HIV testing approaches to reach the first UNAIDS 95% target in sub-Saharan Africa

Intentions of healthcare seeking and self-isolation for MPOX among men who have sex with men in China: a national cross-sectional study

Linking identified MPOX cases to care is essential for MPOX control. This study aims to investigate the intentions of healthcare seeking and self-isolation for MPOX among men who have sex with men (MSM) in China. A cross-sectional online survey was conducted in early August 2023 in China. Respondents were recruited by community-based organizations (CBOs), collecting information on demographics, health status, behavioural and psychological characteristics. Univariate and multivariate logistic regression analyses were performed to examine the predictors of intentions to seek healthcare and self-isolate for MPOX within the MSM population. A total of 7725 participants were recruited, with a median age of 30 years. 92.21% of the participants would seek healthcare for MPOX-like symptoms, but only 52.50% intended to self-isolate if diagnosed. Intentions to seek healthcare were lower among those with MPOX-like symptoms in the past 3 months (standardized prevalence ratio (SPRs) = 0.82, 95% CI: 0.74-0.89) and the willingness to self-isolate was reduced among those diagnosed with MPOX in the past 3 months (SPRs = 0.65, 95% CI: 0.48-0.87). Participants free of sexually transmitted infections (STIs) and those aware of their HIV status were more likely to seek healthcare and self-isolate than those with STIs or unaware of their HIV status. Regular followers of MPOX information and those perceiving a low risk of infection were more inclined to take preventive measures. These findings highlight the need for targeted MPOX prevention strategies for high-risk groups and the importance of addressing barriers in infectious disease prevention response.

Social network strategy (SNS) for HIV testing: a new approach for identifying individuals with undiagnosed HIV infection in Tanzania

Social network strategy (SNS) testing uses network connections to refer individuals at high risk to HIV testing services (HTS). In Tanzania, SNS testing is offered in communities and health facilities. In communities, SNS testing targets key and vulnerable populations (KVP), while in health facilities it complements index testing by reaching unelicited index contacts. Routine data were used to assess performance and trends over time in PEPFAR-supported sites between October 2021 and March 2023. Key indicators included SNS social contacts tested, and new HIV-positives individuals identified. Descriptive and statistical analysis were conducted. Univariable and multivariable analysis were applied, and variables with P-values <0.2 at univariable analysis were considered for multivariable analysis. Overall, 121,739 SNS contacts were tested, and 7731 (6.4%) previously undiagnosed individuals living with HIV were identified. Tested contacts and identified HIV-positives were mostly aged ≥15 years (>99.7%) and females (80.6% of tests, 79.4% of HIV-positives). Most SNS contacts were tested (78,363; 64.7%) and diagnosed (6376; 82.5%) in communities. SNS tests and HIV-positives grew 11.5 and 6.1-fold respectively, from October-December 2021 to January-March 2023, with majority of clients reached in communities vs. facilities (78,763 vs. 42,976). These results indicate that SNS testing is a promising HIV case-finding approach in Tanzania.

Moving beyond hotspots of HIV prevalence to geospatial hotspots of UNAIDS 95-95-95 targets in sub-Saharan Africa

The HIV epidemic in sub-Saharan Africa displays a varied geographical distribution, with particular regions termed as HIV hotspots due to a higher prevalence of infection. Addressing these hotspots is essential for controlling the epidemic. However, these regions, influenced by historical factors, challenge standard interventions. Legacy effects-the lasting impact of past events-play a substantial role in the persistence of these hotspots. To address this challenge of the standard interventions, we propose a shift towards the UNAIDS 95-95-95 targets. Spatial analysis of HIV viral load and antiretroviral therapy coverage can provide a more comprehensive perspective on the epidemic's dynamics. Studies in Zambia and Zimbabwe, using this approach, have revealed disparities in HIV care metrics across regions. By focusing on the UNAIDS 95-95-95 targets, more effective control strategies can be designed, with consideration of both historical and current factors. This approach would offer a solution-oriented strategy, emphasising tailored interventions based on specific regional needs.

Helicobacter pylori Diagnosis and Treatment in Africa: The First Lagos Consensus Statement of the African Helicobacter and Microbiota Study Group

BACKGROUND

Helicobacter pylori (H. pylori) infection is the most prevalent type of bacterial infection. Current guidelines from different regions of the world neglect specific African conditions and requirements. The African Helicobacter and Microbiota Study Group (AHMSG), founded in 2022, aimed to create an Africa-specific consensus report reflecting Africa-specific issues.

SUMMARY

Eighteen experts from nine African countries and two European delegates supported by nine African collaborators from eight other countries prepared statements on the most important African issues in four working groups: (1) epidemiology, (2) diagnosis, (3) indications and prevention, and (4) treatment. Limited resources, restricted access to medical systems, and underdeveloped diagnostic facilities differ from those of other regions. The results of the individual working groups were presented for the final consensus voting, which included all board members.

KEY MESSAGES

There is a need for further studies on H. pylori prevalence in Africa, with diagnosis hinged on specific African situation. Treatment of H. pylori in the African setting should be based on accessibility and reimbursement, while indication and prevention should be defined in specific African countries.

Determinants of HIV Testing Among Migrant Men Who Have Sex With Men from Sub-Saharan Africa and Other Regions Residing in 10 European Countries

Migrant men who have sex with men (mMSM) from sub-Saharan Africa (SSA) and other regions outside Europe are highly vulnerable to HIV. However, research on the determinants of HIV testing among mMSM from SSA, and how these differ across the categories of mMSM living in Europe, is limited. Using data from the European MSM Internet Survey (EMIS-2017), we assessed HIV testing prevalence and recency in mMSM from SSA and other mMSM residing in ten European countries, as well as the determinants of HIV testing across different mMSM categories with logistic regression analyses. Ever-testing for HIV was slightly higher in mMSM from SSA (83%) compared to other mMSM categories (75-80%), except for mMSM from Latin America and Caribbean region (84%). Overall, 20% of mMSM had never tested. In multivariable analysis, higher age (adjusted odds ratio [AOR] 1.05, 95% confidence interval [CI] 1.01-1.10), higher HIV knowledge (AOR 1.45, 95%-CI 1.11-1.90), and residence in smaller settlements (AOR 0.45, 95%-CI 0.21-0.96) were significantly associated with ever testing for HIV in mMSM from SSA. Comparing mMSM from SSA to mMSM from other regions, we found varying significant similarities (higher age, residence in smaller settlements and HIV knowledge) and differences (lower educational attainment, not identifying as gay, being a student, and limited disclosure of homosexual attraction) in the determinants of ever-testing for HIV. Community-specific interventions addressing identified sociodemographic and behavioral determinants to increase HIV testing uptake in the different mMSM categories and better data for further research are warranted.

Temporal Trends and Determinants of HIV Testing at Antenatal Care in Sub-Saharan Africa: A Pooled Analysis of Population-Based Surveys (2005-2021)

BACKGROUND

In sub-Saharan Africa (SSA), integrating HIV testing into antenatal care (ANC) has been crucial toward reducing mother-to-child transmission of HIV. With the introduction of new testing modalities, we explored temporal trends in HIV testing within and outside of ANC and identified sociodemographic determinants of testing during ANC.

METHODS

We analyzed data from 139 nationally representative household surveys conducted between 2005 and 2021, including more than 2.2 million women aged 15-49 years in 41 SSA countries. We extracted data on women's recent HIV testing history (<24 months), by modality (ie, at ANC versus outside of ANC) and sociodemographic variables (ie, age, socioeconomic status, education level, number of births, urban/rural). We used Bayesian generalized linear mixed models to estimate HIV testing coverage and the proportion of those that tested as part of ANC.

RESULTS

HIV testing coverage (<24 months) increased substantially between 2005 and 2021 from 8% to 38%, with significant variations between countries and subregions. Two percent of women received an HIV test in the 24 months preceding the survey interview as part of ANC in 2005 and 11% in 2021. Among women who received an HIV test in the 24 months preceding the survey, the probability of testing at ANC was significantly greater for multiparous, adolescent girls, rural women, women in the poorest wealth quintile, and women in West and Central Africa.

CONCLUSION

ANC testing remains an important component to achieving high levels of HIV testing coverage and benefits otherwise underserved women, which could prove instrumental to progress toward universal knowledge of HIV status in SSA.

Clinical characteristics and morbidity among hospitalized adults with advanced HIV disease in Uganda during 'test and treat' era

Nearly four decades after the first case of AIDS was described, the global number of AIDS-related deaths has steadily declined but falls short of the elimination targets, especially in sub-Saharan Africa. Despite interventions to promote early HIV diagnosis and treatment, hospitalization and mortality related to advanced HIV disease (AHD) remains a significant public health problem in Uganda. We assessed the HIV treatment history and causes of hospitalization among in-patients with AHD at a tertiary hospital in Uganda. In this cross-sectional study, pre-hospitalization HIV treatment history and clinical characteristics of HIV-positive in-patients with CD4<200 cells/μL or WHO stage 3 or 4 clinical events were assessed. Descriptive data were summarized using percentages and medians. Among hospitalized adults with AHD from November 2021 to June 2022, 74% (260/353) knew their HIV status prior to hospitalization and 62% (219/353) were ART experienced at presentation. The median time since ART initiation was 28 months (IQR; 2-97). Overall, 73% (258/353) had at least two etiological diagnoses and the majority (non-mutually exclusive) were diagnosed with tuberculosis (61.2%), cryptococcal meningitis (20.7%), mucosal candidiasis (16.1%) and bacterial infections (15%). In conclusion, nearly two-thirds of in-patients with advanced HIV disease were ART experienced prior to hospitalization and tuberculosis was the most common cause of hospitalization. Innovative strategies to strengthen HIV diagnosis, linkage, and retention in HIV care and to increase coverage of TB preventive therapy are urgently needed.

Knowledge, attitudes, and practices of healthcare workers regarding human immunodeficiency virus index testing in 2021, Burkina Faso

Although knowing one's HIV status is a necessary step in initiating antiretroviral treatment, more than a quarter of Burkinabe who are HIV-positive do not know their status. To reach the target of screening at least 95% of people living with HIV (PLHIV), the country has opted for HIV index testing (screening of sexual partners, children and partners of intravenous drug users). This study assessed the knowledge, attitudes and practices of health workers on HIV index testing. A cross-sectional study was conducted among health workers on index testing pilot sites in Burkina Faso. We constructed scores of health workers' knowledge, attitudes and practices regarding HIV index testing. A total of 132 health workers were surveyed, 62.8% of whom were female. Regarding profiles, 44.7% of the participants were nurses and 5.3% were midwives; physicians and psychosocial counselors accounted for 16.7 and 33.3%, respectively. Most of the participants worked in public health centers (60.6%). Overall, the majority of the participants had poor or average knowledge (85.6%) of the index testing strategy and harmful or inadequate practices (87.1%). Less than half (40.9%) had favorable attitudes toward the strategy. Our study showed that the knowledge of health workers was generally average, their attitudes were not very favorable and their practices were mostly inadequate with regard to HIV index testing. In order to increase the chances of reaching the first 95% of UNAIDS, trainings on the topic must be designed for health workers.

Evaluation of a two-test strategy for HIV screening in a low-prevalence setting and the indications for optimizing clinical management

Objectives

To evaluate a two-test strategy for HIV screening in the low-prevalence population and to assess the feasibility of utilizing the optimal signal-to-cutoff (S/CO) threshold on the chemiluminescence immunoassay(CMIA) and an additional rapid test on the gold immune-chromatography assay (GICA) for screening positive patients and optimization of clinical management.

Methods

We conducted a retrospective study of samples analyzed by the fourth-generation Architect HIV Ag/Ab combo assay (CMIA) in a large medical center between June 2017 and August 2020. Reactive samples underwent a second screening test using the rapid test GICA, followed by Western blot (WB) as the confirmatory test. Receiver operating characteristic (ROC) curve analysis was used to determine the optimal S/CO. We calculated sensitivity, specificity, and predictive value based on our population. The performance of the single-test strategy (CMIA) was compared with that of the two-test strategy (CMIA and GICA). Logistic regression was used to analyze the factors of clinical characteristics leading to false positive results.

Results

A total of 220558 samples were screened by CMIA, and 429 patients met the inclusion criteria. Of these, CMIA produced 199 false-positive results with a median S/CO of 1.93(IQR1.45-3.68) and 230 positive results with a median S/CO of 455.1 (IQR169.3-709.7). The optimal S/CO of the single-test strategy was 8.82, which achieved a sensitivity of 100% and a positive predictive value (PPV) of 90.9%. The two-test strategy (CMIA and GICA) provided a sensitivity of 100% and a PPV of 98.7%, which best correlated with the confirmatory test WB. The combination of S/CO 8.82 on the CMIA assay and additional test results of GICA can be defined as four types used to interpret HIV serostatus. The false positive rate (FPR) was high in the female, the age≤18 group, the pre-operative patients, and the patients from the clinical departments of Pediatrics, Gynecology and Obstetrics, and Oncology, etc.

Conclusions

The false positive rate is high in the low-prevalence setting by using CMIA. The two-test strategy (CMIA and GICA) is recommended for HIV screening in hospitals. Hopefully, the clinicians will be able to interpret HIV serostatus and facilitate clinical decision-making while waiting for the confirmatory results.

Evolving market-shaping strategies to boost access to essential medical products in developing countries with HIV self-testing as a case study

The COVID-9 pandemic has exacerbated health inequities among countries in the Global South with limited access to essential medical products, leading to a higher infection and mortality rate, especially among vulnerable populations. Despite tremendous progress in global health financing, the estimated annual financing gap in developing countries is projected to reach US$371 billion per year by 2030. Therefore, developing market-shaping strategies is of great importance in ensuring adequate supply, affordable prices, and equitable access to essential medical products in low-and middle-income countries. We propose a strategic and appropriate market-shaping intervention framework for governments, international organizations, and NGOs to maximize access to essential medical products in developing countries. In the health field, we believe that market shaping strategy could be defined as a set of purposeful activities that market forces may intervene with to advance the development, production, supply, and distribution of global goods for health, making essential medical products more affordable, accessible, innovative, sustainable and quality assured. We argue that when designing a market-shaping strategy, policy or decision-makers must take full advantage of the key drivers to keep the market dynamic, interactive, and constantly evolving to meet the unmet medical needs. In addition, different forms of market-shaping interventions are determined by objectives and specific issues to be addressed. More comprehensive market shaping strategies, including the strategic use of market expansion, market disruption, market maintenance, and market contraction alone or together, deserve to be explored and key stakeholders are also expected to join forces to make the intervention more efficient and productive.

HIV Recent Infection and Past HIV Testing History Among Newly HIV-Diagnosed 15-24-Year-Olds in Malawi: An Analysis of 2019-2022 HIV Recent Infection Surveillance Data

Awareness of HIV status in Malawi is 88.3% and lowest among 15-24-year-olds (76.2%). There is a need to understand HIV testing history and transmission in this age group. We analyzed pooled HIV surveillance data to describe testing history and HIV recent infection among 8,389 HIV-positive 15-24-year-olds from 251 sites in Malawi between 2019 and 2022. Most HIV-positive 15-24-year-olds were female; aged 23-24 years; rural residents; and diagnosed at voluntary counseling and testing. No prior HIV testing was reported in 43.5% and 32.9% of 15-19-year-olds and males, respectively. Overall, 4.9% of HIV-positive diagnoses were classified as recent HIV infections, with the highest proportions among breastfeeding women (8.2%); persons tested at sexually transmitted infection clinics (9.0%); persons with a prior negative test within 6 months (13.0%); and 17-18-year-olds (7.3%). Tailored and innovative HIV prevention and testing strategies for young adolescents, young males, and pregnant and breastfeeding women are needed for HIV epidemic control.

Uptake and perceptions of oral HIV self-testing delivered by village health teams among men in Central Uganda: A concurrent parallel mixed methods analysis

The World Health Organization (WHO) recommends HIV self-testing (HIVST) to increase access to and utilization of HIV services among underserved populations. We assessed the uptake and perceptions of oral HIVST delivered by Village Health Teams (VHTs) among men in a peri-urban district in Central Uganda. We used a concurrent parallel mixed methods study design and analyzed data from 1628 men enrolled in a prospective cohort in Mpigi district, Central Uganda between October 2018 and June 2019. VHTs distributed HIVST kits and linkage-to-care information leaflets to participants in 30 study villages allowing up-to 10 days each to self-test. At baseline, we collected data on participant socio-demographics, testing history and risk behavior for HIV. During follow-up, we measured HIVST uptake (using self-reports and proof of a used kit) and conducted in-depth interviews to explore participants' perceptions of using HIVST. We used descriptive statistics to analyze the quantitative data and a hybrid inductive, and deductive thematic analysis for the qualitative data and integrated the results at interpretation. The median age of men was 28 years, HIVST uptake was 96% (1564/1628), HIV positivity yield was 4% (63/1564) and reported disclosure of HIVST results to sexual partners and significant others was 75.6% (1183/1564). Men perceived HIVST as a quick, flexible, convenient, and more private form of testing; allowing disclosure of HIV test results to sexual partners, friends and family, and receiving social support. Others perceived it as an opportunity for knowing or re-confirming their sero-status and subsequent linkage or re-linkage to care and prevention. Utilizing VHT networks for community-based delivery of HIVST is effective in reaching men with HIV testing services. Men perceived HIVST as highly beneficial but needed more training on performing the test and the integrating post-test counseling support to optimize use of the test for diagnosing HIV.

The influence of the COVID-19 pandemic on identifying HIV/AIDS cases in China: an interrupted time series study

Background

The COVID-19 pandemic has caused significant global public health challenges, and impacted HIV testing and reporting worldwide. We aimed to estimate the impact of COVID-19 polices on identifying HIV/AIDS cases in China from 2020 to 2022.

Methods

We used an interrupted time series (ITS) design and seasonal autoregressive integrated moving average intervention (SARIMA Intervention) model. Monthly reported data on HIV/AIDS cases were extracted from the National Bureau of Disease Control and Prevention of China from January 2004 to August 2022. Data on Stringency Index (SI) and Economic Support Index (ESI) from January 22, 2020 to August 31, 2022 were extracted from the Oxford COVID-19 Government Response Tracker (OxCGRT). Using these, a SARIMA-Intervention model was constructed to evaluate the association between COVID-19 polices and monthly reported HIV/AIDS case numbers from January 2004 to August 2022 using auto.arima () function from R. The absolute percentage errors (APEs) compared the expected numbers generated by the SARIMA-Intervention model with actual numbers of HIV/AIDS, and was the primary outcome of this study. A second counterfactual model estimated HIV/AIDS case numbers if COVID-19 hadn't occurred in December 2019, and the mean difference between actual and predicted numbers were calculated. All statistical analyses were performed in R software (version 4.2.1) and EmpowerStats 2.0 and a P < 0.05 was considered statistically significant.

Findings

The SARIMA-Intervention model indicated HIV/AIDS monthly reported cases were inversely and significantly correlated with stricter lockdown and COVID-19 related polices (Coefficient for SI = -231.24, 95% CI: -383.17, -79.32) but not with economic support polices (Coefficient for ESI = 124.27, 95% CI: -309.84, 558.38). APEs of the SARIMA-Intervention model for prediction of HIV/AIDS cases from January 2022 through August 2022, were -2.99, 5.08, -13.64, -34.04, -2.76, -1.52, -1.37 and -2.47 respectively, indicating good accuracy and underreporting of cases during COVID-19. The counterfactual model estimates between January 2020 and August 2022 an additional 1314 HIV/AIDS cases should have been established monthly if COVID-19 hadn't occurred.

Interpretation

The COVID-19 pandemic influenced the allocation and acquisition of medical resources which impacted accurate monthly reporting of HIV in China. Interventions that promote continuous HIV testing and ensure the adequate provision of HIV services including remote delivery of HIV testing services (HIV self-testing) and online sexual counseling services are necessary during pandemics in future.

Funding

Ministry of Science and Technology of the People's Republic of China (The grant number: 2020YFC0846300) and Fogarty International Center, National Institutes of Health, USA (The grant number: G11TW010941).

Age-of-consent requirements and adolescent HIV testing in low-and middle-income countries: multinational insights from 51 population-based surveys

BACKGROUND

Pervasive social and structural barriers-including national policies-inhibit HIV testing uptake among priority populations, including adolescents. We assessed the relationship between age-of-consent policies for HIV testing and adolescent HIV testing coverage in 51 low- and middle-income countries.

METHODS

We pooled data from household surveys (2010-2020) and calculated the weighted country-level prevalence of lifetime HIV testing separately for adolescent girls and boys (ages 15-19). We then abstracted age-of-consent requirements for HIV testing across countries. Using multivariable linear regression, we estimated the average difference in national HIV testing coverage estimates for adolescent girls and boys by age-of-consent restrictions for HIV testing.

RESULTS

National HIV testing coverage estimates ranged from 0.7% to 72.5% among girls (median: 18.0%) and 0% to 73.2% among boys (median: 7.5%) in Pakistan and Lesotho, respectively. In adjusted models, HIV testing coverage in countries requiring parental consent for individuals <18 years was, on average, 9.4 percentage-points (pp) lower (95% confidence interval [95%CI] -17.9pp to -0.9pp) among girls and 9.3pp lower (95%CI: -17.3pp to -1.2pp) among boys, relative to countries with less restrictive policies (age-of-consent: ≤16 years). Compared to countries with less restrictive (age-of-consent: ≤14 years) policies, HIV testing prevalence was significantly lower among girls (β -10.5pp, 95%CI: -19.7pp to -1.3pp) and boys (β -10.5pp, 95%CI -19.2pp to -1.8pp) in countries with more restrictive (age-of-consent: 18 years) parental consent requirements.

CONCLUSIONS

Age-of-consent policies are persistent obstacles to adolescent HIV testing. Repealing parental consent requirements for HIV testing is needed to expand coverage and accelerate progress towards global HIV treatment and prevention targets.

Progress on Prevention and Treatment of Cerebral Small Vascular Disease Using Integrative Medicine

Cerebral small vessel disease (CSVD) is a senile brain lesion caused by the abnormal structure and function of arterioles, venules and capillaries in the aging brain. The etiology of CSVD is complex, and disease is often asymptomatic in its early stages. However, as CSVD develops, brain disorders may occur, such as stroke, cognitive dysfunction, dyskinesia and mood disorders, and heart, kidney, eye and systemic disorders. As the population continues to age, the burden of CSVD is increasing. Moreover, there is an urgent need for better screening methods and diagnostic markers for CSVD, in addition to preventive and asymptomatic- and mild-stage treatments. Integrative medicine (IM), which combines the holistic concepts and syndrome differentiations of Chinese medicine with modern medical perspectives, has unique advantages for the prevention and treatment of CSVD. In this review, we summarize the biological markers, ultrasound and imaging features, disease-related genes and risk factors relevant to CSVD diagnosis and screening. Furthermore, we discuss IM-based CSVD prevention and treatment strategies to stimulate further research in this field.

Condom Use Behaviors, Risk Perception, and Partner Communication Following Oral HIV Self-testing Among Adolescents and Young Adults in Kenya: A Cohort Study

HIV self-testing (HIVST) can improve testing completion among adolescents and young adults (AYA), although its influence on sexual behaviors is unclear. We evaluated whether HIVST was associated with changes in talking with sexual partners about HIVST, condom use, and HIV risk perception among AYA ages 15-24 years in a study of HIVST distribution through homes, pharmacies, and nightclubs in Nairobi, Kenya. All participants had negative HIVST results. Regression models were used to evaluate changes between pre-HIVST and 4 months post-HIVST. Overall, there was a significant increase in talking with sexual partners about HIVST. There was a significant reduction in number of condomless sex acts among AYA recruited through pharmacies and homes. Unexpectedly, among females, there was a significant decrease in consistent condom use with casual partners. HIVST services for AYA may benefit from including strategies to support condom use and partner communication about self-testing adapted to specific populations and partnerships.

Spatial disparities of HIV prevalence in South Africa. Do sociodemographic, behavioral, and biological factors explain this spatial variability?

Background

In 2021, an estimated 38 million people were living with human immunodeficiency virus (HIV) globally, with over two-thirds living in African regions. In South Africa, ~20% of South African adults are living with HIV. Accurate estimation of the risk factors and spatial patterns of HIV risk using individual-level data from a nationally representative sample is invaluable for designing geographically targeted intervention and control programs.

Methods

Data were obtained from the 2016 South Africa Demographic and Health Survey (SDHS16). The study involved all men and women aged 15 years and older, who responded to questions and tested for HIV in the SDHS. Generalized additive models (GAMs) were fitted to our data with a nonparametric bivariate smooth term of spatial location parameters (X and Y coordinates). The GAMs were used to assess the spatial disparities and the potential contribution of sociodemographic, biological, and behavioral factors to the spatial patterns of HIV prevalence in South Africa.

Results

A significantly highest risk of HIV was observed in east coast, central and north-eastern regions. South African men and women who are widowed and divorced had higher odds of HIV as compared to their counterparts. Additionally, men and women who are unemployed had higher odds of HIV as compared to the employed. Surprisingly, the odds of HIV infection among men residing in rural areas were 1.60 times higher (AOR 1.60, 95% CI 1.12, 2.29) as compared to those in urban areas. But men who were circumcised had lower odds of HIV (AOR 0.73, 95% CI 0.52, 0.98), while those who had STI in the last 12 months prior to the survey had higher odds of HIV (AOR 1.76, 95% CI 1.44, 3.68).

Conclusion

Spatial heterogeneity in HIV risk persisted even after covariate adjustment but differed by sex, suggesting that there are plausible unobserved influencing factors contributing to HIV uneven variation. This study's findings could guide geographically targeted public health policy and effective HIV intervention in South Africa.

Incentives to promote accessing HIV care and viral suppression among HIV self-screening test users who obtain a reactive result

Introduction

Achieving viral suppression in people with HIV is crucial in ending the AIDS epidemic. Among users of HIV self-screening tests, low rates of linkage to care and early retention in care are key obstacles to achieving viral suppression. This study sought to evaluate the efficacy of financial incentives in supporting HIV case management.

Methods

Young adults within the inner city of Johannesburg, South Africa and surrounding areas who used HIV self-tests, were able to use WhatsApp to communicate with study personnel, reported a reactive or invalid result, and were confirmed to by HIV-positive were enrolled in the study. Participants were randomised to an intervention arm that received reminders and financial rewards for engaging in care, or to a control arm that received the standard of care. The primary outcome was HIV viral load at six months.

Results

Among 2,388 HIV self-test kits that were distributed, 1757/2,388 (73,58%) recipients were able to use their phones to send photos to study personnel. 142/1,757 (8,08%) of these recipients reported reactive or invalid results. Upon confirmatory testing, 99/142 (69,71%) participants were identified as being HIV-positive and were enrolled in the study. 2 (1,41%) participants received an HIV negative result, and 41(28,87%) participants were either lost to follow-up or did not complete the confirmatory testing step. 20/99 (20,2%) from the intervention arm and 18/99 (18,18%) from the control arm completed the study (i.e., attended a 6 month follow up and participated in the exit interview). 29/99 (29,29%) were virally suppressed by at 6 months. Of those achieving viral suppression 15 (51,72%) were from the intervention arm.

Conclusion

Financial incentives and reminders were not effective in promoting engagement with HIV care and viral suppression in this setting.

Factors associated with HIV testing among patients seeking emergent injury care in Kigali, Rwanda

Introduction

Emergency centres (ECs) can be important access points for HIV testing. In Rwanda, one in eight people with HIV are unaware of their infection status, which impedes epidemic control. This could be addressed via increased testing. This cross-sectional study evaluated factors associated with EC-based HIV testing among injured patients at the Centre Hospitalier Universitaire de Kigali (CHUK), in Kigali, Rwanda.

Methods

Adult injury patients were prospectively enrolled between January-June 2020. Trained study personnel collected data on demographics, injury aspects, treatments, HIV testing, and disposition. The primary outcome was the completion of EC-based HIV testing. Differences between those receiving and those not receiving testing were assessed. Regression models yielding adjusted odds ratios with associated 95% confidence intervals (CI) were calculated to quantify magnitudes of effect.

Results

Among 579 patients, the majority were under 45 years of age (78.1%) and male (74.4%). The most common mechanism of injury was road traffic accidents (50.3%). EC discharge occurred in 54.4% of cases. HIV testing was performed in 221 (38.2%) cases, of which 5.9% had a positive result. HIV testing was more likely among males (aOR=1.69, 95% CI: 1.02-2.78; p=0.04), cases transported by prehospital services (aOR=2.07, 95% CI: 1.28-3.35; p=0.003) and those receiving surgical consultation (aOR=3.13, 95% CI: 1.99-4.94; p<0.001). Cases with lower acuity were less likely to be tested (OR=0.70, 95% CI: 0.55-0.90; p=0.004), as were those discharged (OR=0.28, 95% CI: 0.18-0.43; p<0.001).

Conclusion

In the population studied, most patients did not undergo HIV testing. EC-based physician directed testing was more likely among male patients and patients with greater care needs. These results may inform approaches to increase EC-based testing services in Rwanda and other similar settings with high HIV burdens.

Suboptimal Follow-Up on HIV Test Results among Young Men Who Have Sex with Men: A Community-Based Study in Two U.S. Cities

Frequent HIV testing and knowledge of HIV serostatus is the premise before timely access to HIV prevention and treatment services, but a portion of young men who have sex with men (YMSM) do not always follow up on their HIV test results after HIV testing, which is detrimental to the implementation of HIV prevention and care among this subgroup. The comprehensive evaluation of factors associated with inconsistent follow-up on HIV test results may inform relevant interventions to address this critical issue among YMSM. To this end, we conducted a cross-sectional study in Nashville, Tennessee and Buffalo, New York from May 2019 to May 2020 to assess demographic, behavioral, and psychosocial correlates of inconsistent follow-up on HIV test results among YMSM. Of the 347 participants, 27.1% (n = 94) reported inconsistent follow-up on their HIV test results. Multivariable logistic regression showed that inconsistent follow-up on HIV test results was positively associated with condomless receptive anal sex, group sex, recreational drug use before or during sex, internalized homophobia, and stress; while negatively associated with housing stability, social support, and general resilience. Future HIV prevention intervention efforts should target these modifiable determinants to enhance the follow-up on HIV test results among YMSM.

Improving ART initiation among men who use HIV self-testing in Malawi: a qualitative study

INTRODUCTION

HIV self-testing (HIVST) increases HIV testing uptake among men; however, the linkage to antiretroviral therapy (ART) among HIVST users is low. Innovative strategies for ART initiation are needed, yet little is known about the unique barriers to care experienced by male HIVST users, and what ART-related interventions men desire.

METHODS

We conducted semi-structured in-depth interviews with cisgender men (≥15 years) in Malawi who tested HIV positive using HIVST between 2018 and 2020, as well as interviews with their female partners (≥15 years) who distributed the HIVST kits. Medical records from seven facilities were used to identify respondents. We included men who received HIVST from a health facility (primary distribution) and from sexual partners (secondary distribution). Interview guides focused on unique barriers to ART initiation following HIVST and desired interventions to improve linkage and initiation. Interviews were audio recorded, translated and transcribed to English, and analysed using constant comparison methods in Atlas.ti v.8.4. Themes were compared by HIVST distribution strategy. Data were collected between 2019 and 2020.

RESULTS

Twenty-seven respondents were interviewed: eight male/female dyads (16 respondents), eight men without a female partner and three women who represented men who did not participate in the study. Among the 19 men represented (16 men interviewed in person, three represented by secondary report from female partners), seven received HIVST through primary distribution, 12 through secondary distribution. Six men never initiated ART (all secondary HIVST distribution). Barriers to ART initiation centred on the absence of healthcare workers at the time of diagnosis and included lack of external motivation for linkage to care (men had to motivate themselves) and lack of counselling before and after testing (leaving ART-related fears and misconceptions unaddressed)--the latter was especially true for secondary HIVST distribution. Desired interventions were similar across distribution strategies and included ongoing peer mentorship for normalizing treatment adherence, counselling messages tailored to men, outside-facility services for convenience and privacy, and facility navigation to help men understand how to navigate ART clinics.

CONCLUSIONS

Male HIVST users face unique challenges to ART initiation, especially those receiving HIVST through secondary distribution. Male-tailored interventions are desired by men and may help overcome barriers to care.

Prevalence of and factors associated with late diagnosis of HIV in Malawi, Zambia, and Zimbabwe: Results from population-based nationally representative surveys

INTRODUCTION

Late diagnosis of HIV (LD) increases the risk of morbidity, mortality, and HIV transmission. We used nationally representative data from population-based HIV impact assessment (PHIA) surveys in Malawi, Zambia, and Zimbabwe (2015-2016) to characterize adults at risk of LD and to examine associations between LD and presumed HIV transmission to cohabiting sexual partners.

METHODS

We estimated the prevalence of LD, defined as CD4 count <350 cells/μL, among adults newly diagnosed with HIV during the surveys and odds ratios for associated factors. We linked newly diagnosed adults (index cases) to their household sexual partners and calculated adjusted odds ratios for associations between LD of the index case, viral load of the index case, and duration of HIV exposure in the relationship, and the HIV status of the household sexual partner.

RESULTS

Of 1,804 adults who were newly diagnosed with HIV in the surveys, 49% (882) were diagnosed late. LD was associated with male sex, older age, and almost five times the odds of having an HIV-positive household sexual partner (adjusted odds ratio [aOR], 4.65 [95% confidence interval: 2.56-8.45]). Longer duration of HIV exposure in a relationship and higher viral load of the index case were both independently associated with higher odds of having HIV-positive household sexual partners. Individuals with HIV exposure of more than 5 years had more than three times (aOR 3.42 [95% CI: 1.63-7.18]) higher odds of being HIV positive than those with less than 2 years HIV exposure. The odds of being HIV positive were increased in individuals who were in a relationship with an index case with a viral load of 400-3499 copies/mL (aOR 4.06 [95% CI 0.45-36.46]), 3,500-9,999 copies/mL (aOR 11.32 [95% CI: 4.08-31.39]), 10,000-49,999 copies/mL (aOR 17.07 [95% CI: 9.18-31.72]), and ≥50,000 copies/mL (aOR 28.41 [95% CI: 12.18-66.28]) compared to individuals who were in a relationship with an index case with a viral load of <400 copies/mL.

CONCLUSIONS

LD remains a challenge in Southern Africa and is strongly associated with presumed HIV transmission to household sexual partners. Our study underscores the need for earlier HIV diagnosis, particularly among men and older adults, and the importance of index testing.

Does Sexual and Emotional Behavior Differ Between Sexual Partners That Do Not Disclose HIV Status?

Objective:

The objective of the study was to analyze whether the disclosure of HIV serological status among sexual partners is associated with differences in sexual affective behavior.

Methods:

Cross-sectional study was carried out with 173 participants in a specialized assistance service on the treatment of people with the Human Immunodeficiency Virus. Data were collected through interviews.

Results:

Our results show that from the participants who did not disclose their HIV status and who were sexually active, most had multiple sexual partners (44.6%), used combined methods of prevention (75.4%), had casual partners (63.0%), used condoms (66.2%), and had sexual intercourse while under the influence of alcohol (56.9%). The variables i.e., number of partners (p = 0.010) and type of relationship (p <0.001) showed statistical differences.

Conclusion:

Sexual affective behavior variables influenced the decision about disclosing HIV seropositivity to sexual partners that establish different forms of sexual partnerships.

The effect of providing women sustained access to HIV self-tests on male partner testing, couples testing, and HIV incidence in Kenya: a cluster-randomised trial

BACKGROUND

HIV self-testing can overcome barriers to HIV testing, but its potential as an HIV prevention strategy for women in sub-Saharan Africa has not been assessed. We examined whether sustained provision of self-tests to women promotes testing among sexual partners and reduces HIV incidence.

METHODS

We conducted a pair-matched cluster-randomised trial in 66 community clusters in Siaya County, Kenya. Clusters were communities with a high prevalence of transactional sex, including beach communities along Lake Victoria and inland communities with hotspots for transactional sex such as bars and hotels. Within clusters, we recruited HIV-negative women aged 18 years or older with two or more sexual partners within the past 4 weeks. In each of the 33 cluster pairs, we randomly assigned clusters to an intervention and comparison group. In intervention clusters, we provided participants with multiple self-tests at regular intervals and encouraged secondary distribution of self-tests to sexual partners. In comparison clusters, we provided participants referral cards for facility-based testing. Follow-up visits and HIV testing occurred at 6-month intervals for up to 24 months. The primary outcome of HIV incidence among all participants who contributed at least one HIV test was analysed using discrete-time mixed effects models. This study is registered with ClinicalTrials.gov, NCT03135067.

FINDINGS

Between June 4, 2017, and Aug 31, 2018, we enrolled 2090 participants (1033 in the 33 intervention clusters and 1057 in the 33 comparison clusters). Participants' median age was 25 years (IQR 22-31) and 1390 (66·6%) of 2086 participants reported sex work as an income source. 1840 participants completed the 18-month follow-up and 570 participants completed the 24-month follow up, which ended on March 25, 2020, with a median follow-up duration of 17·6 months. HIV incidence was not significantly different between the intervention and comparison groups (1·2 vs 1·0 per 100 person-years; hazard ratio 1·2, 95% CI 0·6-2·3, p=0·64). Social harms related to study participation occurred in three participants (two in the intervention group and one in the comparison group).

INTERPRETATION

Sustained provision of multiple self-tests to women at high risk of HIV infection in Kenya enabled secondary distribution of self-tests to sexual partners but did not affect HIV incidence.

FUNDING

National Institute of Mental Health; Center for Health Incentives and Behavioral Economics; National Institute of Allergies and Infectious Diseases; University of Pennsylvania Center for AIDS Research.

Pregnant women, their male partners and health care providers' perceptions of HIV self-testing in Kampala, Uganda: Implications for integration in prevention of mother-to-child transmission programs and scale-up

Background

HIV status awareness is critical for HIV prevention and care but HIV testing rates remain low in Uganda, especially among men. One suggested approach to increase access and utilisation of HIV testing services is HIV self-testing. We explored perceptions of pregnant and lactating women and their male partners who attended antenatal care, and health care providers in a government hospital in Kampala, Uganda, about HIV self-testing for initial or repeat testing for women and their partners during pregnancy and postpartum We draw implications for scaling-up this new testing approach in Uganda.

Methods

This was a qualitative study conducted at Mulago National Referral Hospital, Kampala, Uganda, between April and December 2017. We conducted in-depth interviews with five pregnant or lactating women and their five male partners; five focus group discussions (two with women, two with health workers and one with male partners of women attending antenatal care) and five key informant interviews with health workers providing prevention of mother-to-child HIV transmission (PMTCT) services. Data were analysed using content thematic approach.

Results

There was limited awareness about HIV self-testing especially among pregnant or lactating women and their male partners. Study participants mentioned that HIV self-testing would enable people to know their HIV status faster, they thought the approach would be cost- and time-saving compared to health facility-based HIV testing, improve confidentiality and reduce stigma for those who test HIV positive. They expressed however, a general fear that HIV self-testing would lead to harm to self and others in case one tested HIV positive, including suicide, violence among couples, intentional transmission of HIV, and limited linkage to care due to lack of counselling. The likely misinterpretation of HIV test results especially among those with no or limited education, and possible coercion exerted by male partners on their wives were other potential concerns raised about the use of HIV self-testing.

Conclusions

There was limited knowledge about HIV self-testing among pregnant and lactating women, their partners and health workers. While the self-testing modality was perceived to be critical for helping people, especially those in casual and distant relationships, to know their HIV status and that of their partners, most study participants believed that HIV self-testing could potentially result in a multitude of negative outcomes in the absence of pre- and post-test counselling. Successful scale-up and integration of self-testing in HIV programs requires community education, provision of information materials and making self-test kits accessible and affordable, especially in rural areas.