame and humiliation can also be significant barriers to disclosure and treatment. The fear predisposes the PLHIV to the need for empathy, support and connection with ART. Mental health and anxiety appear to be comorbid with HIV. Some PLHIV have a small and limited support network leading to very few people living openly with HIV. There is no 'one-size-fits-all' approach, and maximising campaign reach will likely need a multifaceted approach. CONCLUSION Currently, the relationship between nurses and PLHIV can appear to be transactional. Through learning about the community (including PLHIV), there are more chances of communicating in a way that resonates.
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Affiliation(s)
- Sehlulekile Gumede-Moyo
- Healthcare, Ipsos MORI UK, London, UK
- Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Rose Nyirenda
- Ministry of Health and Population Malawi, Lilongwe, Malawi
| | | | | | - Nina Hasen
- HIV and TB, Population Services International, Washington, District of Columbia, USA
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Mulwa S, Baker V, Cawood C, Khanyile D, O'Donnell D, Sarrassat S, Cousens S, Birdthistle I. Evaluating the Intensity of Exposure to MTV Shuga, an Edutainment Program for HIV Prevention: Cross-Sectional Study in Eastern Cape, South Africa. JMIR Form Res 2024; 8:e44111. [PMID: 38349729 PMCID: PMC10900091 DOI: 10.2196/44111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND MTV Shuga is an edutainment campaign designed to equip young people with knowledge, motivation, and informed choices to protect themselves from HIV infection. From 2019 to 2020, a total of 10 episodes of a new dramatic series, MTV Shuga "Down South 2" (DS2), were broadcast via television and the internet, alongside complementary media activities. OBJECTIVE This study aims to investigate whether the intensity of DS2 exposure was linked with positive HIV prevention outcomes in a setting with high HIV prevalence and relatively low levels of HIV testing. METHODS We analyzed data from a web-based survey of participants aged 15 to 24 years in South Africa in 2020. The survey was promoted via social media platforms of schools, universities, and communities in Eastern Cape, South Africa. The primary exposure of interest was the intensity of exposure to DS2, measured by the number of episodes of DS2 watched on the television or the internet or listened to on the radio (out of 10 episodes). Individuals who had not watched or listened to any DS2 episode were classified according to other MTV Shuga content that they had accessed. We estimated associations between the intensity of DS2 exposure and HIV-related outcomes, including knowledge of HIV status, awareness of HIV self-testing (HIVST) and pre-exposure prophylaxis (PrEP), uptake of HIVST, and demand for HIVST and PrEP, adjusting for potential confounders using multivariable logistic regression. RESULTS Among the 3431 survey participants, 827 (24.1%) were exposed to DS2. Specifically, 18.1% (622/3431) watched or listened to only 1 DS2 episode, and 2.4% (82/3431), 1.7% (58/3431), and 1.8% (62/3431) watched or listened to 2 to 4, 5 to 7, and 8 to 10 DS2 episodes, respectively. Increasing the exposure to DS2 was associated with improvements in most outcomes. Exposure to multiple episodes (eg, 2-4, 5-7, and 8-10) was associated with successively higher odds of knowing one's HIV status, awareness of PrEP and HIVST, and uptake of HIVST compared with no MTV Shuga exposure, albeit with statistical uncertainty around some estimates. The interest in using HIVST or PrEP was high overall (>80%), with no measurable differences by DS2 intensity. CONCLUSIONS We found evidence consistent with a dose-response relationship between MTV Shuga DS2 exposure and outcomes, including knowledge of HIV status, awareness and uptake of HIVST, and awareness of PrEP among young people in Eastern Cape. This indicates that greater engagement with a youth-focused edutainment campaign can improve HIV testing and prevention options in a setting and population with high need. However, only a few participants accessed multiple DS2 episodes despite its availability on multiple media platforms. We conclude that there is potential to benefit more young people by increasing access to and interest in the show.
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Affiliation(s)
- Sarah Mulwa
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Venetia Baker
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | | | - Sophie Sarrassat
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Simon Cousens
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Isolde Birdthistle
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
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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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Jonas K, Bergh K, Duby Z, Mangoale K, Mogari N, Kuo C, Reddy T, Mathews C. Using prevention cascades to investigate coverage of contraception services among young women enrolled in a large-scale combination HIV prevention program in South Africa. Contraception 2024; 130:110307. [PMID: 37863465 DOI: 10.1016/j.contraception.2023.110307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/22/2023]
Abstract
OBJECTIVES We investigated the coverage of contraception services (excluding condoms) to prevent unintended pregnancy among young women and girls aged 15 to 24 years who were beneficiaries of one of the two largest combination HIV and pregnancy prevention program in South Africa. STUDY DESIGN We invited 2160 randomly sampled beneficiaries who were living in six of the 12 program districts across six provinces to participate in a telephone survey. We created pregnancy prevention coverage cascades and conducted univariate and multivariable analyses to identify key barriers and facilitators associated with each step of the cascade. RESULTS We achieved a response rate of 23.8%, resulting in 515 respondents, of whom 303 had sex in the 6 months before the survey. Of this subsample, 80.4% had access to contraception services, 60.6% had access and motivation to use contraceptives, and 21.9% had access to, motivation to use, and effectively used contraceptives. Distance to travel to services and not ever being offered contraceptives by health workers were access barriers, while low pregnancy risk perception was a barrier to motivation. CONCLUSIONS Most respondents had access to and were motivated to use contraceptives other than condoms but were not effectively using them. Having been offered contraceptives facilitated better access, while distance to the services was a barrier, suggesting the importance of improving supply-side interventions, such as increasing the number and accessibility of spaces where Sexual and Reproductive Health (SRH) services are offered. We recommend longitudinal behavioral counseling for young people, especially adolescents, as well as risk reduction and information-tailored interventions. IMPLICATIONS Pregnancy prevention cascades are a promising tool to monitor progress toward universal access to contraception services and to identify barriers that need to be addressed to achieve the effective use of contraceptives.
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Affiliation(s)
- Kim Jonas
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.
| | - Kate Bergh
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa; Department of Psychology, University of Cape Town, Cape Town, South Africa
| | - Zoe Duby
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa; Division of Social and Behavioural Sciences in the School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kgahliso Mangoale
- Networking HIV and AIDS Community of Southern Africa (NACOSA), Cape Town, South Africa
| | - Neo Mogari
- Networking HIV and AIDS Community of Southern Africa (NACOSA), Cape Town, South Africa
| | | | - Tarylee Reddy
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
| | - Catherine Mathews
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
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Donnell D, Kansiime S, Glidden DV, Luedtke A, Gilbert PB, Gao F, Janes H. Study design approaches for future active-controlled HIV prevention trials. STATISTICAL COMMUNICATIONS IN INFECTIOUS DISEASES 2024; 15:20230002. [PMID: 38250627 PMCID: PMC10798828 DOI: 10.1515/scid-2023-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 12/30/2023] [Indexed: 01/23/2024]
Abstract
Objectives Vigorous discussions are ongoing about future efficacy trial designs of candidate human immunodeficiency virus (HIV) prevention interventions. The study design challenges of HIV prevention interventions are considerable given rapid evolution of the prevention landscape and evidence of multiple modalities of highly effective products; future trials will likely be 'active-controlled', i.e., not include a placebo arm. Thus, novel design approaches are needed to accurately assess new interventions against these highly effective active controls. Methods To discuss active control design challenges and identify solutions, an initial virtual workshop series was hosted and supported by the International AIDS Enterprise (October 2020-March 2021). Subsequent symposia discussions continue to advance these efforts. As the non-inferiority design is an important conceptual reference design for guiding active control trials, we adopt several of its principles in our proposed design approaches. Results We discuss six potential study design approaches for formally evaluating absolute prevention efficacy given data from an active-controlled HIV prevention trial including using data from: 1) a registrational cohort, 2) recency assays, 3) an external trial placebo arm, 4) a biomarker of HIV incidence/exposure, 5) an anti-retroviral drug concentration as a mediator of prevention efficacy, and 6) immune biomarkers as a mediator of prevention efficacy. Conclusions Our understanding of these proposed novel approaches to future trial designs remains incomplete and there are many future statistical research needs. Yet, each of these approaches, within the context of an active-controlled trial, have the potential to yield reliable evidence of efficacy for future biomedical interventions.
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Affiliation(s)
- Deborah Donnell
- Fred Hutchinson Cancer Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Sheila Kansiime
- Medical Research Council/Uganda Virus Research Council and London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
- Medical Research Council International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Peter B. Gilbert
- Fred Hutchinson Cancer Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Fei Gao
- Fred Hutchinson Cancer Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Holly Janes
- Fred Hutchinson Cancer Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
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Bergh K, Jonas K, Duby Z, Govindasamy D, Mathews C, Reddy T, Slingers N, Whittle G, Abdullah F. Factors Associated with COVID-19 Vaccine Uptake among Schoolgoing Adolescent Girls and Young Women in South Africa. Vaccines (Basel) 2023; 11:1581. [PMID: 37896983 PMCID: PMC10610973 DOI: 10.3390/vaccines11101581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/03/2023] [Accepted: 10/05/2023] [Indexed: 10/29/2023] Open
Abstract
(1) Background: By October 2022, vaccination rates with at least one dose of a COVID-19 vaccine were low among adolescent girls aged 12-17 (38%) and young women aged 18-34 (45%) in South Africa. This study aimed to measure and identify barriers to and facilitators of motivation to take up, access to, and uptake of COVID-19 vaccines among schoolgoing adolescent girls and young women in two districts in South Africa. (2) Methods: Using the theory of the HIV prevention cascade, we conceptualised the relationship between motivation, access, and uptake of COVID-19 vaccines, and associated barriers. Potential barriers and facilitators were identified using bivariate and multivariable Poisson regression. (3) Results: Among all 2375 participants, access was high (69%), but motivation (49%) and vaccination with at least one COVID-19 vaccine (45%) were lower. Fear of injections was a barrier to vaccine uptake (aRR 0.85 95% CI 0.82-0.88), while being tested for COVID-19 (aRR 2.10 95% CI 1.85-2.38) and believing that the COVID-19 vaccine was safe (aRR 1.31 95% CI 1.18-1.44) and would prevent you from getting very sick (aRR 1.11 95% CI 1.04-1.19) were facilitators. (4) Conclusions: The controversy about the value of vaccinating adolescents and the delay in vaccine rollout for adolescents and young adults may have contributed to fears about the safety and efficacy of COVID-19 vaccines, as well as a lack of motivation to get vaccinated.
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Affiliation(s)
- Kate Bergh
- Health Systems Research Unit, South African Medical Research Council, Cape Town 7501, South Africa
- Department of Psychology, University of Cape Town, Cape Town 7700, South Africa
| | - Kim Jonas
- Health Systems Research Unit, South African Medical Research Council, Cape Town 7501, South Africa
| | - Zoe Duby
- Health Systems Research Unit, South African Medical Research Council, Cape Town 7501, South Africa
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town 7925, South Africa
| | - Darshini Govindasamy
- Health Systems Research Unit, South African Medical Research Council, Cape Town 7501, South Africa
| | - Catherine Mathews
- Health Systems Research Unit, South African Medical Research Council, Cape Town 7501, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town 7925, South Africa
| | - Tarylee Reddy
- Biostatistics Research Unit, South African Medical Research Council, Durban 4091, South Africa
| | - Nevilene Slingers
- Office of AIDS and TB Research, South African Medical Research Council, Pretoria 0001, South Africa
| | - Granville Whittle
- Department of Basic Education, Government of South Africa, Pretoria 0001, South Africa
| | - Fareed Abdullah
- Office of AIDS and TB Research, South African Medical Research Council, Pretoria 0001, South Africa
- Division of Infectious Diseases, Department of Internal Medicine, Steve Biko Academic Hospital and University of Pretoria, Pretoria 0002, South Africa
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Pickles M, Gregson S, Moorhouse L, Dadirai T, Dzamatira F, Mandizvidza P, Maswera R, Museka T, Schaefer R, Skovdal M, Thomas R, Tsenesa B, Mugurungi O, Nyamukapa C, Hallett TB. Strengthening the HIV prevention cascade to maximise epidemiological impact in eastern Zimbabwe: a modelling study. Lancet Glob Health 2023; 11:e1105-e1113. [PMID: 37349036 DOI: 10.1016/s2214-109x(23)00206-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 04/19/2023] [Accepted: 04/19/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND HIV prevention cascades provide a systematic understanding of barriers to prevention. In this study we used mathematical modelling to understand the consequences of these barriers and how the cascade could be strengthened to maximise epidemiological impact, providing potentially important insights for programmes. METHODS We used an individual-based model of HIV transmission (PopART-IBM), calibrated to data from the Manicaland cohort from eastern Zimbabwe. HIV prevention cascade estimates from this cohort were used as probabilities for indicators in the model representing an individual's motivation, access, and capacity to effectively use pre-exposure prophylaxis, voluntary male medical circumcision, and condoms. We examined how current barriers affect the number and distribution of HIV infections compared with a no-barrier scenario. Using assumptions about how interventions could strengthen the HIV prevention cascade, we estimated the reduction in HIV infections over a 10-year period through addressing different elements of the cascade. FINDINGS 21 200 new potentially avertable HIV infections will occur over the next 10 years due to existing HIV prevention cascade barriers, 74·2% of the 28 500 new infections that would occur with existing barriers in a population of approximately 1·2 million adults. Removing these barriers would reduce HIV incidence below the benchmarks for epidemic elimination. Addressing all cascade steps in one priority population is substantially more effective than addressing one step across all populations. INTERPRETATION Interventions exist in eastern Zimbabwe to reduce HIV towards elimination, but barriers of motivation, access, and effective use prevent their full effect being realised. Interventions need to be multilayered and address all steps along the HIV prevention cascade. Models incorporating the HIV prevention cascade can help to identify the main barriers to greater effectiveness. FUNDING National Institutes of Mental Health, Bill & Melinda Gates Foundation, and Medical Research Council Centre for Global Infectious Disease Analysis funding from the UK Medical Research Council and UK Foreign, Commonwealth & Development Office (FCDO).
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Affiliation(s)
- Michael Pickles
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK.
| | - Simon Gregson
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK; Biomedical and Research Training Institute, Harare, Zimbabwe
| | - Louisa Moorhouse
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Tawanda Dadirai
- Biomedical and Research Training Institute, Harare, Zimbabwe
| | | | | | | | - Tafadzwa Museka
- Biomedical and Research Training Institute, Harare, Zimbabwe
| | - Robin Schaefer
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Morten Skovdal
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Ranjeeta Thomas
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | | | | | - Constance Nyamukapa
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK; Biomedical and Research Training Institute, Harare, Zimbabwe
| | - Timothy B Hallett
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
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Ferrand RA, Kranzer K. Bending the HIV epidemic curve: can prevention cascades show us how? Lancet Glob Health 2023; 11:e999-e1000. [PMID: 37349046 DOI: 10.1016/s2214-109x(23)00223-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 05/05/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Rashida A Ferrand
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe; Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Katharina Kranzer
- The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe; Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK; Department of Infectious Diseases and Tropical Medicine, Ludwig-Maximilians-Universität, Munich, Germany; German Center for Infection Research, Munich, Germany.
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Utilizing Soccer for Delivery of HIV and Substance Use Prevention for Young South African Men: 6-Month Outcomes of a Cluster Randomized Controlled Trial. AIDS Behav 2023; 27:842-854. [PMID: 36380117 PMCID: PMC9944297 DOI: 10.1007/s10461-022-03819-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 11/16/2022]
Abstract
Young men in South Africa face the intersecting epidemics of HIV, substance use and endemic poverty. We tested the effectiveness of a behavioral intervention using soccer training to reduce the cluster of risks associated with HIV and substance use. This cluster randomized controlled trial was conducted with men aged 18-29 years old in 27 neighborhoods in the townships of Cape Town, South Africa. Neighborhoods were randomized to receive for 6 months either: (1) Soccer League (SL; n = 18 neighborhoods, n = 778 men) who attended soccer three times weekly (72 sessions; 94% uptake, 45.5% weekly attendance rate), combined with an HIV/substance use, cognitive-behavioral intervention; or (2) a Control Condition (CC; n = 9; 415 men) who received educational materials and referrals at 3 month intervals. The primary outcome was the number of significant changes in a cluster of outcomes including HIV-related risks, substance abuse, employment/income, mental health, violence, and community engagement. There was only one significant difference on the rapid diagnostic tests for mandrax at 6 months, an insufficient number of changes to indicate a successful intervention. A group-based behavioral intervention was ineffective in addressing multiple risk behaviors among at-risk young men, similar to the findings of several recent soccer-related interventions. Early adulthood may be too late to alter well-established patterns of risk behaviors.Clinical Trial Registration This trial was prospectively registered on 24 November 2014 with ClinicalTrials.gov NCT02358226.
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Reyes N, Benites C, García-Fernández L, Calderon M, Fiestas F, Vasquez-Becerra R, Aranda E, Yabar CA, García A, Ramal C, Gutiérrez EL. HIV treatment cascade in regions of Peru with the highest HIV prevalence. HIV Med 2022; 24:620-627. [PMID: 36574977 DOI: 10.1111/hiv.13452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 11/22/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To describe the HIV treatment cascade and care continuum in regions of highest HIV prevalence in Peru. METHODS An observational longitudinal study was carried out in 14 tertiary hospitals in Peru. These are the main hospitals that administer antiretroviral treatment (ART) in the regions that represent approximately 95% of reports of HIV/AIDS cases in Peru in 2013. We included individuals older than 18 years newly diagnosed with HIV from 1 January 2011 to 31 December 2012. Medical records were reviewed until 2015. RESULTS A total of 2119 people living with HIV (PLHIV) were identified in the selected health facilities (mean age = 35.26 years, 78% male). 97.25% [1845/1897; 95% confidence interval (CI): 96.4-97.9%] of the patients attended the consultation at least once during the follow-up, but only 64.84% (885/1365; 95% CI: 62.2-67.4%) attended within a month after the diagnosis. After starting ART, 74.63% (95% CI: 71.9-77.2%) of PLHIV remained in healthcare. Regardless of the time after diagnosis, 88.40% (1837/2078; 95% CI: 86.9-89.7%) of PLHIV started ART during the observation time. However, 78.68% (95% CI: 76.8-80.4%) did so during the first post-treatment year and only 28.88% (95% CI: 27.9-31.9%) after 1 month. After starting treatment, it was observed that 51.60% (95% CI: 49.2-54%) of PLHIV reached viral suppression during the follow-up period. CONCLUSIONS Further analysis and improvements in the definition of indicators are required to achieve conclusive results; however, these data will give us a general understanding of the progress of Peruvian health policies in achieving the goal established by the WHO.
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Affiliation(s)
- Nora Reyes
- Instituto Nacional de Salud, Lima, Peru.,Universidad Nacional Mayor de San Marcos, Lima, Peru
| | | | | | | | | | | | | | - Carlos A Yabar
- Instituto Nacional de Salud, Lima, Peru.,Universidad de San Martín de Porres, Facultad de Medicina, Lima, Peru
| | | | | | - Ericson L Gutiérrez
- Instituto Nacional de Salud, Lima, Peru.,Universidad San Ignacio de Loyola, Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Lima, Peru
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12
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Logie CH, Okumu M, Loutet MG, Coelho M, Berry I, Gittings L, Odong Lukone S, Kisubi N, Atama M, Kyambadde P. Todurujo na Kadurok (empowering youth): study protocol of an HIV self-testing and edutainment comic cluster randomised trial among refugee youth in a humanitarian setting in Uganda. BMJ Open 2022; 12:e065452. [PMID: 36418143 PMCID: PMC9685005 DOI: 10.1136/bmjopen-2022-065452] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Refugees experience HIV vulnerabilities due to the confluence of displacement, violence and poverty. HIV self-testing, understudied with refugees, is a promising method to increase testing uptake, yet challenges remain with linkages to confirmatory testing following a positive HIV self-test. This study aims to evaluate the effectiveness of HIV self-testing kits and 'edutainment' comics in increasing HIV testing and HIV status knowledge among refugee youth aged 16-24 years in Bidi Bidi Refugee Settlement, Uganda. METHODS AND ANALYSIS This study will be conducted in Bidi Bidi. We conducted a qualitative formative phase with focus groups (n=40) to generate knowledge of barriers and facilitators of HIV prevention, testing and care among refugee youth (aged 16-24) in Bidi Bidi. These findings were used to create comic scenarios aligning with edutainment approaches to health promotion and inform a four-arm cluster randomised controlled trial in Bidi Bidi using a 2×2 factorial design: (1) HIV self-testing alongside edutainment comics, (2) HIV self-testing alone, (3) edutainment comic alone and (4) standard of care. The target sample size will be 120 youth (30 per arm), who will be enrolled in the trial and followed for 3 months. Data will be collected at baseline and 3 months after enrolment. The primary outcomes (HIV testing frequency, HIV status knowledge) and secondary outcomes (linkage to confirmatory HIV testing, HIV care linkage, HIV self-test kit use, HIV-related stigma, HIV knowledge, safer sex efficacy, condom use, adolescent sexual and reproductive health (SRH) stigma, sexual relationship power, access to SRH services) will be evaluated using descriptive statistics and regression analyses. ETHICS AND DISSEMINATION This study was approved by the University of Toronto Research Ethics Board, Mildmay Uganda Research Ethics Committee and the Uganda National Council for Science and Technology. Results will be shared in peer-reviewed publications and community knowledge sharing. TRIAL REGISTRATION NUMBER NCT05213689.
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Affiliation(s)
- Carmen H Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
- Women's College Research Institute, University of Toronto, Toronto, Ontario, Canada
- United Nations University Institute for Water, Environment and Health (UNU-INWEH), Hamilton, Ontario, Canada
- Centre for Gender & Sexual Health Equity, Vancouver, British Columbia, Canada
| | - Moses Okumu
- School of Social Work, University of Illinois-Champaign, Urbana, Illinois, USA
- School of Social Sciences, Uganda Christian University, Mukono, Uganda
| | - Miranda G Loutet
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Madelaine Coelho
- Department of Sociology, University of Toronto, Toronto, Ontario, Canada
| | - Isha Berry
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Lesley Gittings
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
- University of Cape Town, Rondebosch, South Africa
- School of Health Studies, Faculty of Health Sciences, Western University, London, ON, Canada
| | | | - Nelson Kisubi
- Uganda Refugee and Disaster Management Council, Yumbe, Uganda
| | - Malon Atama
- Yumbe Regional Referral Hospital, Yumbe, Uganda
| | - Peter Kyambadde
- Most at Risk Population Initiative, Mulago Hospital, Kampala, Uganda
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13
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Doyle CM, Cox J, Milwid RM, Bitera R, Delaunay CL, Alary M, Lambert G, Tremblay C, Mishra S, Maheu-Giroux M. Measuring progress towards reaching zero new HIV acquisitions among key populations in Québec (Canada) using routine surveillance data: a mathematical modelling study. J Int AIDS Soc 2022; 25:e25994. [PMID: 36050916 PMCID: PMC9437443 DOI: 10.1002/jia2.25994] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 07/27/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Men who have sex with men (MSM) and people who inject drugs (PWID) are disproportionately impacted by the HIV epidemic in Canada. Having the second‐highest provincial diagnosis rate, an improved understanding of the epidemic among these populations in Québec could aid ongoing elimination efforts. We estimated HIV incidence and other epidemic indicators among MSM and PWID in Montréal and across Québec using a back‐calculation model synthesizing surveillance data. Methods We developed a deterministic, compartmental mathematical model stratified by age, HIV status and disease progression, and clinical care stages. Using AIDS and HIV diagnoses data, including self‐reported time since the last negative test and laboratory results of CD4 cell count at diagnosis, we estimated HIV incidence in each population over 1975–2020 by modelling a cubic M‐spline. The prevalence, undiagnosed fraction, fraction diagnosed that started antiretroviral treatment (ART) and median time to diagnosis were also estimated. Since the COVID‐19 pandemic disrupted testing, we excluded 2020 data and explored this in sensitivity analyses. Results HIV incidence in all populations peaked early in the epidemic. In 2020, an estimated 97 (95% CrI: 33–227) and 266 (95% CrI: 103–508) HIV acquisitions occurred among MSM in Montréal and Québec, respectively. Among PWID, we estimated 2 (95% CrI: 0–14) and 6 (95% CrI: 1–26) HIV acquisitions in those same regions. With 2020 data, unless testing rates were reduced by 50%, these estimates decreased, except among Québec PWID, whose increased. Among all, the median time to diagnosis shortened to <2 years before 2020 and the undiagnosed fraction decreased to <10%. This fraction was higher in younger MSM, with 22% of 15–24 year‐olds living with HIV in Montréal (95% CrI: 9–39%) and 31% in Québec (95% CrI: 17–48%) undiagnosed by 2020 year‐end. Finally, ART access neared 100% in all diagnosed populations. Conclusions HIV incidence has drastically decreased in MSM and PWID across Québec, alongside significant improvements in diagnosis and treatment coverage—and the 2013 introduction of pre‐exposure prophylaxis. Despite this, HIV transmission continued. Effective efforts to halt this transmission and rapidly diagnose people who acquired HIV, especially among younger MSM, are needed to achieve elimination. Further, as the impacts of the COVID‐19 pandemic on HIV transmission are understood, increased efforts may be needed to overcome these.
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Affiliation(s)
- Carla M Doyle
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, Québec, Canada
| | - Joseph Cox
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, Québec, Canada.,Direction Régionale de Santé Publique de Montréal, Montréal, Québec, Canada.,Clinical Outcomes Research and Evaluation, Research Institute - McGill University Health Centre, Montréal, Québec, Canada
| | - Rachael M Milwid
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, Québec, Canada
| | - Raphaël Bitera
- Institut national de santé publique du Québec, Québec, Québec, Canada
| | - Charlotte Lanièce Delaunay
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, Québec, Canada.,Clinical Outcomes Research and Evaluation, Research Institute - McGill University Health Centre, Montréal, Québec, Canada
| | - Michel Alary
- Institut national de santé publique du Québec, Québec, Québec, Canada.,Centre de recherche du CHU de Québec - Université Laval, Québec, Québec, Canada.,Département de médecine sociale et préventive, Université Laval, Québec, Québec, Canada
| | - Gilles Lambert
- Direction Régionale de Santé Publique de Montréal, Montréal, Québec, Canada
| | - Cécile Tremblay
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada.,Department of Microbiology, Infectiology and Immunology, University of Montréal, Montréal, Québec, Canada
| | - Sharmistha Mishra
- Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Mathieu Maheu-Giroux
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, Québec, Canada
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14
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Pyra M, Heffron R, Haberer JE, Kiarie J. HIV prevention metrics: lessons to be learned from contraception. J Int AIDS Soc 2022; 25:e25958. [PMID: 35929343 PMCID: PMC9353407 DOI: 10.1002/jia2.25958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/27/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction As the range of effective HIV prevention options, including multiple biomedical tools, increases, there are many challenges to measuring HIV prevention efforts. In part, there is the challenge of varying prevention needs, between individuals as well as within individuals over time. The field of contraception faces many similar challenges, such as the range of prevention methods and changing contraceptive needs, and has developed many metrics for assessing contraceptive use at the program level, using frameworks that move beyond the HIV prevention cascade. We explore these similarities and differences between these two prevention fields and then discuss how each of these contraceptive metrics could be adapted to assessing HIV prevention. Discussion We examined measures of initiation, coverage and persistence. Among measures of initiation, HIV Prevention–Post Testing would be a useful corollary to Contraceptive Use–Post Partum for a subset of the population. As a measure of coverage, both Net Prevention Coverage and HIV Protection Index (modelled off the Contraception Protection Index) may be useful. Finally, as a measure of persistence, Person‐Years of HIV Protection could be adapted from Couple‐Years Protection. As in contraception, most programs will not reach 100% on HIV prevention metrics but these metrics are highly useful for making comparisons. Conclusions While we may not be able to perfectly capture the true population of who would benefit from HIV prevention, by building off the work of the contraceptive field to use and refine these metrics, we can assess and compare HIV prevention over time and across programs. Furthermore, these metrics can help us reach global targets, such as the 2025 UNAIDS Goals, and reduce HIV incidence.
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Affiliation(s)
- Maria Pyra
- University of Chicago, Chicago, Illinois, USA
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15
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Maxwell S, Shahmanesh M, Gafos M. Pre-exposure prophylaxis (PrEP) uptake and adherence experiences of gay and bisexual men who engage in chemsex: A qualitative study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 103:103630. [DOI: 10.1016/j.drugpo.2022.103630] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 11/24/2022]
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16
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Seidman D, Logan R, Weber S, Gandhi A, Blackstock O. Reimagining Preexposure Prophylaxis Provision for Women in the United States. Clin Infect Dis 2022; 74:2243-2248. [PMID: 35482659 PMCID: PMC9890470 DOI: 10.1093/cid/ciab959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Indexed: 02/05/2023] Open
Abstract
Structural determinants of health drive inequities in the acquisition of human immunodeficiency virus (HIV) and the use of preexposure prophylaxis (PrEP) for HIV prevention among cisgender women in the United States. However, current PrEP clinical guidance and implementation paradigms largely focus on individual behaviors and characteristics, resulting in missed opportunities to improve PrEP access, and the implicit transferring of prevention work from health systems to individuals. In this viewpoint article, we outline ways to apply a structural lens to clinical guidance and PrEP implementation for women and propose areas for future work.
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Affiliation(s)
- Dominika Seidman
- Correspondence: Dominika Seidman, 1001 Potrero Ave, Ward 6D, San Francisco, CA 94110, USA ()
| | - Rachel Logan
- Family and Community Medicine, University of California San Francisco, San Francisco, California, USA
| | | | - Anisha Gandhi
- Racial Equity and Social Justice Initiatives, Bureau of HIV, New York City Department of Health and Mental Hygiene, New York, New York, USA
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17
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Gallego-Márquez N, Iniesta C. Targeting fast-track goals: Missed opportunities for HIV testing in the Community of Madrid. ENFERMEDADES INFECCIOSAS Y MICROBIOLOGIA CLINICA (ENGLISH ED.) 2022; 40:138-141. [PMID: 34969654 DOI: 10.1016/j.eimce.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/20/2021] [Accepted: 04/22/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION In Spain HIV testing is recommended to people with risk behaviors for HIV and with indicator conditions (IC) related to HIV infection. Missed diagnostic opportunities (MO) are defining as situations where these recommendations are not followed. OBJECTIVE To characterize MO due to risk behaviors (directed) and due to IC (indicated) among people diagnosed with HIV in the Region of Madrid. METHODS A total of 109 participants newly diagnosed with HIV were recruited from 7 health centers (April 2018-March 2019) by a telephone survey. Diagnostic opportunities were defined as any contact with the healthcare system in which an HIV test should have been carried out. Frequency of MO was calculated within the previous 2 years from HIV diagnosis. RESULTS Of the 32 directed and indicated diagnostic opportunities, 96.9% and 57.8% respectively resulted in MO. Overall, 83.8% of diagnostic opportunities resulted in MO. CONCLUSION MO, both directed and indicated, are an important area for improvement to reduce late diagnosis.
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Affiliation(s)
- Nuria Gallego-Márquez
- Unidad de Vigilancia de VIH, Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Madrid, Spain; Master of Science in Public Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States
| | - Carlos Iniesta
- Unidad de Coordinación de la Cohorte de la Red de Investigación en Sida (CoRIS), Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Madrid, Spain.
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18
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Parmley LE, Harris TG, Chingombe I, Mapingure M, Mugurungi O, Rogers JH, Gozhora P, Wu Y, Samba C, Musuka G, Hakim AJ. Engagement in the pre-exposure prophylaxis (PrEP) cascade among a respondent-driven sample of sexually active men who have sex with men and transgender women during early PrEP implementation in Zimbabwe. J Int AIDS Soc 2022; 25:e25873. [PMID: 35148029 PMCID: PMC8834645 DOI: 10.1002/jia2.25873] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 12/16/2021] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Zimbabwe is scaling up pre-exposure prophylaxis (PrEP) for key populations, including men who have sex with men (MSM) and transgender women (TGW). To assess implementation and inform HIV programming, we evaluated gaps in PrEP awareness, uptake and use, and correlates of awareness and uptake among a sample of MSM, TGW and genderqueer individuals (GQ) in Harare and Bulawayo, Zimbabwe. METHODS Respondent-driven sampling was used to recruit 1194 MSM and 344 TGW/GQ aged ≥18 to participate in a cross-sectional survey assessing HIV-related outcomes in 2019. Consenting participants completed a questionnaire on socio-demographic information, sexual risk practices and engagement in HIV services and underwent HIV testing. Descriptive statistics were used to assess the PrEP cascade. Multiple logistic regression models were used to identify factors associated with PrEP awareness and uptake among HIV-negative participants. Data were unweighted as the sample did not reach convergence on key estimates. RESULTS Among the 1167 HIV-negative participants, most (79.2%) were MSM compared to TGW/GQ (20.8%). Median age was 24 years. Overall, 45.8% were aware of PrEP and of those, 31.3% had ever taken PrEP. Most (71.1%) reporting never taking PrEP were willing to start PrEP; the main reasons for never starting PrEP included not knowing where to access it (24.8%) and fearing side effects (20.4%). Among those who had ever taken PrEP, 74.9% had taken PrEP in the last 6 months; of these, 42.4% had taken PrEP the day of or day preceding the survey. Side effects represented the most common (59.5%) reason for discontinuing PrEP. MSM (adjusted odds ratio [aOR]: 2.5, 95% confidence interval [CI]: 1.8-3.6) and TGW/GQ in Harare (aOR: 3.1, 95% CI: 2.1-4.7), and TGW/GQ in Bulawayo (aOR: 2.4, 95% CI: 1.1-5.3) had higher awareness of PrEP than MSM in Bulawayo. Overall, TGW/GQ were more likely to have ever taken PrEP compared to MSM (aOR: 1.6, 95% CI: 1.01-2.4). CONCLUSIONS Findings emphasize the need for tailored interventions to promote PrEP among key populations. As HIV programs in Zimbabwe continue to expand PrEP services, these data, including barriers to starting and continuing PrEP, can inform strategies to address gaps along the PrEP cascade.
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Affiliation(s)
| | - Tiffany G Harris
- ICAP at Columbia University, New York, New York, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | | | | | - Owen Mugurungi
- Zimbabwe Ministry of Health and Child Care, Harare, Zimbabwe
| | - John H Rogers
- Division of Global HIV & TB, U.S. Centers for Disease Control, Harare, Zimbabwe
| | | | - Yingfeng Wu
- ICAP at Columbia University, New York, New York, USA
| | | | | | - Avi J Hakim
- Division of Global HIV & TB, U.S. Centers for Disease Control, Atlanta, Georgia, USA
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Gaps in the congenital syphilis prevention cascade: qualitative findings from Kern County, California. BMC Infect Dis 2022; 22:129. [PMID: 35123425 PMCID: PMC8818245 DOI: 10.1186/s12879-022-07100-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/18/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Congenital syphilis is preventable through timely access to prenatal care, syphilis screening and treatment of pregnant women diagnosed as infected. In 2018, California had the second highest number of congenital syphilis cases in the United States (U.S.), a nearly twofold increase in cases since 2014. This study assessed gaps in preventing congenital syphilis in the high morbidity region of Kern County, California.
Methods
Between May 2018 and January 2019, we conducted five focus group discussions with pregnant/postpartum women and ten semi-structured interviews with prenatal care providers in Kern County. Focus group and interview data were recorded, transcribed, and analyzed to identify emergent themes pertaining to facilitators and barriers at each step (prenatal care, syphilis screening and treatment) in the congenital syphilis prevention cascade.
Results
Gaps in congenital syphilis prevention discussed in focus group discussions with pregnant/postpartum women were related to limited prenatal care access, social-, economic-, and cultural-barriers, and substance use and co-occurring intimate partner/domestic violence. The gaps identified from interviews with prenatal care providers included social economic vulnerabilities of pregnant women and stigma and shame around the vulnerabilities, distrust in medical system, prenatal substance use, limited prenatal substance use disorder treatment facilities, and inadequate provider training on context-specific congenital syphilis management strategies. Gaps in partner notification, screening and treatment for syphilis were brought up by pregnant/postpartum women and prenatal care providers.
Conclusions
Congenital syphilis continues to increase in Kern County and throughout the U.S. In high syphilis morbidity areas, comprehensive and tailored public health approaches addressing setting-specific gaps in prenatal screening and treatment are needed.
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Heck CJ, Mathur S, Alwang’a H, Daniel OM, Obanda R, Owiti M, Okal J. Oral PrEP Consultations Among Adolescent Girls and Young Women in Kisumu County, Kenya: Insights from the DREAMS Program. AIDS Behav 2022; 26:2516-2530. [PMID: 35099640 PMCID: PMC9252953 DOI: 10.1007/s10461-022-03590-z] [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] [Accepted: 01/15/2022] [Indexed: 11/29/2022]
Abstract
Although Kenya nationally scaled up oral pre-exposure prophylaxis (PrEP) in May 2017, adolescent girls' (AG, aged 15-19 years) and young women's (YW, aged 20-24 years) PrEP use remains suboptimal. Thus, we analyzed PrEP consultations-interactions with a healthcare provider about PrEP-among Kenyan AGYW. In April-June 2018, AGYW enrolled in DREAMS in Kisumu County, Kenya self-reported their HIV-related knowledge, behaviors, and service use. Among HIV negative, sexually active AG (n = 154) and YW (n = 289), we examined associations between PrEP eligibility and PrEP consultations using prevalence ratios (PR, adjusted: aPR). Most AG (90.26%) and YW (94.12%) were PrEP-eligible due to inconsistent/no condom use, violence survivorship, or recent sexually transmitted infection symptoms. Between PrEP-eligible AG and YW, more YW were ever-orphaned (58.09%), ever-married (54.41%), ever-pregnant (80.88%), and out of school (78.31%); more PrEP-eligible YW reported PrEP consultations (41.18% vs. 24.46%, aPR = 1.51 [1.01-2.27]). AG who used PEP (post-exposure prophylaxis) reported more consultations (aPR = 5.63 [3.53-8.97]). Among YW, transactional sex engagers reported more consultations (58.62% vs. 39.09%, PR = 1.50 [1.06-2.12]), but only PEP use (aPR = 2.81 [2.30-3.43]) and multiple partnerships (aPR = 1.39 [1.06-1.82]) were independently associated with consultations. Consultations were lowest among those with 1 eligibility criterion (AG = 11.11%/YW = 27.18%). Comparatively, consultations were higher among AG and YW with 2 (aPR = 3.71 [1.64-8.39], PR = 1.60 [1.07-2.38], respectively) or ≥ 3 (aPR = 2.51 [1.09-5.78], PR = 2.05 [1.42-2.97], respectively) eligibility criteria. Though most AGYW were PrEP-eligible, PrEP consultations were rare and differed by age and vulnerability. In high-incidence settings, PrEP consultations should be conducted with all AGYW. PrEP provision guidelines must be re-assessed to accelerate AGYW's PrEP access.
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Affiliation(s)
- Craig J. Heck
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY 10032 USA
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21
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Conley C, Johnson R, Bond K, Brem S, Salas J, Randolph S. US Black cisgender women and pre-exposure prophylaxis for human immunodeficiency virus prevention: A scoping review. WOMEN'S HEALTH (LONDON, ENGLAND) 2022; 18:17455057221103098. [PMID: 35699104 PMCID: PMC9201306 DOI: 10.1177/17455057221103098] [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] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 04/28/2022] [Accepted: 05/06/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Black cisgender women in the United States experience a disproportionate burden of human immunodeficiency virus acquisition. Pre-exposure prophylaxis is an effective oral daily medication that reduces the risk of human immunodeficiency virus through sex by 99% when taken as prescribed. However, less than 2% of eligible Black cisgender women take pre-exposure prophylaxis. The purpose of this scoping review was to describe the types of research studies done in this area, gaps in knowledge, and potential areas of research needed to increase pre-exposure prophylaxis use among Black cisgender women in the United States. METHODS We conducted our search in MEDLINE (PubMed), Embase (Elsevier), CINAHL (EBSCOhost), PsycINFO (EBSCOhost), and Scopus (Elsevier) using a combination of keywords and database-specific subject headings for the following concepts: pre-exposure prophylaxis, African American/Black or minority, and women. We used the Joanna Briggs Institute's Reviewers' Manual process for Scoping Reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews to ensure comprehensive and standardized reporting of each part of the review. RESULTS Fifty-nine studies were included in the final review. Results of the study were classified according to the three phases of the Human Immunodeficiency Virus Prevention Cascade-demand side, supply side, and adherence and retention. The majority of studies (n = 24, 41%) were cross-sectional quantitative surveys and 43 (34%) focused on the demand-side phase of the Human Immunodeficiency Virus Prevention Cascade. Fifty-eight percent of studies either assessed women's pre-exposure prophylaxis knowledge, attitudes, and intentions to use, or assessed perceived barriers and facilitators. Seven studies (12%) tested pre-exposure prophylaxis uptake and adherence among Black cisgender women. CONCLUSION This review found multiple missed opportunities to increase women's demand for pre-exposure prophylaxis and health care provider screening and referral for pre-exposure prophylaxis. Additional studies are needed to effectively assess pre-exposure prophylaxis uptake and adherence among Black cisgender women.
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Affiliation(s)
| | | | - Keosha Bond
- City University of New York School of
Medicine, New York, NY, USA
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22
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Feasibility and acceptability of a peer-led HIV self-testing model among female sex workers in Malawi: a qualitative study. BMJ Open 2021. [PMCID: PMC8718425 DOI: 10.1136/bmjopen-2021-049248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
ObjectivesHIV testing is the gateway to HIV prevention and care services. Female sex workers (FSW) may benefit from HIV self-testing (HIVST), which offers greater control and confidentiality than other approaches. However, FSW also have unique vulnerabilities, making it critical to understand their perspective of HIVST to best contextualise HIVST to their needs. This study explored feasibility and acceptability of providing oral fluid-based peer-led HIVST to FSW to inform tailored HIVST delivery approaches.DesignQualitative study.SettingMalawi.ParticipantsThirty-nine FSW who had obtained a HIVST kit and eight peer distributors.ResultsPeer distributors’ accounts suggested that peer-led HIVST is feasible. Overall, FSW spoke positively about peer-led HIVST and younger FSW preferred it to facility-based HIV testing. FSW highlighted both greater control of their testing experience and that HIVST could allow them to avoid discriminatory attitudes frequently experienced in public facilities. Some also felt that HIVST kits could enable them to establish the HIV status of their sexual partners, better informing their decisions about condomless sex. Despite overall acceptance of HIVST, a few expressed doubts in the procedure. Some FSW already aware of their HIV-positive status reported using HIVST. A few accounts suggested peer pressure to self-test predominantly from peer distributors.ConclusionsThis study enabled us to explore feasibility and acceptability of peer-led HIVST among FSW, as well as potential shortcomings of the HIV testing modality. Peer distributors are a welcome additional model. However, they should avoid distribution in actual venues. Programmes should ensure a range of testing options are available and expand peer’s representation. Study findings will be used to tailor the HIVST distribution model to ensure its enhanced uptake among key populations in general and FSW, specifically.
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Morin L, Béhanzin L, Guédou FA, Kêkê RK, Bushman L, Anderson PL, Gangbo F, Diabaté S, Nagot N, Alary M. HIV Prevention and Treatment Cascades Among Female Sex Workers in Benin, West Africa. Sex Transm Dis 2021; 48:654-662. [PMID: 33633072 DOI: 10.1097/olq.0000000000001399] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Benin has a long-standing history of HIV prevention programs aimed at female sex workers (FSWs). We used data from a national survey among FSWs (2017) to assess the prevention and care cascades in this population. METHODS Female sex workers were recruited through cluster sampling of sex work sites. A questionnaire was administered, and HIV tested. HIV-positive participants were asked to provide dried blood spots and were tested for antiretroviral and viral load. We assessed 2 prevention cascades (HIV testing and safer sex) and the treatment cascade, using a combination of self-reported and biological variables. RESULTS Mean age of the 1086 FSWs was 30 years. Half of them were Beninese, and two-thirds had a primary school education level or less. Almost all FSWs had ever heard of HIV/AIDS. More than half (79.1%) had ever been tested, and 84.1% of the latter had been tested in the last year. In the previous 6 months, 90.1% were exposed to prevention messages. Women exposed to any HIV prevention message reported a higher level of consistent condom use in the last month (69.0%) than those who were not (48.5%, P < 0.0001). HIV prevalence was 7.7%. Among HIV-positive women, 60.6% knew their status; among those, 90.5% were on antiretroviral and 81.8% of them had a suppressed viral load. CONCLUSIONS Despite long-standing HIV prevention programs for FSWs, the prevention indicators were often low. Linkage to care was good, viral suppression was suboptimal, but knowledge of HIV-positive status was low. Exposing women to prevention messages is necessary, as to increase HIV testing.
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Affiliation(s)
| | | | | | | | - Lane Bushman
- University of Colorado Anschutz Medical Campus-Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | - Peter L Anderson
- University of Colorado Anschutz Medical Campus-Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | | | | | - Nicolas Nagot
- CHU de Montpellier et INSERM UMR 1058, Montpellier, France
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24
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Hensen B, Machingura F, Busza J, Birdthistle I, Chabata S, Chiyaka T, Floyd S, Jamali G, Mushati P, Hargreaves J, Cowan F. How Can We Support the Use of Oral PrEP Among Young Women who Sell Sex? A PrEP Cascade Analysis. J Acquir Immune Defic Syndr 2021; 88:45-56. [PMID: 34050101 PMCID: PMC8357043 DOI: 10.1097/qai.0000000000002733] [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: 12/22/2020] [Accepted: 04/19/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND We constructed self-reported pre-exposure prophylaxis (PrEP) cascades and explored factors associated with and barriers to PrEP use to inform efforts to support PrEP use among young women who sell sex. METHODS Using self-reported data from HIV-negative young women who sell sex enrolled into a cohort study using respondent-driven sampling in Zimbabwe, we constructed PrEP cascades assessing knowledge of, ever offered, ever used, and current PrEP use in 2017 and 2019. We used logistic regression to examine factors associated with PrEP use by 2019. Through qualitative interviews with 43 women enrolled in the cohort, we investigated barriers to PrEP use. RESULTS At enrollment, 50% of women had heard of PrEP, 12% had ever been offered PrEP, and 7% ever used PrEP. Over time, all cascade domains: 96% of women had heard of and 55% reported an active offer of PrEP. Among women retained in the study in 2019 (56%; n = 538), 34% ever took PrEP by 2019. PrEP use was associated with, at enrollment, reporting more clients in the past month (10+: 45% vs 1-3: 27% adjOR = 1.71 95% CI: 1.06 to 2.76), duration of selling sex (24% <2 years vs 38% 2-3 years; adjOR = 0.51 95% CI: 0.32 to 0.83), and having visited a female sex worker program in the past 12 months (55% vs 27%; adjOR = 2.92 95% CI: 1.91 to 4.46). Qualitative interviews revealed fear of disclosing sex work, HIV-related/ART-related stigma, and (opportunity) costs of accessing PrEP as barriers to use. CONCLUSION PrEP use was associated with factors known to increase HIV risk. Fear of stigma, disclosure, and supply-side barriers need to be addressed to increase women's ability to use PrEP.
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Affiliation(s)
- B. Hensen
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom;
| | - F. Machingura
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
| | - J. Busza
- Centre for Evaluation, London School of Hygiene and Tropical Medicine, London, United Kingdom;
| | - I. Birdthistle
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; and
| | - S.T. Chabata
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
| | - T. Chiyaka
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
| | - S. Floyd
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; and
| | - G. Jamali
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
| | - P. Mushati
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
| | - J. Hargreaves
- Centre for Evaluation, London School of Hygiene and Tropical Medicine, London, United Kingdom;
| | - F.M. Cowan
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe;
- Faculty of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
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25
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Garnett GP. Reductions in HIV incidence are likely to increase the importance of key population programmes for HIV control in sub-Saharan Africa. J Int AIDS Soc 2021; 24 Suppl 3:e25727. [PMID: 34189844 PMCID: PMC8242973 DOI: 10.1002/jia2.25727] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 03/24/2021] [Accepted: 04/20/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION An efficient HIV response requires that resources be focussed on effective interventions for those most at risk of acquiring and transmitting infection. As HIV epidemics evolve the distribution of HIV across key and other populations will change. Here, the epidemiological concepts underpinning these changes are described and the importance of appropriate allocation of effective interventions is discussed. DISCUSSION In many sub-Saharan African countries HIV epidemics have been categorized as "generalized," and HIV testing, treatment and prevention interventions have focussed on the "general" population. As HIV epidemics are better controlled the relative importance of "key" populations will increase, dominating the ongoing burden of disease and providing the potential for repeated outbreaks of HIV if interventions are relaxed. The basic reproductive number (R0 ) describes the potential for an infectious disease to spread at the boundary of invasion or elimination, whereas the effective reproduction number (Rt ) describes the current potential for spread. Heterogeneity in risk means that while Rt is temporarily below one and prevalence declining, the R0 can remain above one, preventing eventual elimination. Patterns of HIV acquisition are often used to guide interventions but inadequately capture the transmission dynamics of the virus and the most efficient approach to controlling HIV. Risks for HIV acquisition are not identical to risks for HIV transmission and will change depending on the epidemiological context. In addition to the challenges in measuring HIV transmission dynamics, there is a tension between using epidemiology to drive the HIV response and the social and political realities constraining how programmes and providers can practically and appropriately focus on key populations and maintain political support. In addition to being well focussed, interventions need to be effective and cost-effective, which requires a better understanding of packages of interventions rather than specific tools. CONCLUSIONS Continued control of HIV will increasingly rely on resources, programmes and interventions supporting key populations. Current epidemiological and programmatic approaches for key populations in sub-Saharan Africa are insufficient with a need for an improved understanding of local epidemiology and the effectiveness of interventions.
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Affiliation(s)
- Geoff P Garnett
- Tuberculosis and HIV Strategic TeamBill & Melinda Gates FoundationSeattleWAUSA
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26
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Gallego-Márquez N, Iniesta C. Targeting fast-track goals: Missed opportunities for HIV testing in the Community of Madrid. Enferm Infecc Microbiol Clin 2021; 40:S0213-005X(21)00181-6. [PMID: 34112557 DOI: 10.1016/j.eimc.2021.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/20/2021] [Accepted: 04/22/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION In Spain HIV testing is recommended to people with risk behaviors for HIV and with indicator conditions related to HIV infection. Missed diagnostic opportunities (MO) are defining as situations where these recommendations are not followed. OBJECTIVE To characterize MO due to risk behaviors (directed) and due to indicator conditions (indicated) among people diagnosed with HIV in the Region of Madrid. METHODS A total of 109 participants newly diagnosed with HIV were recruited from 7 health centers (April 2018-March 2019) by a telephone survey. Diagnostic opportunities were defined as any contact with the healthcare system in which an HIV test should have been carried out. Frequency of MO was calculated within the previous 2 years from HIV diagnosis. RESULTS Of the 32 directed and indicated diagnostic opportunities, 96.9 and 57.8% respectively resulted in MO. Overall, 83.8% of diagnostic opportunities resulted in MO. CONCLUSION MO, both directed and indicated, are an important area for improvement to reduce late diagnosis.
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Affiliation(s)
- Nuria Gallego-Márquez
- Unidad de Vigilancia de VIH, Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Madrid, España; Master of Science in Public Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, EE. UU
| | - Carlos Iniesta
- Unidad de coordinación de la Cohorte de la Red de Investigación en Sida (CoRIS), Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Madrid, España.
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Ongolly FK, Dolla A, Ngure K, Irungu EM, Odoyo J, Wamoni E, Peebles K, Mugwanya K, Mugo NR, Bukusi EA, Morton J, Baeten JM, O’Malley G. "I Just Decided to Stop:" Understanding PrEP Discontinuation Among Individuals Initiating PrEP in HIV Care Centers in Kenya. J Acquir Immune Defic Syndr 2021; 87:e150-e158. [PMID: 33492024 PMCID: PMC8026512 DOI: 10.1097/qai.0000000000002625] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/30/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Preexposure prophylaxis (PrEP) discontinuation rates in clinical trials and demonstration projects have been well characterized; however, little is known about discontinuation in routine public health settings in sub-Saharan Africa. Understanding discontinuation in nonstudy settings is important for establishing expectations for PrEP continuation in national programs and for facilitating effective PrEP scale-up. METHODS We conducted in-depth interviews with 46 individuals who had initiated PrEP at 25 HIV comprehensive care clinics (CCCs) in central and western Kenya and whose clinic records indicated they had discontinued. RESULTS Many of our study participants discontinued PrEP when their perceived risk decreased (eg, hiatus or end of a sexual relationship or partner known to be living with HIV became virally suppressed). Others reported discontinuation due to side effects, daily pill burden, preference for condoms, or their partner's insistence. Participant narratives frequently described facility level factors such as stigma-related discomforts with accessing PrEP at CCCs, inconvenient clinic location or operating hours, long wait times, and short refill dates as discouraging factors, suggesting actionable areas for improving PrEP access and continuation. CONCLUSION Clients frequently make intentional decisions to discontinue PrEP as they weigh different prevention options within the context of complex lives. Many clients will decide to discontinue PrEP when perceiving themselves to be at reduced risk and PrEP counseling must include provisions for addressing seasons of risk. PrEP will not be the right prevention method for everyone, or forever. Expanding PrEP access points and increasing sex-positive messaging may facilitate PrEP being a better option for many.
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Affiliation(s)
| | - Annabel Dolla
- Center for Microbiology Research, Kenya Medical Research Institute; Nairobi, Kenya
| | - Kenneth Ngure
- Department of Global Health, Seattle, Washington, USA
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Elizabeth M. Irungu
- Center for Clinical Research, Kenya Medical Research Institute; Nairobi, Kenya
| | - Josephine Odoyo
- Center for Microbiology Research, Kenya Medical Research Institute; Nairobi, Kenya
| | - Elizabeth Wamoni
- Center for Clinical Research, Kenya Medical Research Institute; Nairobi, Kenya
| | - Kathryn Peebles
- Department of Epidemiology, Medicine, Seattle, Washington, USA
- University of Washington, Seattle, Washington, USA
| | - Kenneth Mugwanya
- Department of Global Health, Seattle, Washington, USA
- University of Washington, Seattle, Washington, USA
| | - Nelly R. Mugo
- Center for Clinical Research, Kenya Medical Research Institute; Nairobi, Kenya
- Department of Global Health, Seattle, Washington, USA
| | - Elizabeth A. Bukusi
- Department of Global Health, Seattle, Washington, USA
- Department of Obstetrics and Gynecology, Seattle, Washington, USA
- Center for Microbiology Research, Kenya Medical Research Institute; Nairobi, Kenya
| | - Jennifer Morton
- Department of Global Health, Seattle, Washington, USA
- University of Washington, Seattle, Washington, USA
| | - Jared M. Baeten
- Department of Global Health, Seattle, Washington, USA
- Department of Epidemiology, Medicine, Seattle, Washington, USA
- University of Washington, Seattle, Washington, USA
- Center for Microbiology Research, Kenya Medical Research Institute; Nairobi, Kenya
| | - Gabrielle O’Malley
- Department of Global Health, Seattle, Washington, USA
- University of Washington, Seattle, Washington, USA
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Mastro TD, Bateganya M, Mahler H. The Need to Optimize Human Immunodeficiency Virus Test-and-Treat Programs in Africa. J Infect Dis 2021; 223:1117-1119. [PMID: 33474562 DOI: 10.1093/infdis/jiab022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 01/03/2023] Open
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Cox J, Apelian H, Moodie EEM, Messier-Peet M, Hart TA, Grace D, Moore DM, Lachowsky NJ, Armstrong HL, Jollimore J, Skakoon-Sparling S, Rodrigues R, Tan DHS, Maheu-Giroux M, Noor SW, Lebouché B, Tremblay C, Olarewaju G, Lambert G. Use of HIV pre-exposure prophylaxis among urban Canadian gay, bisexual and other men who have sex with men: a cross-sectional analysis of the Engage cohort study. CMAJ Open 2021; 9:E529-E538. [PMID: 34021010 PMCID: PMC8177951 DOI: 10.9778/cmajo.20200198] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In Canada, gay, bisexual and other men who have sex with men (GBM) are disproportionately affected by HIV. Our objective was to describe access to HIV pre-exposure prophylaxis (PrEP) and identify factors associated with not using PrEP among self-reported HIV-negative or HIV-unknown GBM. METHODS This was a cross-sectional analysis of the Engage study cohort. Between 2017 and 2019, sexually active GBM aged 16 years or more in Montréal, Toronto and Vancouver were recruited via respondent-driven sampling (RDS). Participation included testing for HIV and sexually transmitted and blood-borne infections, and completion of a questionnaire. We examined PrEP access using a health care services model and fit RDS-adjusted logistic regressions to determine correlates of not using PrEP among those for whom PrEP was clinically recommended and who were aware of the intervention. RESULTS A total of 2449 GBM were recruited, of whom 2008 were HIV-negative or HIV-unknown; 1159 (511 in Montréal, 247 in Toronto and 401 in Vancouver) met clinical recommendations for PrEP. Of the 1159, 1100 were aware of PrEP (RDS-adjusted proportion: Montréal 84.6%, Toronto 94.2%, Vancouver 92.7%), 678 had felt the need for PrEP in the previous 6 months (RDS-adjusted proportion: Montréal 39.2%, Toronto 56.1%, Vancouver 49.0%), 406 had tried to access PrEP in the previous 6 months (RDS-adjusted proportion: Montréal 20.6%, Toronto 33.2%, Vancouver 29.6%) and 319 had used PrEP in the previous 6 months (RDS-adjusted proportion: Montréal 14.5%, Toronto 21.6%, Vancouver 21.8%). Not using PrEP was associated with several factors, including not feeling at high enough risk, viewing PrEP as not completely effective, not having a primary care provider and lacking medication insurance. INTERPRETATION Although half of GBM met clinical recommendations for PrEP, less than a quarter of them reported use. Despite high levels of awareness, a programmatic response that addresses PrEP-related perceptions and health care system barriers is needed to scale up PrEP access among GBM in Canada.
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Affiliation(s)
- Joseph Cox
- Department of Epidemiology, Biostatistics & Occupational Health (Cox, Moodie, Maheu-Giroux), McGill University; Direction régionale de santé publique, Centre intégré universitaire de santé et de services sociaux Centre-Sud-de-l'Ile-de-Montréal (Cox, Apelian, Messier-Peet, Lambert); Research Institute of the McGill University Health Centre (Apelian, Messier-Peet), Montréal, Que.; Department of Psychology (Hart, Skakoon-Sparling, Rodrigues, Noor), Ryerson University; Dalla Lana School of Public Health (Grace), University of Toronto, Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Moore, Armstrong, Olarewaju); Faculty of Medicine (Moore), University of British Columbia, Vancouver, BC; School of Public Health & Social Policy (Lachowsky), Faculty of Human & Social Development, University of Victoria, Victoria, BC; Department of Psychology (Armstrong), University of Southampton, Southampton, UK; Community-Based Research Centre (Jollimore), Vancouver, BC; Division of Infectious Diseases (Tan), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto, Toronto, Ont.; Department of Family Medicine (Lebouché), Faculty of Medicine, McGill University; Centre for Outcomes Research and Evaluation (Lebouché), Research Institute of the McGill University Health Centre; Centre de recherche du centre hospitalier de l'Université de Montréal (Tremblay); Institut national de santé publique du Québec (Lambert), Montréal, Que.
| | - Herak Apelian
- Department of Epidemiology, Biostatistics & Occupational Health (Cox, Moodie, Maheu-Giroux), McGill University; Direction régionale de santé publique, Centre intégré universitaire de santé et de services sociaux Centre-Sud-de-l'Ile-de-Montréal (Cox, Apelian, Messier-Peet, Lambert); Research Institute of the McGill University Health Centre (Apelian, Messier-Peet), Montréal, Que.; Department of Psychology (Hart, Skakoon-Sparling, Rodrigues, Noor), Ryerson University; Dalla Lana School of Public Health (Grace), University of Toronto, Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Moore, Armstrong, Olarewaju); Faculty of Medicine (Moore), University of British Columbia, Vancouver, BC; School of Public Health & Social Policy (Lachowsky), Faculty of Human & Social Development, University of Victoria, Victoria, BC; Department of Psychology (Armstrong), University of Southampton, Southampton, UK; Community-Based Research Centre (Jollimore), Vancouver, BC; Division of Infectious Diseases (Tan), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto, Toronto, Ont.; Department of Family Medicine (Lebouché), Faculty of Medicine, McGill University; Centre for Outcomes Research and Evaluation (Lebouché), Research Institute of the McGill University Health Centre; Centre de recherche du centre hospitalier de l'Université de Montréal (Tremblay); Institut national de santé publique du Québec (Lambert), Montréal, Que
| | - Erica E M Moodie
- Department of Epidemiology, Biostatistics & Occupational Health (Cox, Moodie, Maheu-Giroux), McGill University; Direction régionale de santé publique, Centre intégré universitaire de santé et de services sociaux Centre-Sud-de-l'Ile-de-Montréal (Cox, Apelian, Messier-Peet, Lambert); Research Institute of the McGill University Health Centre (Apelian, Messier-Peet), Montréal, Que.; Department of Psychology (Hart, Skakoon-Sparling, Rodrigues, Noor), Ryerson University; Dalla Lana School of Public Health (Grace), University of Toronto, Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Moore, Armstrong, Olarewaju); Faculty of Medicine (Moore), University of British Columbia, Vancouver, BC; School of Public Health & Social Policy (Lachowsky), Faculty of Human & Social Development, University of Victoria, Victoria, BC; Department of Psychology (Armstrong), University of Southampton, Southampton, UK; Community-Based Research Centre (Jollimore), Vancouver, BC; Division of Infectious Diseases (Tan), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto, Toronto, Ont.; Department of Family Medicine (Lebouché), Faculty of Medicine, McGill University; Centre for Outcomes Research and Evaluation (Lebouché), Research Institute of the McGill University Health Centre; Centre de recherche du centre hospitalier de l'Université de Montréal (Tremblay); Institut national de santé publique du Québec (Lambert), Montréal, Que
| | - Marc Messier-Peet
- Department of Epidemiology, Biostatistics & Occupational Health (Cox, Moodie, Maheu-Giroux), McGill University; Direction régionale de santé publique, Centre intégré universitaire de santé et de services sociaux Centre-Sud-de-l'Ile-de-Montréal (Cox, Apelian, Messier-Peet, Lambert); Research Institute of the McGill University Health Centre (Apelian, Messier-Peet), Montréal, Que.; Department of Psychology (Hart, Skakoon-Sparling, Rodrigues, Noor), Ryerson University; Dalla Lana School of Public Health (Grace), University of Toronto, Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Moore, Armstrong, Olarewaju); Faculty of Medicine (Moore), University of British Columbia, Vancouver, BC; School of Public Health & Social Policy (Lachowsky), Faculty of Human & Social Development, University of Victoria, Victoria, BC; Department of Psychology (Armstrong), University of Southampton, Southampton, UK; Community-Based Research Centre (Jollimore), Vancouver, BC; Division of Infectious Diseases (Tan), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto, Toronto, Ont.; Department of Family Medicine (Lebouché), Faculty of Medicine, McGill University; Centre for Outcomes Research and Evaluation (Lebouché), Research Institute of the McGill University Health Centre; Centre de recherche du centre hospitalier de l'Université de Montréal (Tremblay); Institut national de santé publique du Québec (Lambert), Montréal, Que
| | - Trevor A Hart
- Department of Epidemiology, Biostatistics & Occupational Health (Cox, Moodie, Maheu-Giroux), McGill University; Direction régionale de santé publique, Centre intégré universitaire de santé et de services sociaux Centre-Sud-de-l'Ile-de-Montréal (Cox, Apelian, Messier-Peet, Lambert); Research Institute of the McGill University Health Centre (Apelian, Messier-Peet), Montréal, Que.; Department of Psychology (Hart, Skakoon-Sparling, Rodrigues, Noor), Ryerson University; Dalla Lana School of Public Health (Grace), University of Toronto, Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Moore, Armstrong, Olarewaju); Faculty of Medicine (Moore), University of British Columbia, Vancouver, BC; School of Public Health & Social Policy (Lachowsky), Faculty of Human & Social Development, University of Victoria, Victoria, BC; Department of Psychology (Armstrong), University of Southampton, Southampton, UK; Community-Based Research Centre (Jollimore), Vancouver, BC; Division of Infectious Diseases (Tan), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto, Toronto, Ont.; Department of Family Medicine (Lebouché), Faculty of Medicine, McGill University; Centre for Outcomes Research and Evaluation (Lebouché), Research Institute of the McGill University Health Centre; Centre de recherche du centre hospitalier de l'Université de Montréal (Tremblay); Institut national de santé publique du Québec (Lambert), Montréal, Que
| | - Daniel Grace
- Department of Epidemiology, Biostatistics & Occupational Health (Cox, Moodie, Maheu-Giroux), McGill University; Direction régionale de santé publique, Centre intégré universitaire de santé et de services sociaux Centre-Sud-de-l'Ile-de-Montréal (Cox, Apelian, Messier-Peet, Lambert); Research Institute of the McGill University Health Centre (Apelian, Messier-Peet), Montréal, Que.; Department of Psychology (Hart, Skakoon-Sparling, Rodrigues, Noor), Ryerson University; Dalla Lana School of Public Health (Grace), University of Toronto, Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Moore, Armstrong, Olarewaju); Faculty of Medicine (Moore), University of British Columbia, Vancouver, BC; School of Public Health & Social Policy (Lachowsky), Faculty of Human & Social Development, University of Victoria, Victoria, BC; Department of Psychology (Armstrong), University of Southampton, Southampton, UK; Community-Based Research Centre (Jollimore), Vancouver, BC; Division of Infectious Diseases (Tan), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto, Toronto, Ont.; Department of Family Medicine (Lebouché), Faculty of Medicine, McGill University; Centre for Outcomes Research and Evaluation (Lebouché), Research Institute of the McGill University Health Centre; Centre de recherche du centre hospitalier de l'Université de Montréal (Tremblay); Institut national de santé publique du Québec (Lambert), Montréal, Que
| | - David M Moore
- Department of Epidemiology, Biostatistics & Occupational Health (Cox, Moodie, Maheu-Giroux), McGill University; Direction régionale de santé publique, Centre intégré universitaire de santé et de services sociaux Centre-Sud-de-l'Ile-de-Montréal (Cox, Apelian, Messier-Peet, Lambert); Research Institute of the McGill University Health Centre (Apelian, Messier-Peet), Montréal, Que.; Department of Psychology (Hart, Skakoon-Sparling, Rodrigues, Noor), Ryerson University; Dalla Lana School of Public Health (Grace), University of Toronto, Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Moore, Armstrong, Olarewaju); Faculty of Medicine (Moore), University of British Columbia, Vancouver, BC; School of Public Health & Social Policy (Lachowsky), Faculty of Human & Social Development, University of Victoria, Victoria, BC; Department of Psychology (Armstrong), University of Southampton, Southampton, UK; Community-Based Research Centre (Jollimore), Vancouver, BC; Division of Infectious Diseases (Tan), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto, Toronto, Ont.; Department of Family Medicine (Lebouché), Faculty of Medicine, McGill University; Centre for Outcomes Research and Evaluation (Lebouché), Research Institute of the McGill University Health Centre; Centre de recherche du centre hospitalier de l'Université de Montréal (Tremblay); Institut national de santé publique du Québec (Lambert), Montréal, Que
| | - Nathan J Lachowsky
- Department of Epidemiology, Biostatistics & Occupational Health (Cox, Moodie, Maheu-Giroux), McGill University; Direction régionale de santé publique, Centre intégré universitaire de santé et de services sociaux Centre-Sud-de-l'Ile-de-Montréal (Cox, Apelian, Messier-Peet, Lambert); Research Institute of the McGill University Health Centre (Apelian, Messier-Peet), Montréal, Que.; Department of Psychology (Hart, Skakoon-Sparling, Rodrigues, Noor), Ryerson University; Dalla Lana School of Public Health (Grace), University of Toronto, Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Moore, Armstrong, Olarewaju); Faculty of Medicine (Moore), University of British Columbia, Vancouver, BC; School of Public Health & Social Policy (Lachowsky), Faculty of Human & Social Development, University of Victoria, Victoria, BC; Department of Psychology (Armstrong), University of Southampton, Southampton, UK; Community-Based Research Centre (Jollimore), Vancouver, BC; Division of Infectious Diseases (Tan), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto, Toronto, Ont.; Department of Family Medicine (Lebouché), Faculty of Medicine, McGill University; Centre for Outcomes Research and Evaluation (Lebouché), Research Institute of the McGill University Health Centre; Centre de recherche du centre hospitalier de l'Université de Montréal (Tremblay); Institut national de santé publique du Québec (Lambert), Montréal, Que
| | - Heather L Armstrong
- Department of Epidemiology, Biostatistics & Occupational Health (Cox, Moodie, Maheu-Giroux), McGill University; Direction régionale de santé publique, Centre intégré universitaire de santé et de services sociaux Centre-Sud-de-l'Ile-de-Montréal (Cox, Apelian, Messier-Peet, Lambert); Research Institute of the McGill University Health Centre (Apelian, Messier-Peet), Montréal, Que.; Department of Psychology (Hart, Skakoon-Sparling, Rodrigues, Noor), Ryerson University; Dalla Lana School of Public Health (Grace), University of Toronto, Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Moore, Armstrong, Olarewaju); Faculty of Medicine (Moore), University of British Columbia, Vancouver, BC; School of Public Health & Social Policy (Lachowsky), Faculty of Human & Social Development, University of Victoria, Victoria, BC; Department of Psychology (Armstrong), University of Southampton, Southampton, UK; Community-Based Research Centre (Jollimore), Vancouver, BC; Division of Infectious Diseases (Tan), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto, Toronto, Ont.; Department of Family Medicine (Lebouché), Faculty of Medicine, McGill University; Centre for Outcomes Research and Evaluation (Lebouché), Research Institute of the McGill University Health Centre; Centre de recherche du centre hospitalier de l'Université de Montréal (Tremblay); Institut national de santé publique du Québec (Lambert), Montréal, Que
| | - Jody Jollimore
- Department of Epidemiology, Biostatistics & Occupational Health (Cox, Moodie, Maheu-Giroux), McGill University; Direction régionale de santé publique, Centre intégré universitaire de santé et de services sociaux Centre-Sud-de-l'Ile-de-Montréal (Cox, Apelian, Messier-Peet, Lambert); Research Institute of the McGill University Health Centre (Apelian, Messier-Peet), Montréal, Que.; Department of Psychology (Hart, Skakoon-Sparling, Rodrigues, Noor), Ryerson University; Dalla Lana School of Public Health (Grace), University of Toronto, Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Moore, Armstrong, Olarewaju); Faculty of Medicine (Moore), University of British Columbia, Vancouver, BC; School of Public Health & Social Policy (Lachowsky), Faculty of Human & Social Development, University of Victoria, Victoria, BC; Department of Psychology (Armstrong), University of Southampton, Southampton, UK; Community-Based Research Centre (Jollimore), Vancouver, BC; Division of Infectious Diseases (Tan), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto, Toronto, Ont.; Department of Family Medicine (Lebouché), Faculty of Medicine, McGill University; Centre for Outcomes Research and Evaluation (Lebouché), Research Institute of the McGill University Health Centre; Centre de recherche du centre hospitalier de l'Université de Montréal (Tremblay); Institut national de santé publique du Québec (Lambert), Montréal, Que
| | - Shayna Skakoon-Sparling
- Department of Epidemiology, Biostatistics & Occupational Health (Cox, Moodie, Maheu-Giroux), McGill University; Direction régionale de santé publique, Centre intégré universitaire de santé et de services sociaux Centre-Sud-de-l'Ile-de-Montréal (Cox, Apelian, Messier-Peet, Lambert); Research Institute of the McGill University Health Centre (Apelian, Messier-Peet), Montréal, Que.; Department of Psychology (Hart, Skakoon-Sparling, Rodrigues, Noor), Ryerson University; Dalla Lana School of Public Health (Grace), University of Toronto, Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Moore, Armstrong, Olarewaju); Faculty of Medicine (Moore), University of British Columbia, Vancouver, BC; School of Public Health & Social Policy (Lachowsky), Faculty of Human & Social Development, University of Victoria, Victoria, BC; Department of Psychology (Armstrong), University of Southampton, Southampton, UK; Community-Based Research Centre (Jollimore), Vancouver, BC; Division of Infectious Diseases (Tan), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto, Toronto, Ont.; Department of Family Medicine (Lebouché), Faculty of Medicine, McGill University; Centre for Outcomes Research and Evaluation (Lebouché), Research Institute of the McGill University Health Centre; Centre de recherche du centre hospitalier de l'Université de Montréal (Tremblay); Institut national de santé publique du Québec (Lambert), Montréal, Que
| | - Ricky Rodrigues
- Department of Epidemiology, Biostatistics & Occupational Health (Cox, Moodie, Maheu-Giroux), McGill University; Direction régionale de santé publique, Centre intégré universitaire de santé et de services sociaux Centre-Sud-de-l'Ile-de-Montréal (Cox, Apelian, Messier-Peet, Lambert); Research Institute of the McGill University Health Centre (Apelian, Messier-Peet), Montréal, Que.; Department of Psychology (Hart, Skakoon-Sparling, Rodrigues, Noor), Ryerson University; Dalla Lana School of Public Health (Grace), University of Toronto, Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Moore, Armstrong, Olarewaju); Faculty of Medicine (Moore), University of British Columbia, Vancouver, BC; School of Public Health & Social Policy (Lachowsky), Faculty of Human & Social Development, University of Victoria, Victoria, BC; Department of Psychology (Armstrong), University of Southampton, Southampton, UK; Community-Based Research Centre (Jollimore), Vancouver, BC; Division of Infectious Diseases (Tan), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto, Toronto, Ont.; Department of Family Medicine (Lebouché), Faculty of Medicine, McGill University; Centre for Outcomes Research and Evaluation (Lebouché), Research Institute of the McGill University Health Centre; Centre de recherche du centre hospitalier de l'Université de Montréal (Tremblay); Institut national de santé publique du Québec (Lambert), Montréal, Que
| | - Darrell H S Tan
- Department of Epidemiology, Biostatistics & Occupational Health (Cox, Moodie, Maheu-Giroux), McGill University; Direction régionale de santé publique, Centre intégré universitaire de santé et de services sociaux Centre-Sud-de-l'Ile-de-Montréal (Cox, Apelian, Messier-Peet, Lambert); Research Institute of the McGill University Health Centre (Apelian, Messier-Peet), Montréal, Que.; Department of Psychology (Hart, Skakoon-Sparling, Rodrigues, Noor), Ryerson University; Dalla Lana School of Public Health (Grace), University of Toronto, Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Moore, Armstrong, Olarewaju); Faculty of Medicine (Moore), University of British Columbia, Vancouver, BC; School of Public Health & Social Policy (Lachowsky), Faculty of Human & Social Development, University of Victoria, Victoria, BC; Department of Psychology (Armstrong), University of Southampton, Southampton, UK; Community-Based Research Centre (Jollimore), Vancouver, BC; Division of Infectious Diseases (Tan), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto, Toronto, Ont.; Department of Family Medicine (Lebouché), Faculty of Medicine, McGill University; Centre for Outcomes Research and Evaluation (Lebouché), Research Institute of the McGill University Health Centre; Centre de recherche du centre hospitalier de l'Université de Montréal (Tremblay); Institut national de santé publique du Québec (Lambert), Montréal, Que
| | - Mathieu Maheu-Giroux
- Department of Epidemiology, Biostatistics & Occupational Health (Cox, Moodie, Maheu-Giroux), McGill University; Direction régionale de santé publique, Centre intégré universitaire de santé et de services sociaux Centre-Sud-de-l'Ile-de-Montréal (Cox, Apelian, Messier-Peet, Lambert); Research Institute of the McGill University Health Centre (Apelian, Messier-Peet), Montréal, Que.; Department of Psychology (Hart, Skakoon-Sparling, Rodrigues, Noor), Ryerson University; Dalla Lana School of Public Health (Grace), University of Toronto, Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Moore, Armstrong, Olarewaju); Faculty of Medicine (Moore), University of British Columbia, Vancouver, BC; School of Public Health & Social Policy (Lachowsky), Faculty of Human & Social Development, University of Victoria, Victoria, BC; Department of Psychology (Armstrong), University of Southampton, Southampton, UK; Community-Based Research Centre (Jollimore), Vancouver, BC; Division of Infectious Diseases (Tan), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto, Toronto, Ont.; Department of Family Medicine (Lebouché), Faculty of Medicine, McGill University; Centre for Outcomes Research and Evaluation (Lebouché), Research Institute of the McGill University Health Centre; Centre de recherche du centre hospitalier de l'Université de Montréal (Tremblay); Institut national de santé publique du Québec (Lambert), Montréal, Que
| | - Syed W Noor
- Department of Epidemiology, Biostatistics & Occupational Health (Cox, Moodie, Maheu-Giroux), McGill University; Direction régionale de santé publique, Centre intégré universitaire de santé et de services sociaux Centre-Sud-de-l'Ile-de-Montréal (Cox, Apelian, Messier-Peet, Lambert); Research Institute of the McGill University Health Centre (Apelian, Messier-Peet), Montréal, Que.; Department of Psychology (Hart, Skakoon-Sparling, Rodrigues, Noor), Ryerson University; Dalla Lana School of Public Health (Grace), University of Toronto, Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Moore, Armstrong, Olarewaju); Faculty of Medicine (Moore), University of British Columbia, Vancouver, BC; School of Public Health & Social Policy (Lachowsky), Faculty of Human & Social Development, University of Victoria, Victoria, BC; Department of Psychology (Armstrong), University of Southampton, Southampton, UK; Community-Based Research Centre (Jollimore), Vancouver, BC; Division of Infectious Diseases (Tan), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto, Toronto, Ont.; Department of Family Medicine (Lebouché), Faculty of Medicine, McGill University; Centre for Outcomes Research and Evaluation (Lebouché), Research Institute of the McGill University Health Centre; Centre de recherche du centre hospitalier de l'Université de Montréal (Tremblay); Institut national de santé publique du Québec (Lambert), Montréal, Que
| | - Bertrand Lebouché
- Department of Epidemiology, Biostatistics & Occupational Health (Cox, Moodie, Maheu-Giroux), McGill University; Direction régionale de santé publique, Centre intégré universitaire de santé et de services sociaux Centre-Sud-de-l'Ile-de-Montréal (Cox, Apelian, Messier-Peet, Lambert); Research Institute of the McGill University Health Centre (Apelian, Messier-Peet), Montréal, Que.; Department of Psychology (Hart, Skakoon-Sparling, Rodrigues, Noor), Ryerson University; Dalla Lana School of Public Health (Grace), University of Toronto, Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Moore, Armstrong, Olarewaju); Faculty of Medicine (Moore), University of British Columbia, Vancouver, BC; School of Public Health & Social Policy (Lachowsky), Faculty of Human & Social Development, University of Victoria, Victoria, BC; Department of Psychology (Armstrong), University of Southampton, Southampton, UK; Community-Based Research Centre (Jollimore), Vancouver, BC; Division of Infectious Diseases (Tan), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto, Toronto, Ont.; Department of Family Medicine (Lebouché), Faculty of Medicine, McGill University; Centre for Outcomes Research and Evaluation (Lebouché), Research Institute of the McGill University Health Centre; Centre de recherche du centre hospitalier de l'Université de Montréal (Tremblay); Institut national de santé publique du Québec (Lambert), Montréal, Que
| | - Cecile Tremblay
- Department of Epidemiology, Biostatistics & Occupational Health (Cox, Moodie, Maheu-Giroux), McGill University; Direction régionale de santé publique, Centre intégré universitaire de santé et de services sociaux Centre-Sud-de-l'Ile-de-Montréal (Cox, Apelian, Messier-Peet, Lambert); Research Institute of the McGill University Health Centre (Apelian, Messier-Peet), Montréal, Que.; Department of Psychology (Hart, Skakoon-Sparling, Rodrigues, Noor), Ryerson University; Dalla Lana School of Public Health (Grace), University of Toronto, Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Moore, Armstrong, Olarewaju); Faculty of Medicine (Moore), University of British Columbia, Vancouver, BC; School of Public Health & Social Policy (Lachowsky), Faculty of Human & Social Development, University of Victoria, Victoria, BC; Department of Psychology (Armstrong), University of Southampton, Southampton, UK; Community-Based Research Centre (Jollimore), Vancouver, BC; Division of Infectious Diseases (Tan), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto, Toronto, Ont.; Department of Family Medicine (Lebouché), Faculty of Medicine, McGill University; Centre for Outcomes Research and Evaluation (Lebouché), Research Institute of the McGill University Health Centre; Centre de recherche du centre hospitalier de l'Université de Montréal (Tremblay); Institut national de santé publique du Québec (Lambert), Montréal, Que
| | - Gbolahan Olarewaju
- Department of Epidemiology, Biostatistics & Occupational Health (Cox, Moodie, Maheu-Giroux), McGill University; Direction régionale de santé publique, Centre intégré universitaire de santé et de services sociaux Centre-Sud-de-l'Ile-de-Montréal (Cox, Apelian, Messier-Peet, Lambert); Research Institute of the McGill University Health Centre (Apelian, Messier-Peet), Montréal, Que.; Department of Psychology (Hart, Skakoon-Sparling, Rodrigues, Noor), Ryerson University; Dalla Lana School of Public Health (Grace), University of Toronto, Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Moore, Armstrong, Olarewaju); Faculty of Medicine (Moore), University of British Columbia, Vancouver, BC; School of Public Health & Social Policy (Lachowsky), Faculty of Human & Social Development, University of Victoria, Victoria, BC; Department of Psychology (Armstrong), University of Southampton, Southampton, UK; Community-Based Research Centre (Jollimore), Vancouver, BC; Division of Infectious Diseases (Tan), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto, Toronto, Ont.; Department of Family Medicine (Lebouché), Faculty of Medicine, McGill University; Centre for Outcomes Research and Evaluation (Lebouché), Research Institute of the McGill University Health Centre; Centre de recherche du centre hospitalier de l'Université de Montréal (Tremblay); Institut national de santé publique du Québec (Lambert), Montréal, Que
| | - Gilles Lambert
- Department of Epidemiology, Biostatistics & Occupational Health (Cox, Moodie, Maheu-Giroux), McGill University; Direction régionale de santé publique, Centre intégré universitaire de santé et de services sociaux Centre-Sud-de-l'Ile-de-Montréal (Cox, Apelian, Messier-Peet, Lambert); Research Institute of the McGill University Health Centre (Apelian, Messier-Peet), Montréal, Que.; Department of Psychology (Hart, Skakoon-Sparling, Rodrigues, Noor), Ryerson University; Dalla Lana School of Public Health (Grace), University of Toronto, Toronto, Ont.; British Columbia Centre for Excellence in HIV/AIDS (Moore, Armstrong, Olarewaju); Faculty of Medicine (Moore), University of British Columbia, Vancouver, BC; School of Public Health & Social Policy (Lachowsky), Faculty of Human & Social Development, University of Victoria, Victoria, BC; Department of Psychology (Armstrong), University of Southampton, Southampton, UK; Community-Based Research Centre (Jollimore), Vancouver, BC; Division of Infectious Diseases (Tan), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto, Toronto, Ont.; Department of Family Medicine (Lebouché), Faculty of Medicine, McGill University; Centre for Outcomes Research and Evaluation (Lebouché), Research Institute of the McGill University Health Centre; Centre de recherche du centre hospitalier de l'Université de Montréal (Tremblay); Institut national de santé publique du Québec (Lambert), Montréal, Que
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Kawuma R, Ssemata AS, Bernays S, Seeley J. Women at high risk of HIV-infection in Kampala, Uganda, and their candidacy for PrEP. SSM Popul Health 2021; 13:100746. [PMID: 33604448 PMCID: PMC7873676 DOI: 10.1016/j.ssmph.2021.100746] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 11/26/2022] Open
Abstract
Pre-exposure prophylaxis (PrEP), antiretroviral medication for prevention of HIV-acquisition, is part of biomedical HIV prevention strategies recommended for people at risk of HIV-infection. A decision to take PrEP depends on an assessment of 'being at risk' either by an individual, or healthcare provider. In this paper, we draw on the concept of 'candidacy' to examine the different ways in which women attending a dedicated clinic in Kampala, Uganda, for women at risk of HIV infection (including sex workers), assessed their suitability for PrEP. We conducted in-depth interviews with 30 HIV negative women up to four different times, to gather information on the motives for taking PrEP, and their life history and daily life. All the women described the relevance of PrEP to mitigate their risk of HIV infection. However, there were challenges to adherence because of alcohol use, irregular working hours and a fear of being seen taking pills that others might assume to be HIV treatment. The ways in which the different women used PrEP and interpreted the place of PrEP in their lives were not solely based on their assessment of protecting themselves during sex work. They also used PrEP to guard against infection from their regular partners, and as a tool to allow them to make more money safely, by having sex without a condom with clients. While eligibility to access PrEP was predicated on the women's being in an 'at risk' population group, an incentive to use PrEP was to protect themselves from HIV acquisition from a long-term partner and preserve the 'trust' in their intimate relationship by having condom-less sex. Applying a candidacy lens we highlight the complexity in how women experience and present as being 'at risk' and query the criteria on which categories of risk and PrEP eligibility are determined.
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Affiliation(s)
- Rachel Kawuma
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | | | - Sarah Bernays
- School of Public Health, University of Sydney, Sydney, Australia
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Janet Seeley
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- School of Public Health, University of Sydney, Sydney, Australia
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Berendes S, Gubijev A, McCarthy OL, Palmer MJ, Wilson E, Free C. Sexual health interventions delivered to participants by mobile technology: a systematic review and meta-analysis of randomised controlled trials. Sex Transm Infect 2021; 97:190-200. [PMID: 33452130 DOI: 10.1136/sextrans-2020-054853] [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: 10/23/2020] [Revised: 12/10/2020] [Accepted: 12/22/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The use of mobile technologies to prevent STIs is recognised as a promising approach worldwide; however, evidence has been inconclusive, and the field has developed rapidly. With about 1 million new STIs a day globally, up-to-date evidence is urgently needed. OBJECTIVE To assess the effectiveness of mobile health interventions delivered to participants for preventing STIs and promoting preventive behaviour. METHODS We searched seven databases and reference lists of 49 related reviews (January 1990-February 2020) and contacted experts in the field. We included randomised controlled trials of mobile interventions delivered to adolescents and adults to prevent sexual transmission of STIs. We conducted meta-analyses and assessed risk of bias and certainty of evidence following Cochrane guidance. RESULTS After double screening 6683 records, we included 22 trials into the systematic review and 20 into meta-analyses; 18 trials used text messages, 3 used smartphone applications and 1 used Facebook messages as delivery modes. The certainty of evidence regarding intervention effects on STI/HIV occurrence and adverse events was low or very low. There was moderate certainty of evidence that in the short/medium-term text messaging interventions had little or no effect on condom use (standardised mean differences (SMD) 0.02, 95% CI -0.09 to 0.14, nine trials), but increased STI/HIV testing (OR 1.83, 95% CI 1.41 to 2.36, seven trials), although not if the standard-of-care control already contained an active text messaging component (OR 1.00, 95% CI 0.68 to 1.47, two trials). Smartphone application messages also increased STI/HIV testing (risk ratio 1.40, 95% CI 1.22 to 1.60, subgroup analysis, two trials). The effects on other outcomes or of social media or blended interventions is uncertain due to low or very low certainty evidence. CONCLUSIONS Text messaging interventions probably increase STI/HIV testing but not condom use in the short/medium term. Ongoing trials will report the effects on biological and other outcomes.
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Affiliation(s)
- Sima Berendes
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Anasztazia Gubijev
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Ona L McCarthy
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Melissa J Palmer
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Emma Wilson
- Population, Policy & Practice Department, Faculty of Population Health Sciences, University College London GOS Institute of Child Health, London, UK
| | - Caroline Free
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
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Goga A, Bekker LG, Van de Perre P, El-Sadr W, Ahmed K, Malahleha M, Ramraj T, Ramokolo V, Magasana V, Gray G. Centring adolescent girls and young women in the HIV and COVID-19 responses. Lancet 2020; 396:1864-1866. [PMID: 33271130 DOI: 10.1016/s0140-6736(20)32552-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Ameena Goga
- South African Medical Research Council, 7505 Cape Town, South Africa; Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa.
| | - Linda Gail Bekker
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Philippe Van de Perre
- Pathogenesis and Control of Chronic Infections, INSERM, Etablissement Français du Sang, University of Montpellier, CHU Montpellier, Montpellier, France
| | | | - Khatija Ahmed
- Setshaba Research Centre, Soshanguve, Pretoria, South Africa
| | | | - Trisha Ramraj
- South African Medical Research Council, 7505 Cape Town, South Africa
| | - Vundli Ramokolo
- South African Medical Research Council, 7505 Cape Town, South Africa
| | | | - Glenda Gray
- South African Medical Research Council, 7505 Cape Town, South Africa
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33
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Systematic Review of Interventions to Reduce HIV Risk Among Men Who Purchase Sex in Low- and Middle-Income Countries: Outcomes, Lessons Learned, and Opportunities for Future Interventions. AIDS Behav 2020; 24:3414-3435. [PMID: 32468354 DOI: 10.1007/s10461-020-02915-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Along with other partners of key population groups, men who purchase sex (MWPS) contributed to around 18% of new reported HIV cases in 2018 among people aged 15-49 years worldwide. A systematic review was performed to evaluate interventions conducted to reduce HIV risk among MWPS in low- and middle-income countries (LMICs). A comprehensive search of studies published in Embase, Medline, Global Health, Scopus, and Cinahl was performed. Among 32,115 studies found, 21 studies met the review's inclusion criteria. Only four studies recruited MWPS, while the rest recruited groups often used as proxy populations for MWPS. The interventions were made primarily to increase HIV-related knowledge or perceptions through education and to improve condom usage rates through promotion and distribution. Few studies evaluated the impact of interventions on HIV testing rates and none looked at HIV treatment. Given the important role of testing as a prevention gate, together with UNAIDS' 90-90-90 testing and treatment coverage goals for people infected with HIV, more studies which evaluate the impact of HIV testing and treatment provision among this group are needed.
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34
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Gangi MF, Karamouzian M, Nedjat S, Rahimi-Movaghar A, Yazdani K, Shokoohi M, Mirzazadeh A. HIV prevention cascades for injection and sexual risk behaviors among HIV-negative people who inject drug in Iran. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 84:102868. [PMID: 32717706 PMCID: PMC7738401 DOI: 10.1016/j.drugpo.2020.102868] [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: 12/09/2019] [Revised: 07/06/2020] [Accepted: 07/07/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The HIV prevention cascade complements the HIV treatment cascade and helps evaluate the access to and use of harm reduction programs among HIV-negative individuals at risk for HIV, including people who inject drugs (PWID). This study aimed to estimate the HIV prevention cascades among PWID in Iran. METHODS Using data from the 2014 national bio-behavioral surveillance survey, 2,391 PWID were recruited from 31 harm reduction facilities and through outreach efforts across 10 major cities. PWID aged ≥18 years who reported drug injection in the past year were interviewed, and information regarding their demographic characteristics, sexual and drug injection practices, and access to services were gathered. PWID were also tested for HIV infection. We examined the prevention cascade framework among HIV-negative PWID. RESULTS The majority of PWID were male (97.6%) and more than half aged ≥ 35 years old (55.5%). Overall, 2,092 (92.5% [95% CI: 90.8, 93.9]) were HIV-negative; 93% of whom knew illicit drug injection could increase the risk of HIV transmission, 54% had access to free-of-charge sterile needles and syringes, 51% used sterile needles and syringes in their last injection practice, and 33% used sterile needles and syringes in all injection practices in the past month. Also, 87.8% (95% CI: 85.1, 90.0) of HIV-negative PWID had sex with any partner in the past year; 88% of whom knew using condoms could reduce the risk of HIV transmission, 35% had access to free-of-charge condoms, 32% used condoms in their last sexual practice, and 18% used condoms in all of their sexual practices in the past month. CONCLUSION The majority of HIV-negative PWID in Iran were at risk for HIV acquisition through unsafe drug injection or sexual practices. Harm reduction programs should improve access to free sterile needles, syringes, and condoms for PWID.
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Affiliation(s)
- Monireh Faghir Gangi
- Department of Epidemiology and Biostatistics, School of public health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Karamouzian
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; 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
| | - Saharnaz Nedjat
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Afarin Rahimi-Movaghar
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran
| | - Kamran Yazdani
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Shokoohi
- 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; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - 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, Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA.
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HIV Preexposure Prophylaxis Cascades to Assess Implementation in Australia: Results From Repeated, National Behavioral Surveillance of Gay and Bisexual Men, 2014-2018. J Acquir Immune Defic Syndr 2020; 83:e16-e22. [PMID: 31913993 DOI: 10.1097/qai.0000000000002243] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND HIV prevention cascades can assist in monitoring the implementation of prevention methods like preexposure prophylaxis (PrEP). We developed 2 PrEP cascades for Australia's primary HIV-affected population, gay and bisexual men. METHODS Data were drawn from 2 national, repeated, cross-sectional surveys (the Gay Community Periodic Surveys and PrEPARE Project). One cascade had 3 steps, and the other had 7 steps. Trends over time were assessed using logistic regression. For the most recent year, we identified the biggest drop between steps in each cascade and compared the characteristics of men between the 2 steps using multivariate logistic regression. RESULTS Thirty-nine thousand six hundred and seventy non-HIV-positive men participated in the Periodic Surveys during 2014-2018. PrEP eligibility increased from 28.1% (1901/6762) in 2014 to 37.3% (2935/7878) in 2018 (P < 0.001), awareness increased from 29.6% (563/1901) to 87.1% (2555/2935; P < 0.001), and PrEP use increased from 3.7% (21/563) to 45.2% (1155/2555; P < 0.001). Of 1038 non-HIV-positive men in the PrEPARE Project in 2017, 54.2% (n = 563) were eligible for PrEP, 97.2% (547/563) were aware, 67.6% (370/547) were willing to use PrEP, 73.5% (272/370) had discussed PrEP with a doctor, 78.3% (213/272) were using PrEP, 97.2% (207/213) had recently tested, and 75.8% (157/207) reported reduced HIV concern and increased pleasure because of PrEP. The break point analyses indicated that PrEP coverage was affected by geographical availability, education level, employment, and willingness to use PrEP. CONCLUSIONS PrEP eligibility, awareness, and use have rapidly increased among Australian gay and bisexual men. The cascades identify disparities in uptake by eligible men as a result of socioeconomic factors and PrEP's acceptability.
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Cai M, Shah N, Li J, Chen WH, Cuomo RE, Obradovich N, Mackey TK. Identification and characterization of tweets related to the 2015 Indiana HIV outbreak: A retrospective infoveillance study. PLoS One 2020; 15:e0235150. [PMID: 32845882 PMCID: PMC7449407 DOI: 10.1371/journal.pone.0235150] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/20/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION From late 2014 through 2015, Scott County, Indiana faced an HIV outbreak triggered by opioid abuse and transition to injection drug use. Investigating the origins, risk factors, and responses related to this outbreak is critical to inform future surveillance, interventions, and policymaking. In response, this retrospective infoveillance study identifies and characterizes user-generated messages related to opioid abuse, heroin injection drug use, and HIV status using natural language processing (NLP) among Twitter users in Indiana during the period of this HIV outbreak. MATERIALS AND METHODS Our study consisted of two phases: data collection and processing, and data analysis. We collected Indiana geolocated tweets from the public Twitter API using Amazon Web Services EC2 instances filtered for geocoded messages in the immediate pre and post period of the outbreak. In the data analysis phase we applied an unsupervised machine learning approach using NLP called the Biterm Topic Model (BTM) to identify tweets related to opioid, heroin/injection, and HIV behavior and then examined these messages for HIV risk-related topics that could be associated with the outbreak. RESULTS More than 10 million geocoded tweets occurring in Indiana during the immediate pre and post period of the outbreak were collected for analysis. Using BTM, we identified 1350 tweets thought to be relevant to the outbreak and then confirmed 358 tweets using human annotation. The most prevalent themes identified were tweets related to self-reported abuse of illicit and prescription drugs, opioid use disorder, self-reported HIV status, and public sentiment regarding the outbreak. Geospatial analysis found that these messages clustered in population dense areas outside of the outbreak, including Indianapolis and neighboring Clark County. DISCUSSION This infoveillance study characterized the social media conversations of communities in Indiana in the pre and post period of the 2015 HIV outbreak. Behavioral themes detected reflect discussion about risk factors related to HIV transmission stemming from opioid and heroin abuse for priority populations, and also help identify community attitudes that could have motivated or detracted the use of HIV prevention methods, along with helping identify factors that can impede access to prevention services. CONCLUSIONS Infoveillance approaches, such as the analysis conducted in this study, represent a possibly strategy to detect "signal" of the emergence of risk factors associated with an outbreak though may be limited in their scope and generalizability. Our results, in conjunction with other forms of public health surveillance, can leverage the growing ubiquity of social media platforms to better detect opioid-related HIV risk knowledge, attitudes and behavior, as well as inform future prevention efforts.
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Affiliation(s)
- Mingxiang Cai
- Global Health Policy Institute, San Diego, CA, United States of America
- Department of Healthcare Research and Policy, University of California, San Diego, CA, United States of America
- Department of Computer Science and Engineering, University of California, San Diego, CA, United States of America
| | - Neal Shah
- Global Health Policy Institute, San Diego, CA, United States of America
- Department of Healthcare Research and Policy, University of California, San Diego, CA, United States of America
| | - Jiawei Li
- Global Health Policy Institute, San Diego, CA, United States of America
- Department of Healthcare Research and Policy, University of California, San Diego, CA, United States of America
- Department of Computational Science, Mathematics and Engineering, University of California, San Diego, CA, United States of America
| | - Wen-Hao Chen
- Department of Healthcare Research and Policy, University of California, San Diego, CA, United States of America
- Department of Computer Science and Engineering, University of California, San Diego, CA, United States of America
| | - Raphael E. Cuomo
- Global Health Policy Institute, San Diego, CA, United States of America
- Department of Anesthesiology, San Diego School of Medicine, University of California, San Diego, CA, United States of America
| | | | - Tim K. Mackey
- Global Health Policy Institute, San Diego, CA, United States of America
- Department of Healthcare Research and Policy, University of California, San Diego, CA, United States of America
- Department of Anesthesiology, San Diego School of Medicine, University of California, San Diego, CA, United States of America
- Division of Infections Disease and Global Public Health, Department of Medicine, San Diego School of Medicine, University of California, San Diego, CA, United States of America
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Virkud AV, Arimi P, Ssengooba F, Mulholland GE, Herce ME, Markiewicz M, Weir S, Edwards JK. Access to HIV prevention services in East African cross-border areas: a 2016-2017 cross-sectional bio-behavioural study. J Int AIDS Soc 2020; 23 Suppl 3:e25523. [PMID: 32602638 PMCID: PMC7325514 DOI: 10.1002/jia2.25523] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 03/11/2020] [Accepted: 04/23/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION East African cross-border areas are visited by mobile and vulnerable populations, such as men, female sex workers, men who have sex with men, truck drivers, fisher folks and young women. These groups may not benefit from traditional HIV prevention interventions available at the health facilities where they live, but may benefit from services offered at public venues identified as places where people meet new sexual partners (e.g. bars, nightclubs, transportation hubs and guest houses). The goal of this analysis was to estimate availability, access and uptake of prevention services by populations who visit these venues. METHODS We collected cross-sectional data using the Priorities for Local AIDS Control Efforts sampling method at cross-border locations near or along the land and lake borders of Kenya, Rwanda, Tanzania and Uganda from June 2016-February 2017. This bio-behavioural survey captured information from a probability sample of 11,428 individuals at 833 venues across all areas. Data were weighted using survey sampling weights and analysed using methods to account for the complex sampling design. RESULTS Among the 85.6% of persons who had access to condoms, 60.5% did not use a condom at their last anal or vaginal sexual encounter. Venues visited by high percentages of persons living with HIV were not more likely than other venues to offer condoms. In 12 of the 22 cross-border areas, male or female condoms were available at less than 33% of the venues visited by persons having difficulty accessing condoms. In 17 of the 22 cross-border areas, education outreach visits in the preceding six months occurred at less than 50% of the venues where participants had low effective use of condoms. CONCLUSIONS Individuals visiting venues in cross-border areas report poor access to and low effective use of condoms and other prevention services. Availability of HIV prevention services differed by venue and population type and cross-border area, suggesting opportunities for more granular targeting of HIV prevention interventions and transnational coordination of HIV programming.
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Affiliation(s)
- Arti V Virkud
- Department of EpidemiologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Peter Arimi
- U.S. Agency for International DevelopmentKenya/East Africa Regional MissionNairobiKenya
| | - Freddie Ssengooba
- College of Health SciencesSchool of Public HealthMakerere UniversityKampalaUganda
| | - Grace E Mulholland
- Department of EpidemiologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Michael E Herce
- Department of MedicineDivision of Infectious DiseasesUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Milissa Markiewicz
- MEASURE EvaluationCarolina Population CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Sharon Weir
- Department of EpidemiologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
- MEASURE EvaluationCarolina Population CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Jessie K Edwards
- Department of EpidemiologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
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Rice BD, de Wit M, Welty S, Risher K, Cowan FM, Murphy G, Chabata ST, Waruiru W, Magutshwa S, Motoku J, Kwaro D, Ochieng B, Reniers G, Rutherford G. Can HIV recent infection surveillance help us better understand where primary prevention efforts should be targeted? Results of three pilots integrating a recent infection testing algorithm into routine programme activities in Kenya and Zimbabwe. J Int AIDS Soc 2020; 23 Suppl 3:e25513. [PMID: 32602625 PMCID: PMC7325505 DOI: 10.1002/jia2.25513] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 03/24/2020] [Accepted: 04/22/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Surveillance of recent HIV infections in national testing services has the potential to inform primary prevention programming activities. Focusing on procedures required to accurately determine recent infection, and the potential for recent infection surveillance to inform prevention efforts, we present the results of three independent but linked pilots of recency testing. METHODS To distinguish recently acquired HIV infection from long-standing infection, in 2018 we applied a Recent Infection Testing Algorithm that combined a laboratory-based Limiting Antigen Avidity Enzyme Immunoassay with clinical information (viral-load; history of prior HIV diagnosis; antiretroviral therapy-exposure). We explored potential misclassification of test results and analysed the characteristics of participants with recent infection. We applied the algorithm in antenatal clinics providing prevention of mother-to-child transmission services in Siaya County, Kenya, outreach sites serving female sex workers in Zimbabwe, and routine HIV testing and counselling facilities in Nairobi, Kenya. In Nairobi, we also conducted recency testing among partners of HIV-positive participants. RESULTS In Siaya County, 2.3% (10/426) of HIV-positive pregnant women were classified as recent. A risk factor analysis comparing women testing recent with those testing HIV-negative found women in their first trimester were significantly more likely to test recent than those in their second or third trimester. In Zimbabwe, 10.5% (33/313) of female sex workers testing HIV-positive through the outreach programme were classified recent. A risk factor analysis of women testing recent versus those testing HIV-negative, found no strong evidence of an association with recent infection. In Nairobi, among 532 HIV-positive women and men, 8.6% (46) were classified recent. Among partners of participants, almost a quarter of those who tested HIV-positive were classified as recent (23.8%; 5/21). In all three settings, the inclusion of clinical information helped improve the positive predictive value of recent infection testing by removing cases that were likely misclassified. CONCLUSIONS We successfully identified recently acquired infections among persons testing HIV-positive in routine testing settings and highlight the importance of incorporating additional information to accurately classify recent infection. We identified a number of groups with a significantly higher proportion of recent infection, suggesting recent infection surveillance, when rolled-out nationally, may help in further targeting primary prevention efforts.
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Affiliation(s)
- Brian D Rice
- London School of Hygiene & Tropical MedicineLondonUK
| | | | | | | | - Frances M Cowan
- Centre for Sexual Health and HIV/AIDS ResearchHarareZimbabwe
| | - Gary Murphy
- Independent consultant in HIV laboratory diagnosticsLondonUK
| | | | | | | | - John Motoku
- Eastern Deanery AIDS Relief ProgrammeNairobiKenya
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Hargreaves JR, Auerbach JD, Hensen B, Johnson S, Gregson S. Strengthening primary HIV prevention: better use of data to improve programmes, develop strategies and evaluate progress. J Int AIDS Soc 2020; 23 Suppl 3:e25538. [PMID: 32602656 PMCID: PMC7325501 DOI: 10.1002/jia2.25538] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 11/26/2022] Open
Affiliation(s)
- James R Hargreaves
- Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Judith D Auerbach
- Department of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Bernadette Hensen
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Saul Johnson
- Health PracticeGenesis AnalyticsJohannesburgSouth Africa
| | - Simon Gregson
- Faculty of MedicineImperial College LondonLondonUnited Kingdom
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Hill LM, Maseko B, Chagomerana M, Hosseinipour MC, Bekker L, Pettifor A, Rosenberg NE. HIV risk, risk perception, and PrEP interest among adolescent girls and young women in Lilongwe, Malawi: operationalizing the PrEP cascade. J Int AIDS Soc 2020; 23 Suppl 3:e25502. [PMID: 32602649 PMCID: PMC7325511 DOI: 10.1002/jia2.25502] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 03/12/2020] [Accepted: 04/06/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION As a user-controlled HIV prevention method, oral pre-exposure prophylaxis (PrEP) holds particular promise for adolescent girls and young women (AGYW). HIV prevention cascades, critical frameworks for the design and evaluation of PrEP programmes, outline the priorities of identifying individuals at greatest HIV risk and motivating them to initiate PrEP through perceived HIV risk. To inform future iterations of these cascades and PrEP delivery for AGYW, the objective of this study was to understand the level of interest in PrEP among AGYW at highest HIV risk, and the potential role of perceived risk in motivating PrEP interest. METHODS Using data from a cohort study of HIV-negative AGYW in Lilongwe, Malawi (February 2016 to August 2017), we assessed the relationship between epidemiologic HIV risk (risk index developed in a previous analysis) and PrEP interest, and the extent to which perceived risk explains the relationship between HIV risk and PrEP interest. We further aimed to operationalize the pre-initiation steps of the HIV prevention cascade in the study population. RESULTS In total, 825 AGYW were included in analyses, of which 43% met the criterion for high epidemiologic HIV risk. While epidemiologic risk scores were positively associated with PrEP interest, high numbers of AGYW both above and below the high-risk cutoff were very interested in PrEP (68% vs. 63%). Perceived risk partially explained the relationship between HIV risk and PrEP interest; greater epidemiologic HIV risk was associated with high perceived risk, which was in turn associated with PrEP interest. Many more high-risk AGYW were interested in PrEP (68%) than expressed a high level of perceived HIV risk (26%). CONCLUSIONS These results highlight key relationships between epidemiologic HIV risk, risk perception and interest in PrEP. While risk perception did partially explain the relationship between epidemiologic risk and PrEP interest, there may be other important motivational mechanisms that are not captured in many HIV prevention cascades. The high number of participants with risk scores below the high-risk cutoff who both expressed high perceived risk and interest in PrEP suggests that demand for PrEP among AGYW may not be well aligned with epidemiologic risk.
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Affiliation(s)
- Lauren M Hill
- Department of Health BehaviorUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Cecil G. Sheps Center for Health Services ResearchUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | | | - Maganizo Chagomerana
- UNC Project‐MalawiLilongweMalawi
- Institute for Global Health and Infectious DiseasesUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Mina C Hosseinipour
- UNC Project‐MalawiLilongweMalawi
- Institute for Global Health and Infectious DiseasesUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Linda‐Gail Bekker
- Desmond Tutu HIV CentreUCTFaculty of Health SciencesCape TownSouth Africa
| | - Audrey Pettifor
- Department of EpidemiologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Nora E Rosenberg
- Department of Health BehaviorUniversity of North Carolina at Chapel HillChapel HillNCUSA
- UNC Project‐MalawiLilongweMalawi
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Auerbach JD, Gerritsen AAM, Dallabetta G, Morrison M, Garnett GP. A tale of two cascades: promoting a standardized tool for monitoring progress in HIV prevention. J Int AIDS Soc 2020; 23 Suppl 3:e25498. [PMID: 32602653 PMCID: PMC7325507 DOI: 10.1002/jia2.25498] [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: 10/01/2019] [Revised: 03/11/2020] [Accepted: 04/06/2020] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION To achieve significant progress in global HIV prevention from 2020 onward, it is essential to ensure that appropriate programmes are being delivered with high quality and sufficient intensity and scale and then taken up by the people who most need and want them in order to have both individual and public health impact. Yet, currently, there is no standard way of assessing this. Available HIV prevention indicators do not provide a logical set of measures that combine to show reduction in HIV incidence and allow for comparison of success (or failure) of HIV prevention programmes and for monitoring progress in meeting global targets. To redress this, attention increasingly has turned to the prospects of devising an HIV prevention cascade, similar to the now-standard HIV treatment cascade; but this has proven to be a controversial enterprise, chiefly due to the complexity of primary prevention. DISCUSSION We address a number of core issues attendant with devising prevention cascades, including: determining the population of interest and accounting for the variability and fluidity of HIV-related risk within it; the fact that there are multiple HIV prevention methods, and many people are exposed to a package of them, rather than a single method; and choosing the final step (outcome) in the cascade. We propose two unifying models of prevention cascades-one more appropriate for programme managers and monitors and the other for researchers and programme developers-and note their relationship. We also provide some considerations related to cascade data quality and improvement. CONCLUSIONS The HIV prevention field has been grappling for years with the idea of developing a standardised way to regularly assess progress and to monitor and improve programmes accordingly. The cascade provides the potential to do this, but it is complicated and highly nuanced. We believe the two models proposed here reflect emerging consensus among the range of stakeholders who have been engaging in this discussion and who are dedicated to achieving global HIV prevention goals by ensuring the most appropriate and effective programmes and methods are supported.
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Affiliation(s)
- Judith D Auerbach
- Department of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | | | - Gina Dallabetta
- HIV DeliveryTB/HIV TeamBill & Melinda Gates FoundationWashingtonDCUSA
| | - Michelle Morrison
- HIV Epidemiology and SurveillanceBill & Melinda Gates FoundationSeattleWAUSA
| | - Geoffrey P Garnett
- Data and MetricsTB/HIV TeamBill & Melinda Gates FoundationSeattleWAUSA
- Department of Global HealthUniversity of Washington SeattleSeattleWAUSA
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Ramautarsing RA, Meksena R, Sungsing T, Chinbunchorn T, Sangprasert T, Fungfoosri O, Meekrua D, Sumalu S, Pasansai T, Bunainso W, Wongsri T, Mainoy N, Colby D, Avery M, Mills S, Vannakit R, Phanuphak P, Phanuphak N. Evaluation of a pre-exposure prophylaxis programme for men who have sex with men and transgender women in Thailand: learning through the HIV prevention cascade lens. J Int AIDS Soc 2020; 23 Suppl 3:e25540. [PMID: 32602660 PMCID: PMC7325508 DOI: 10.1002/jia2.25540] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 05/04/2020] [Accepted: 05/11/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Men who have sex with men (MSM) and transgender women (TGW) are two key populations (KPs) in Thailand at high risk for HIV. Uptake and scale-up of pre-exposure prophylaxis (PrEP) among them has been slow. We used data from Princess PrEP, Thailand's largest KP-led PrEP programme, to operationalize PrEP service cascades. We identified gaps and pointed out where additional data are needed to inform a larger HIV prevention cascade. METHODS Numbers of people tested for HIV, tested HIV negative, eligible for PrEP (defined as any of the following in the past three months: condomless sex with partners of unknown/uncertain HIV status or antiretroviral treatment or viral load status, multiple partners, engaging in sex work, sexually transmitted infections, injecting drugs, using amphetamine-type stimulants, or repeated use of post-exposure prophylaxis), offered PrEP and accepted PrEP during January to November 2019 were retrieved from Princess PrEP database to inform PrEP service cascades for MSM and TGW. Reasons for not accepting PrEP were documented. RESULTS Of 6287 MSM who received HIV testing in Princess PrEP, 92.3% were HIV negative and 70.2% of them were eligible for PrEP. PrEP was offered to 94.7% of those eligible and 48.0% of those offered accepted it. Among 900 TGW who had HIV testing, 95.3% tested HIV negative and 64.8% of them met PrEP eligibility criteria. Of these, 95.0% were offered PrEP and 43.9% of them accepted it. Among MSM and TGW who met PrEP eligibility criteria, no or low-HIV-risk perception was the most common reason provided (46.7% of 2007 MSM and 41.9% of 296 TGW) for not accepting PrEP. CONCLUSIONS PrEP service cascades from the Princess PrEP programme identified no or low-risk perception as key barrier to PrEP acceptance among MSM and TGW who met PrEP eligibility criteria. More implementation research studies are needed to explore PrEP motivation and access in larger communities outside of clinical services. This is to identify gaps and strategies to address them within motivation, access and effective use domains of the HIV prevention cascade.
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Affiliation(s)
| | | | | | | | | | | | | | - Saman Sumalu
- Service Workers in Group FoundationBangkokThailand
| | | | | | | | | | - Donn Colby
- Thai Red Cross AIDS Research CentreSEARCHBangkokThailand
| | | | | | - Ravipa Vannakit
- Office of Public HealthUnited States Agency for International DevelopmentBangkokThailand
| | | | - Nittaya Phanuphak
- Thai Red Cross AIDS Research CentrePREVENTIONBangkokThailand
- Thai Red Cross AIDS Research CentreSEARCHBangkokThailand
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Wall KM, Inambao M, Kilembe W, Karita E, Chomba E, Vwalika B, Mulenga J, Parker R, Sharkey T, Tichacek A, Hunter E, Yohnka R, Streeb G, Corso PS, Allen S. Cost-effectiveness of couples' voluntary HIV counselling and testing in six African countries: a modelling study guided by an HIV prevention cascade framework. J Int AIDS Soc 2020; 23 Suppl 3:e25522. [PMID: 32602618 PMCID: PMC7325504 DOI: 10.1002/jia2.25522] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 03/17/2020] [Accepted: 04/23/2020] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Couples' voluntary HIV counselling and testing (CVCT) is a high-impact HIV prevention intervention in Rwanda and Zambia. Our objective was to model the cost-per-HIV infection averted by CVCT in six African countries guided by an HIV prevention cascade framework. The HIV prevention cascade as yet to be applied to evaluating CVCT effectiveness or cost-effectiveness. METHODS We defined a priority population for CVCT in Africa as heterosexual adults in stable couples. Based on our previous experience nationalizing CVCT in Rwanda and scaling-up CVCT in 73 clinics in Zambia, we estimated HIV prevention cascade domains of motivation for use, access and effectiveness of CVCT as model parameters. Costs-per-couple tested were also estimated based on our previous studies. We used these parameters as well as country-specific inputs to model the impact of CVCT over a five-year time horizon in a previously developed and tested deterministic compartmental model. We consider six countries across Africa with varied HIV epidemics (South Africa, Zimbabwe, Kenya, Tanzania, Ivory Coast and Sierra Leone). Outcomes of interest were the proportion of HIV infections averted by CVCT, nationwide CVCT implementation costs and costs-per-HIV infection averted by CVCT. We applied 3%/year discounting to costs and outcomes. Univariate and Monte Carlo multivariate sensitivity analyses were conducted. RESULTS We estimated that CVCT could avert between 54% (Sierra Leone) and 62% (South Africa) of adult HIV infections. Average costs-per-HIV infection averted were lowest in Zimbabwe ($550) and highest in South Africa ($1272). Nationwide implementations would cost between 7% (Kenya) and 21% (Ivory Coast) of a country's President's Emergency Plan for AIDS Relief (PEPFAR) budget over five years. In sensitivity analyses, model outputs were most sensitive to estimates of cost-per-couple tested; the proportion of adults in heterosexual couples and HIV prevention cascade domains of CVCT motivation and access. CONCLUSIONS Our model indicates that nationalized CVCT could prevent over half of adult HIV infections for 7% to 21% of the modelled countries' five-year PEPFAR budgets. While other studies have indicated that CVCT motivation is high given locally relevant promotional and educational efforts, without required indicators, targets and dedicated budgets, access remains low.
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Affiliation(s)
- Kristin M Wall
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
- Department of EpidemiologyRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
| | - Mubiana Inambao
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
- Department of Obstetrics and GynecologyNdola Central HospitalNdolaZambia
| | - William Kilembe
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
| | - Etienne Karita
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
| | | | - Bellington Vwalika
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
- Department of Obstetrics and GynecologySchool of MedicineUniversity of ZambiaLusakaZambia
| | - Joseph Mulenga
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
| | - Rachel Parker
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
| | - Tyronza Sharkey
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
| | - Amanda Tichacek
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
| | - Eric Hunter
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
- Department of Pathology & Laboratory MedicineSchool of MedicineEmory UniversityAtlantaGAUSA
- Emory Vaccine CenterYerkes National Primate Research CenterEmory UniversityAtlantaGAUSA
| | - Robert Yohnka
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
| | - Gordon Streeb
- Departments of Economics and Political ScienceEmory UniversityAtlantaGAUSA
| | | | - Susan Allen
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
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Sibanda EL, Webb K, Fahey CA, Kang Dufour M, McCoy SI, Watadzaushe C, Dirawo J, Deda M, Chimwaza A, Taramusi I, Mushavi A, Mukungunugwa S, Padian N, Cowan FM. Use of data from various sources to evaluate and improve the prevention of mother-to-child transmission of HIV programme in Zimbabwe: a data integration exercise. J Int AIDS Soc 2020; 23 Suppl 3:e25524. [PMID: 32602644 PMCID: PMC7325515 DOI: 10.1002/jia2.25524] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 03/13/2020] [Accepted: 04/23/2020] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Despite improvements in prevention of mother-to-child transmission (PMTCT) of HIV outcomes, there remain unacceptably high numbers of mother-to-child transmissions (MTCT) of HIV. Programmes and research collect multiple sources of PMTCT data, yet this data is rarely integrated in a systematic way. We conducted a data integration exercise to evaluate the Zimbabwe national PMTCT programme and derive lessons for strengthening implementation and documentation. METHODS We used data from four sources: research, Ministry of Health and Child Care (MOHCC) programme, Implementer - Organization for Public Health Interventions and Development, and modelling. Research data came from serial population representative cross-sectional surveys that evaluated the national PMTCT programme in 2012, 2014 and 2017/2018. MOHCC and Organization for Public Health Interventions and Development collected data with similar indicators for the period 2018 to 2019. Modelling data from 2017/18 UNAIDS Spectrum was used. We systematically integrated data from the different sources to explore PMTCT programme performance at each step of the cascade. We also conducted spatial analysis to identify hotspots of MTCT. RESULTS We developed cascades for HIV-positive and negative-mothers, and HIV exposed and infected infants to 24 months post-partum. Most data were available on HIV positive mothers. Few data were available 6-8 weeks post-delivery for HIV exposed/infected infants and none were available post-delivery for HIV-negative mothers. The different data sources largely concurred. Antenatal care (ANC) registration was high, although women often presented late. There was variable implementation of PMTCT services, MTCT hotspots were identified. Factors positively associated with MTCT included delayed ANC registration and mobility (use of more than one health facility) during pregnancy/breastfeeding. There was reduced MTCT among women whose partners accompanied them to ANC, and infants receiving antiretroviral prophylaxis. Notably, the largest contribution to MTCT was from postnatal women who had previously tested negative (12/25 in survey data, 17.6% estimated by Spectrum modelling). Data integration enabled formulation of interventions to improve programmes. CONCLUSIONS Data integration was feasible and identified gaps in programme implementation/documentation leading to corrective interventions. Incident infections among mothers are the largest contributors to MTCT: there is need to strengthen the prevention cascade among HIV-negative women.
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Affiliation(s)
- Euphemia L Sibanda
- Centre for Sexual Health and HIV AIDS ResearchHarareZimbabwe
- Liverpool School of Tropical MedicineLiverpoolUK
| | - Karen Webb
- Organization for Public Health Interventions and Development (OPHID)HarareZimbabwe
- London School of Hygiene and Tropical MedicineLondonUK
| | | | | | | | | | - Jeffrey Dirawo
- Centre for Sexual Health and HIV AIDS ResearchHarareZimbabwe
| | - Marsha Deda
- Organization for Public Health Interventions and Development (OPHID)HarareZimbabwe
| | - Anesu Chimwaza
- Ministry of Health and Child Care, ZimbabweHarareZimbabwe
| | | | - Angela Mushavi
- Ministry of Health and Child Care, ZimbabweHarareZimbabwe
| | | | | | - Frances M Cowan
- Centre for Sexual Health and HIV AIDS ResearchHarareZimbabwe
- Liverpool School of Tropical MedicineLiverpoolUK
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Chabata ST, Hensen B, Chiyaka T, Mushati P, Busza J, Floyd S, Birdthistle I, Hargreaves JR, Cowan FM. Condom use among young women who sell sex in Zimbabwe: a prevention cascade analysis to identify gaps in HIV prevention programming. J Int AIDS Soc 2020; 23 Suppl 3:e25512. [PMID: 32602611 PMCID: PMC7325503 DOI: 10.1002/jia2.25512] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 03/31/2020] [Accepted: 04/22/2020] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Adolescent girls and young women (AGYW), including those who sell sex in sub-Saharan Africa, are especially vulnerable to HIV. Reaching them with effective prevention is a programmatic priority. The HIV prevention cascade can be used to track intervention coverage, and identify gaps and opportunities for programme strengthening. The aim of this study was to characterise gaps in condom use and identify reasons underlying these gaps among young women who sell sex (YWSS) in Zimbabwe using data from enrolment into an impact evaluation of the DREAMS programme. DREAMS provided a package of biomedical, social and economic interventions to AGYW aged 10 to 24 with the aim of reducing HIV incidence. METHODS In 2017, we recruited YWSS aged 18 to 24 using respondent-driven sampling in six sites across Zimbabwe. We measured knowledge about efficacy of, access to, and effective (consistent) use of condoms with the most recent three sexual partners, separately by whether YWSS self-identified as female sex workers (FSW) or not. Among YWSS without knowledge about efficacy of, not having access to, and not effectively using condoms, we described the potential reasons underlying the gaps in the condom cascade. To identify socio-demographic characteristics associated with effective condom use, we used logistic regression modelling. All analyses were RDS-II weighted and restricted to YWSS testing HIV-negative at enrolment. RESULTS We enrolled 2431 YWSS. Among 1842 (76%) YWSS testing HIV-negative, 66% (n = 1221) self-identified as FSW. 89% of HIV-negative YWSS demonstrated knowledge about efficacy of condoms, 80% reported access to condoms and 58% reported using condoms consistently with the three most recent sexual partners. Knowledge about efficacy of and effective use of condoms was similar regardless of whether or not YWSS self-identified as FSW, but YWSS self-identifying as FSW reported better access to condoms compared to those who did not (87% vs 68%; age- and site-adjusted (adjOR) = 2.69; 95% CI: 2.01 to 3.60; p < 0.001). Women who reported experiencing sexual violence in the past year and common mental disorder in the past week were less likely to use condoms consistently (43% vs. 60%; adjOR = 0.49; 95% CI: 0.35 to 0.68; p < 0.001) and (51% vs. 61%; adjOR = 0.76; 95% CI: 0.60 to 0.97; p = 0.029), respectively. CONCLUSIONS Despite high knowledge about efficacy of and access to condoms, there remain large gaps in self-reported consistent condom use among YWSS. Addressing the structural determinants of YWSS' inconsistent condom use, including violence, could reduce this gap. YWSS who do not self-identify as FSW have less access to condoms and may require additional programmatic intervention.
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Affiliation(s)
- Sungai T Chabata
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) ZimbabweHarareZimbabwe
| | - Bernadette Hensen
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Tarisai Chiyaka
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) ZimbabweHarareZimbabwe
| | - Phillis Mushati
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) ZimbabweHarareZimbabwe
| | - Joanna Busza
- Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Sian Floyd
- Faculty of Epidemiology and Population HealthLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Isolde Birdthistle
- Faculty of Epidemiology and Population HealthLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - James R Hargreaves
- Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Frances M Cowan
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) ZimbabweHarareZimbabwe
- Faculty of Clinical Sciences and International Public HealthLiverpool School of Tropical MedicineLiverpoolUnited Kingdom
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Dumchev K, Sazonova Y, Smyrnov P, Cheshun O, Pashchuk O, Saliuk T, Varetska O. Operationalizing the HIV prevention cascade for PWID using the integrated bio-behavioural survey data from Ukraine. J Int AIDS Soc 2020; 23 Suppl 3:e25509. [PMID: 32602659 PMCID: PMC7325510 DOI: 10.1002/jia2.25509] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 03/17/2020] [Accepted: 04/20/2020] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION People who inject drugs (PWID) remain at high risk of HIV in many countries. The HIV prevention cascades have been proposed to replicate the success of the treatment cascades and reinvigorate the prevention programmes through improved monitoring, planning and delivery. We adapted the cascade framework to the PWID context in Ukraine, assessed gaps and analysed factors associated with achieving "access" and "effective use" outcomes. METHODS Self-reported data on the use of prevention services and risk behaviours from the 2017 integrated bio-behavioural survey among PWID in Ukraine were used to construct cascades for needle/syringe and condom programmes (NSP and CP). Socio-demographic and behavioural variables were evaluated as potential correlates of cascade outcomes. RESULTS The NSP cascade analysis included 7815 HIV-negative PWID. Motivation to use clean syringes was not assessed and assumed at 100%. Access to clean syringes through NSP in the past 12 months was reported by 2789 participants (35.7%). Effective use of syringes (no sharing in the past 30 days) was reported by 7405 participants (94.8%). NSP access was higher among women, individuals older than 44, and mixed drug users; while effective use was reported more frequently by men and opioid users, with no difference by age. The CP cascade analysis included 6606 (85%) of the HIV-negative PWID who had sex in the past three months. Of those, 2282 (34.5%) received condoms, and 1708 (25.9%) reported consistent use with all partners in the past three months. Older PWID and mixed-drug users accessed condoms more frequently; whereas younger subgroups and opioid users used them more consistently. CONCLUSIONS Overall, the cascade framework was useful to describe the status of HIV prevention among PWID in Ukraine and to identify areas for improvement in the programming and evaluation of HIV prevention. Access to needle/syringe and condom programmes was substantially below the recommended levels. Effective use of clean syringes was reported by a vast majority of PWID, although likely affected by self-report bias; whereas consistent condom use was infrequent. Socio-demographic and behavioural variables showed significant associations in NSP and CP cascade analyses, with little consistency between the access and effective use outcomes.
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Shahmanesh M, Harling G, Coltart CEM, Bailey H, King C, Gibbs J, Seeley J, Phillips A, Sabin CA, Aldridge RW, Sonnenberg P, Hart G, Rowson M, Pillay D, Johnson AM, Abubakar I, Field N. From the micro to the macro to improve health: microorganism ecology and society in teaching infectious disease epidemiology. THE LANCET. INFECTIOUS DISEASES 2020; 20:e142-e147. [PMID: 32386611 PMCID: PMC7252039 DOI: 10.1016/s1473-3099(20)30136-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 02/14/2020] [Accepted: 02/18/2020] [Indexed: 12/21/2022]
Abstract
Chronic and emerging infectious diseases and antimicrobial resistance remain a substantial global health threat. Microbiota are increasingly recognised to play an important role in health. Infections also have a profound effect beyond health, especially on global and local economies. To maximise health improvements, the field of infectious disease epidemiology needs to derive learning from ecology and traditional epidemiology. New methodologies and tools are transforming understanding of these systems, from a better understanding of socioeconomic, environmental, and cultural drivers of infection, to improved methods to detect microorganisms, describe the immunome, and understand the role of human microbiota. However, exploiting the potential of novel methods to improve global health remains elusive. We argue that to exploit these advances a shift is required in the teaching of infectious disease epidemiology to ensure that students are well versed in a breadth of disciplines, while maintaining core epidemiological skills. We discuss the following key points using a series of teaching vignettes: (1) integrated training in classic and novel techniques is needed to develop future scientists and professionals who can work from the micro (interactions between pathogens, their cohabiting microbiota, and the host at a molecular and cellular level), with the meso (the affected communities), and to the macro (wider contextual drivers of disease); (2) teach students to use a team-science multidisciplinary approach to effectively integrate biological, clinical, epidemiological, and social tools into public health; and (3) develop the intellectual skills to critically engage with emerging technologies and resolve evolving ethical dilemmas. Finally, students should appreciate that the voices of communities affected by infection need to be kept at the heart of their work.
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Affiliation(s)
- Maryam Shahmanesh
- Institute for Global Health, University College London, London, UK; Africa Health Research Institute, Durban, South Africa.
| | - Guy Harling
- Institute for Global Health, University College London, London, UK; Africa Health Research Institute, Durban, South Africa; MRC/Wits-Agincourt Unit, University of the Witwatersrand, Johannesburg, South Africa; Harvard Centre for Population and Development Studies, Harvard T H Chan School of Public Health, Boston, MA, USA
| | | | - Heather Bailey
- Institute for Global Health, University College London, London, UK
| | - Carina King
- Institute for Global Health, University College London, London, UK; Department of Public Health Sciences, Karolinska Institutet, Solna, Sweden
| | - Jo Gibbs
- Institute for Global Health, University College London, London, UK
| | - Janet Seeley
- Africa Health Research Institute, Durban, South Africa; London School of Hygiene and Tropical Medicine, London, UK
| | - Andrew Phillips
- Institute for Global Health, University College London, London, UK
| | - Caroline A Sabin
- Institute for Global Health, University College London, London, UK
| | - Robert W Aldridge
- Institute of Health Informatics, University College London, London, UK
| | - Pam Sonnenberg
- Institute for Global Health, University College London, London, UK
| | - Graham Hart
- Institute for Global Health, University College London, London, UK
| | - Mike Rowson
- Institute for Global Health, University College London, London, UK
| | - Deenan Pillay
- Division of infection and immunity, University College London, London, UK; Africa Health Research Institute, Durban, South Africa
| | - Anne M Johnson
- Institute for Global Health, University College London, London, UK
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK
| | - Nigel Field
- Institute for Global Health, University College London, London, UK
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Thomas R, Skovdal M, Galizzi MM, Schaefer R, Moorhouse L, Nyamukapa C, Maswera R, Mandizvidza P, Hallett TB, Gregson S. Improving risk perception and uptake of voluntary medical male circumcision with peer-education sessions and incentives, in Manicaland, East Zimbabwe: study protocol for a pilot randomised trial. Trials 2020; 21:108. [PMID: 31973744 PMCID: PMC6979356 DOI: 10.1186/s13063-020-4048-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 01/06/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Voluntary medical male circumcision (VMMC) is a key component of combination HIV-prevention programmes. Several high-HIV-prevalence countries in sub-Saharan Africa, including Zimbabwe, are looking to scale up VMMC activities. There is limited evidence on how a combination of social learning from peer education by a role model with different behavioural incentives influences demand for VMMC in such settings. METHODS/DESIGN This matched-cluster randomised controlled trial with 1740 participants will compare two behavioural incentives against a control with no intervention. In the intervention clusters, participants will participate in an education session delivered by a circumcised young male ("role model") on the risks of HIV infection and the benefits from medical male circumcision. All participants will receive contributions towards transport costs to access medical male circumcision at participating clinics. Via blocked randomisation, in the intervention clusters participants will be randomly assigned to receive one of two types of incentives - fixed cash payment or lottery payment - both conditional on undergoing surgical VMMC. In two sites, a community-led intervention will also be implemented to address social obstacles and to increase support from peers, families and social structures. Baseline measures of endpoints will be gathered in surveys. Follow-up assessment at 6 months will include self-reported uptake of VMMC triangulated with clinic data. DISCUSSION This is the first trial to pilot-test social learning to improve risk perception and self-efficacy and to address the fear of pain associated with VMMC and possible present-biased preferences with front-loaded compensations as well as fixed or lottery-based cash payments. This study will generate important knowledge to inform HIV-prevention policies about the effectiveness of behavioural interventions and incentives, which could be easily scaled-up. TRIAL REGISTRATION This trial has been registered on ClinicalTrials.gov (identifier: NCT03565588). Registered on 21 June 2018.
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Affiliation(s)
- Ranjeeta Thomas
- Department of Health Policy, London School of Economics and Political Science, Cowdray House, London, WC2 2AE UK
| | - Morten Skovdal
- Section of Health Services Research, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5 opg, B, Postb 15, Building: 15.0.17, 1014 København K, Denmark
| | - Matteo M. Galizzi
- Department of Psychological and Behavioural Science, London School of Economics and Political Science, London, WC2 2AE UK
| | - Robin Schaefer
- Department of Infectious Disease Epidemiology, Imperial College London, St Mary’s Campus Norfolk Place, London, W2 1PG UK
| | - Louisa Moorhouse
- Department of Infectious Disease Epidemiology, Imperial College London, St Mary’s Campus Norfolk Place, London, W2 1PG UK
| | - Constance Nyamukapa
- Department of Infectious Disease Epidemiology, Imperial College London, St Mary’s Campus Norfolk Place, London, W2 1PG UK
- Biomedical Research and Training Institute, 10 Seagrave, Avondale, Harare, Zimbabwe
| | - Rufurwokuda Maswera
- Biomedical Research and Training Institute, 10 Seagrave, Avondale, Harare, Zimbabwe
| | - Phyllis Mandizvidza
- Biomedical Research and Training Institute, 10 Seagrave, Avondale, Harare, Zimbabwe
| | - Timothy B. Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, St Mary’s Campus Norfolk Place, London, W2 1PG UK
| | - Simon Gregson
- Department of Infectious Disease Epidemiology, Imperial College London, St Mary’s Campus Norfolk Place, London, W2 1PG UK
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Thomas R, Skovdal M, Galizzi MM, Schaefer R, Moorhouse L, Nyamukapa C, Maswera R, Mandizvidza P, Hallett TB, Gregson S. Improving risk perception and uptake of pre-exposure prophylaxis (PrEP) through interactive feedback-based counselling with and without community engagement in young women in Manicaland, East Zimbabwe: study protocol for a pilot randomized trial. Trials 2019; 20:668. [PMID: 31791405 PMCID: PMC6889525 DOI: 10.1186/s13063-019-3791-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 10/05/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND HIV incidence in adolescent girls and young women remains high in sub-Saharan Africa. Progress towards uptake of HIV prevention methods remains low. Studies of oral pre-exposure prophylaxis (PrEP) have shown that uptake and adherence may be low due to low-risk perception and ambivalence around using antiretrovirals for prevention. No evidence exists on whether an interactive intervention aimed at adjusting risk perception and addressing the uncertainty around PrEP will improve uptake. This pilot research trial aims to provide an initial evaluation of the impact of an interactive digital tablet-based counselling session, correcting risk perception, and addressing ambiguity around availability, usability, and effectiveness of PrEP. METHODS/DESIGN This is a matched-cluster randomized controlled trial which will compare an interactive tablet-based education intervention against a control with no intervention. The study will be implemented in eight sites. In each site, two matched clusters of villages will be created. One cluster will be randomly allocated to intervention. In two sites, a community engagement intervention will also be implemented to address social obstacles and to increase support from peers, families, and social structures. A total of 1200 HIV-negative young women aged 18-24 years, not on PrEP at baseline, will be eligible. Baseline measures of endpoints will be gathered in surveys. Follow-up assessment at six months will include biomarkers of PrEP uptake and surveys. DISCUSSION This will be the first randomized controlled trial to determine whether interactive feedback counselling leads to uptake of HIV prevention methods such as PrEP and reduces risky sexual behavior. If successful, policymakers could consider such an intervention in school-based education campaigns or as post-HIV-testing counselling for young people. TRIAL REGISTRATION Clinicaltrials.gov, NCT03565575. Registered on 21 June 2018.
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Affiliation(s)
- Ranjeeta Thomas
- Department of Health Policy, London School of Economics and Political Science, Cowdray House, London, WC2 2AE UK
| | - Morten Skovdal
- Section of Health Services Research, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5 opg. B, Postb, 15, Building: 15.0.17, 1014 København K, Denmark
| | - Matteo M. Galizzi
- Department of Psychological and Behavioural Science, London School of Economics and Political Science, London, WC2 2AE UK
| | - Robin Schaefer
- Department of Infectious Disease Epidemiology, Imperial College London, St Mary’s Campus Norfolk Place, London, W2 1PG UK
| | - Louisa Moorhouse
- Department of Infectious Disease Epidemiology, Imperial College London, St Mary’s Campus Norfolk Place, London, W2 1PG UK
| | - Constance Nyamukapa
- Department of Infectious Disease Epidemiology, Imperial College London, St Mary’s Campus Norfolk Place, London, W2 1PG UK
- Biomedical Research and Training Institute, 10 Seagrave, Avondale, Harare, Zimbabwe
| | - Rufurwokuda Maswera
- Biomedical Research and Training Institute, 10 Seagrave, Avondale, Harare, Zimbabwe
| | - Phyllis Mandizvidza
- Biomedical Research and Training Institute, 10 Seagrave, Avondale, Harare, Zimbabwe
| | - Timothy B. Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, St Mary’s Campus Norfolk Place, London, W2 1PG UK
| | - Simon Gregson
- Department of Infectious Disease Epidemiology, Imperial College London, St Mary’s Campus Norfolk Place, London, W2 1PG UK
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The Political, Research, Programmatic, and Social Responses to Adolescent Sexual and Reproductive Health and Rights in the 25 Years Since the International Conference on Population and Development. J Adolesc Health 2019; 65:S16-S40. [PMID: 31761001 DOI: 10.1016/j.jadohealth.2019.09.011] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/24/2019] [Accepted: 09/24/2019] [Indexed: 12/21/2022]
Abstract
Among the ground-breaking achievements of the International Conference on Population and Development (ICPD) was its call to place adolescent sexual and reproductive health (ASRH) on global health and development agendas. This article reviews progress made in low- and middle-income countries in the 25 years since the ICPD in six areas central to ASRH-adolescent pregnancy, HIV, child marriage, violence against women and girls, female genital mutilation, and menstrual hygiene and health. It also examines the ICPD's contribution to the progress made. The article presents epidemiologic levels and trends; political, research, programmatic and social responses; and factors that helped or hindered progress. To do so, it draws on research evidence and programmatic experience and the expertise and experiences of a wide number of individuals, including youth leaders, in numerous countries and organizations. Overall, looking across the six health topics over a 25-year trajectory, there has been great progress at the global and regional levels in putting adolescent health, and especially adolescent sexual and reproductive health and rights, higher on the agenda, raising investment in this area, building the epidemiologic and evidence-base, and setting norms to guide investment and action. At the national level, too, there has been progress in formulating laws and policies, developing strategies and programs and executing them, and engaging communities and societies in moving the agenda forward. Still, progress has been uneven across issues and geography. Furthermore, it has raced ahead sometimes and has stalled at others. The ICPD's Plan of Action contributed to the progress made in ASRH not just because of its bold call in 1994 but also because it provided a springboard for advocacy, investment, action, and research that remains important to this day.
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