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Bousmah MAQ, Iwuji C, Okesola N, Orne-Gliemann J, Pillay D, Dabis F, Larmarange J, Boyer S. Costs and economies of scale in repeated home-based HIV counselling and testing: Evidence from the ANRS 12249 treatment as prevention trial in South Africa. Soc Sci Med 2022; 305:115068. [PMID: 35665689 PMCID: PMC9214548 DOI: 10.1016/j.socscimed.2022.115068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/29/2022] [Accepted: 05/21/2022] [Indexed: 11/27/2022]
Abstract
Universal HIV testing is now recommended in generalised HIV epidemic settings. Although home-based HIV counselling and testing (HB-HCT) has been shown to be effective in achieving high levels of HIV status awareness, little is still known about the cost implications of universal and repeated HB-HCT. We estimated the costs of repeated HB-HCT and the scale economies that can be obtained when increasing the population coverage of the intervention. We used primary data from the ANRS 12249 Treatment as Prevention (TasP) trial in rural South Africa (2012–2016), whose testing component included six-monthly repeated HB-HCT. We relied on the dynamic system generalised method of moments (GMM) approach to produce unbiased short- and long-run estimates of economies of scale, using the number of contacts made by HIV counsellors for HB-HCT as the scale variable. We also estimated the mediating effect of the contact quality – measured as the proportion of HIV tests performed among all contacts eligible for an HIV test – on scale economies. The mean cost (standard deviation) of universal and repeated HB-HCT was $24.2 (13.7) per contact, $1694.3 (1527.8) per new HIV diagnosis, and $269.2 (279.0) per appropriate referral to HIV care. The GMM estimations revealed the presence of economies of scale, with a 1% increase in the number of contacts for HB-HCT leading to a 0.27% decrease in the mean cost. Our results also suggested a significant long-run relationship between mean cost and scale, with a 1% increase in the scale leading to a 0.36% decrease in mean cost in the long run. Overall, we showed that significant cost savings can be made from increasing population coverage. Nevertheless, there is a risk that this gain is made at the expense of quality: the higher the quality of HB-HCT activities, the lower the economies of scale. We estimated the costs of repeated home-based HIV counselling and testing (HB-HCT). The mean cost per new HIV diagnosis, which increased over HB-HCT rounds, was $1694. However, the mean cost per appropriate referral to HIV care was $269. A 1% increase in the scale of HB-HCT reduced the average cost per contact by 0.27%. Expanding the population coverage of HB-HCT offers opportunities for cost savings.
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Affiliation(s)
- Marwân-Al-Qays Bousmah
- Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France; Université Paris Cité, IRD, Inserm, Ceped, F-75006, Paris, France.
| | - Collins Iwuji
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa; Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | | | - Joanna Orne-Gliemann
- University of Bordeaux, National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Centre, Bordeaux, France
| | - Deenan Pillay
- Research Department of Infection and Population Health, University College London, London, UK; Division of Infection and Immunity, University College London, London, UK
| | - François Dabis
- University of Bordeaux, National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Centre, Bordeaux, France
| | | | - Sylvie Boyer
- Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France
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Justice AC, Goetz MB, Stewart CN, Hogan BC, Humes E, Luz PM, Castilho JL, Nash D, Brazier E, Musick B, Yiannoutsos C, Malateste K, Jaquet A, Cornell M, Shamu T, Rajasuriar R, Jiamsakul A, Althoff KN. Delayed presentation of HIV among older individuals: a growing problem. Lancet HIV 2022; 9:e269-e280. [PMID: 35218732 PMCID: PMC9128643 DOI: 10.1016/s2352-3018(22)00003-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 11/30/2021] [Accepted: 01/05/2022] [Indexed: 12/31/2022]
Abstract
Late presentation for care is a major impediment to the prevention and effective treatment of HIV infection. Older individuals are at increased risk of late presentation, represent a growing proportion of people with late presentation, and might require interventions tailored to their age group. We provide a summary of the literature published globally between 2016-21 (reporting data from 1984-2018) and quantify the association of age with delayed presentation. Using the most common definitions of late presentation and older age from these earlier studies, we update this work with data from the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium, focusing on data from 2000-19, encompassing four continents. Finally, we consider how late presentation among older individuals might be more effectively addressed as electronic medical records become widely adopted.
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Affiliation(s)
- Amy C Justice
- VA Connecticut Healthcare System, Yale Schools of Medicine and Public Health, Yale University, West Haven, CT, USA.
| | - Matthew B Goetz
- VA Greater Los Angeles Healthcare System, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Cameron N Stewart
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Brenna C Hogan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Elizabeth Humes
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Paula M Luz
- Affiliation Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Jessica L Castilho
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Denis Nash
- City University of New York Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA
| | - Ellen Brazier
- Institute for Implementation Science in Population Health, Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA
| | - Beverly Musick
- Department of Biostatistics and Health Data Science, School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Constantin Yiannoutsos
- Department of Biostatistics, Richard M Fairbanks School of Public Health, Indiana University, Indianapolis, IN, USA
| | - Karen Malateste
- Inserm, French National Research Institute for Sustainable Development, Universite de Bordeaux, Bordeaux, France
| | - Antoine Jaquet
- Inserm, French National Research Institute for Sustainable Development, Universite de Bordeaux, Bordeaux, France
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Tinei Shamu
- Graduate School of Health Sciences, Institute of Social and Preventative Medicine, University of Bern, Bern, Switzerland
| | - Reena Rajasuriar
- Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Awachana Jiamsakul
- Biostatistics and Databases Program, The Kirby Institute, UNSW, Sydney, NSW, Australia
| | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Ryan JH, Young A, Musara P, Reddy K, Macagna N, Guma V, Seyama L, Piper J, van der Straten A. Sexual Attitudes, Beliefs, Practices, and HIV Risk During Pregnancy and Post-delivery: A Qualitative Study in Malawi, South Africa, Uganda, and Zimbabwe. AIDS Behav 2022; 26:996-1005. [PMID: 34907478 PMCID: PMC8840901 DOI: 10.1007/s10461-021-03454-y] [Citation(s) in RCA: 1] [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] [Accepted: 08/27/2021] [Indexed: 12/03/2022]
Abstract
Women who acquire HIV during the pregnancy and breastfeeding periods have a higher risk of transmitting the virus to their child than women who become infected with HIV before pregnancy. We explore the context of sexual beliefs and practices that may shape both HIV risk and willingness to use HIV prevention products during pregnancy and postpartum in Malawi, South Africa, Uganda and Zimbabwe. Twenty-three single sex focus group discussions and 36 in-depth interviews took place between May and November 2018 with recently pregnant or breastfeeding women, men, mothers and mothers-in-law of pregnant or breastfeeding women, and key informants. Participants across study groups and sites (N = 232) reported various perceived benefits and harms of sex during pregnancy and postpartum. Participants discussed reasons why men might seek sex outside of the relationship. There is a critical need for alternative prevention options to protect pregnant and breastfeeding women from HIV.
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Affiliation(s)
- Julia H. Ryan
- Women’s Global Health Imperative (WGHI), RTI International, Berkeley, CA USA
| | - Alinda Young
- Women’s Global Health Imperative (WGHI), RTI International, Berkeley, CA USA
| | - Petina Musara
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
| | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
| | | | - Victor Guma
- Makerere University – Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Linly Seyama
- Johns Hopkins Project-College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Ariane van der Straten
- Women’s Global Health Imperative (WGHI), RTI International, Berkeley, CA USA
- Center for AIDS Prevention Studies (CAPS), University of California San Francisco, San Francisco, CA USA
| | - the MTN-
041/MAMMA Study Team
- Women’s Global Health Imperative (WGHI), RTI International, Berkeley, CA USA
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
- FHI 360, Durham, NC USA
- Makerere University – Johns Hopkins University Research Collaboration, Kampala, Uganda
- Johns Hopkins Project-College of Medicine, University of Malawi, Blantyre, Malawi
- DAIDS, NIH/NIAID, Bethesda, MD USA
- Center for AIDS Prevention Studies (CAPS), University of California San Francisco, San Francisco, CA USA
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'It is not fashionable to suffer nowadays': Community motivations to repeatedly participate in outreach HIV testing indicate UHC potential in Tanzania. PLoS One 2021; 16:e0261408. [PMID: 34937061 PMCID: PMC8694479 DOI: 10.1371/journal.pone.0261408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 12/01/2021] [Indexed: 11/19/2022] Open
Abstract
Objective This study examined people’s motivations for (repeatedly) utilizing HIV testing services during community-based testing events in urban and rural Shinyanga, Tanzania and potential implications for Universal Health Coverage (UHC). Methods As part of a broader multidisciplinary study on the implementation of a HIV Test and Treat model in Shinyanga Region, Tanzania, this ethnographic study focused on community-based testing campaigns organised by the implementing partner. Between April 2018 and December 2019, we conducted structured observations (24), short questionnaires (42) and in-depth interviews with HIV-positive (23) and HIV-negative clients (8). Observations focused on motivations for (re-)testing, and the counselling and testing process. Thematic analysis based on inductive and deductive coding was completed using NVivo software. Results Regular HIV testing was encouraged by counsellors. Most participants in testing campaigns were HIV-negative; 51.1% had tested more than once over their lifetimes. Testing campaigns provided an accessible way to learn one’s HIV status. Motivations for repeat testing included: monitoring personal health to achieve (temporary) reassurance, having low levels of trust toward sexual partners, feeling at risk, seeking proof of (ill)-health, and acting responsibly. Repeat testers also associated testing with a desire to start treatment early to preserve a healthy-looking body, should they prove HIV positive. Conclusions Community-based testing campaigns serve three valuable functions related to HIV prevention and treatment: 1) enable community members to check their HIV status regularly as part of a personalized prevention strategy that reinforces responsible behaviour; 2) identify recently sero-converted clients who would not otherwise be targeted; and 3) engage community with general prevention and care messaging and services. This model could be expanded to include routine management of other (chronic) diseases and provide an entry for scaling up UHC.
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Astuti DA, Hakimi M, Prabandari YS, Laksanawati IS, Triratnawati A. The Prevention of Mother-to-Child HIV/AIDS Transmission at Public Health Centers: A Phenomenology Study. Open Nurs J 2021. [DOI: 10.2174/1874434602115010195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective:
Mothers with HIV are likely to transmit the virus to their babies during pregnancy, delivery, or through breastfeeding. According to studies, the risk of mother-to-child HIV transmission among mothers that do not receive any form of treatment during pregnancy is approximately 15-45%. In Indonesia, the lack of a prevention program for HIV led to the provision of antiretroviral therapy (ART) for the prevention of mother-to-child transmission (PMTCT). The policies, financial facilities, the healthcare system, and human resources, including health workers, are factors that influence the PMTCT. This research discusses the perceptions of several doctors and midwives regarding the prevention of mother-to-child transmission at public health centers. Furthermore, information regarding policies and implementation of the PMTCT program at public health centers in Yogyakarta was qualitatively collected through semi-structured interviews.
Methods:
This research involved 6 participants, comprising of 3 heads of public health centers and 3 midwives as the HIV/AIDS program managers. A total of 5 themes were selected for the interview, namely policies of mandatory HIV testing for pregnant mothers, inadequate knowledge of the virus, need for PMTCT training, infrastructure and facilities, and HIV retesting.
Results:
Pregnant mothers are at potential risk of exposing health workers to HIV. They are also prone to contracting the virus due to poor educational background and less exposure to health information. Therefore, midwives need Prongs 3 and 4 to avoid contracting the virus while assisting pregnant mothers. Presently, there is a shortage of health promotion media for PMTCT, which include both electronic and print educational media. Therefore, the implementation of HIV testing in Indonesia is mandatory for pregnant mothers at their first antenatal care (ANC). However, despite the importance of conducting this test before labor, there is no regulation to ensure its implementation.
Conclusion:
The success of HIV mitigation is closely associated with the participation of academicians, policymakers, and community networks in providing collaborative planning strategies for the reduction of its spread, and evaluation of the mitigation result.
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Myburgh H, Reynolds L, Hoddinott G, van Aswegen D, Grobbelaar N, Gunst C, Jennings K, Kruger J, Louis F, Mubekapi-Musadaidzwa C, Viljoen L, Wademan D, Bock P. Implementing 'universal' access to antiretroviral treatment in South Africa: a scoping review on research priorities. Health Policy Plan 2021; 36:923-938. [PMID: 33963393 PMCID: PMC8227479 DOI: 10.1093/heapol/czaa094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2020] [Indexed: 01/15/2023] Open
Abstract
‘Universal’ access to antiretroviral treatment (ART) has become the global standard for treating people living with HIV and achieving epidemic control; yet, findings from numerous ‘test and treat’ trials and implementation studies in sub-Saharan Africa suggest that bringing ‘universal' access to ART to scale is more complex than anticipated. Using South Africa as a case example, we describe the research priorities and foci in the literature on expanded ART access. To do so, we adapted Arksey and O’Malley’s six-stage scoping review framework to describe the peer-reviewed literature and opinion pieces on expanding access to ART in South Africa between 2000 and 2017. Data collection included systematic searches of two databases and hand-searching of a sub-sample of reference lists. We used an adapted socio-ecological thematic framework to categorize data according to where it located the challenges and opportunities of expanded ART eligibility: individual/client, health worker–client relationship, clinic/community context, health systems infrastructure and/or policy context. We included 194 research articles and 23 opinion pieces, of 1512 identified, addressing expanded ART access in South Africa. The peer-reviewed literature focused on the individual and health systems infrastructure; opinion pieces focused on changing roles of individuals, communities and health services implementers. We contextualized our findings through a consultative process with a group of researchers, HIV clinicians and programme managers to consider critical knowledge gaps. Unlike the published literature, the consultative process offered particular insights into the importance of researching and intervening in the relational aspects of HIV service delivery as South Africa’s HIV programme expands. An overwhelming focus on individual and health systems infrastructure factors in the published literature on expanded ART access in South Africa may skew understanding of HIV programme shortfalls away from the relational aspects of HIV services delivery and delay progress with finding ways to leverage non-medical modalities for achieving HIV epidemic control.
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Affiliation(s)
- Hanlie Myburgh
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa.,Amsterdam Institute for Social Science Research (AISSR), University of Amsterdam, Nieuwe Achtergracht 166, WV, Amsterdam, the Netherlands
| | - Lindsey Reynolds
- Department of Sociology and Social Anthropology, Faculty of Arts and Social Sciences, Stellenbosch University, c/o Merriman and Ryneveld Avenue, Stellenbosch, 7600, South Africa
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
| | - Dianne van Aswegen
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
| | - Nelis Grobbelaar
- The Anova Health Institute, Willie Van Schoor Avenue, Bellville, Cape Town, 7530, South Africa
| | - Colette Gunst
- Division of Family Medicine and Primary Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa.,Western Cape Department of Health, Cape Winelands District, 7 Haarlem Street, Worcester, 6850, South Africa
| | - Karen Jennings
- City of Cape Town Health Department, Cape Town Municipality, 12 Hertzog Boulevard, Cape Town, 8001, South Africa
| | - James Kruger
- Western Cape Department of Health, HIV Treatment and PMTCT Programme, 4 Dorp Street, Cape Town, 8000, South Africa
| | - Francoise Louis
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
| | - Constance Mubekapi-Musadaidzwa
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
| | - Lario Viljoen
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
| | - Dillon Wademan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
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Financial incentives and deposit contracts to promote HIV retesting in Uganda: A randomized trial. PLoS Med 2021; 18:e1003630. [PMID: 33945526 PMCID: PMC8131095 DOI: 10.1371/journal.pmed.1003630] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 05/18/2021] [Accepted: 04/15/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Frequent retesting for HIV among persons at increased risk of HIV infection is critical to early HIV diagnosis of persons and delivery of combination HIV prevention services. There are few evidence-based interventions for promoting frequent retesting for HIV. We sought to determine the effectiveness of financial incentives and deposit contracts in promoting quarterly HIV retesting among adults at increased risk of HIV. METHODS AND FINDINGS In peri-urban Ugandan communities from October to December 2018, we randomized HIV-negative adults with self-reported risk to 1 of 3 strategies to promote HIV retesting: (1) no incentive; (2) cash incentives (US$7) for retesting at 3 and 6 months (total US$14); or (3) deposit contracts: participants could voluntarily deposit US$6 at baseline and at 3 months that would be returned with interest (total US$7) upon retesting at 3 and 6 months (total US$14) or lost if participants failed to retest. The primary outcome was retesting for HIV at both 3 and 6 months. Of 1,482 persons screened for study eligibility following community-based recruitment, 524 participants were randomized to either no incentive (N = 180), incentives (N = 172), or deposit contracts (N = 172): median age was 25 years (IQR: 22 to 30), 44% were women, and median weekly income was US$13.60 (IQR: US$8.16 to US$21.76). Among participants randomized to deposit contracts, 24/172 (14%) made a baseline deposit, and 2/172 (1%) made a 3-month deposit. In intent-to-treat analyses, HIV retesting at both 3 and 6 months was significantly higher in the incentive arm (89/172 [52%]) than either the control arm (33/180 [18%], odds ratio (OR) 4.8, 95% CI: 3.0 to 7.7, p < 0.001) or the deposit contract arm (28/172 [16%], OR 5.5, 95% CI: 3.3 to 9.1, p < 0.001). Among those in the deposit contract arm who made a baseline deposit, 20/24 (83%) retested at 3 months; 11/24 (46%) retested at both 3 and 6 months. Among 282 participants who retested for HIV during the trial, three (1%; 95%CI: 0.2 to 3%) seroconverted: one in the incentive group and two in the control group. Study limitations include measurement of retesting at the clinic where baseline enrollment occurred, only offering clinic-based (rather than community-based) HIV retesting and lack of measurement of retesting after completion of the trial to evaluate sustained retesting behavior. CONCLUSIONS Offering financial incentives to high-risk adults in Uganda resulted in significantly higher HIV retesting. Deposit contracts had low uptake and overall did not increase retesting. As part of efforts to increase early diagnosis of HIV among high-risk populations, strategic use of incentives to promote retesting should receive greater consideration by HIV programs. TRIAL REGISTRATION clinicaltrials.gov: NCT02890459.
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Marson K, Ndyabakira A, Kwarisiima D, Camlin CS, Kamya MR, Havlir D, Thirumurthy H, Chamie G. HIV retesting and risk behaviors among high-risk, HIV-uninfected adults in Uganda. AIDS Care 2020; 33:675-681. [PMID: 33172300 DOI: 10.1080/09540121.2020.1842319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
There are limited data characterizing HIV retesting among high-risk adults in sub-Saharan Africa. From October-December 2018, we distributed recruitment cards offering health evaluations with HIV testing at venues frequented by individuals at-risk of HIV infection in Southwest Uganda. Those who attended were asked about their HIV testing history and risk factors: having >1 sexual partner, an HIV+ partner, STIs, and/or transactional sex. We defined "highest risk" as ≥3 risk factors and "frequent testing" as ≥3 tests within the past year. Of 1,777 cards distributed, 1,482 (83%) adults came to clinic: median age was 26(IQR: 22-31), 598 (40%) were men, and 334 (23%) were HIV+. Of 1,148 HIV-negative adults, 338 (29%) were highest risk and 205 (18%) were frequent testers. Frequent testing was similar in women (19%) and men (16%, p = 0.22). Among women, those at highest risk were more likely to report any testing (90% vs. 81%, p = 0.01) and frequent testing (25% vs. 18%, p = 0.06) than those at lower risk. Among men, any testing and frequent testing were similar between risk levels. Among adults recruited from high-risk venues in peri-urban Uganda, HIV risk behaviors were commonly reported, yet frequent retesting remained low. Interventions to promote retesting are needed, particularly among men.
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Affiliation(s)
- Kara Marson
- Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Moses R Kamya
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Diane Havlir
- Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Harsha Thirumurthy
- Division of Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Gabriel Chamie
- Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, CA, USA
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9
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Dzinamarira T, Mulindabigwi A, Mashamba-Thompson TP. Co-creation of a health education program for improving the uptake of HIV self-testing among men in Rwanda: nominal group technique. Heliyon 2020; 6:e05378. [PMID: 33163663 PMCID: PMC7610321 DOI: 10.1016/j.heliyon.2020.e05378] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/15/2020] [Accepted: 10/27/2020] [Indexed: 11/29/2022] Open
Abstract
Objective This study sought to collaborate with key stakeholders to reach a consensus regarding the predominant barriers preventing the uptake of HIV testing services (HTS) by men and co-create an acceptable educational program to improve the knowledge of HIV self-testing (HIVST) among men in Rwanda. Methods We employed the nominal group technique to identify a consensus regarding the predominant barriers currently impeding the male uptake of HTS. The health education program content was guided by the ranked barriers. We applied Mezirow's Transformational Learning Theory for curriculum development. Results Eleven key barriers currently impeding the male uptake of HTS were identified in the nominal group process. The stakeholders co-created an interactive, structured curriculum containing information on the health locus of control; HIV etiology, transmission, diagnosis, status disclosure benefits, care and treatment services; and an overview of the HIVST background and test procedure to address multiple barriers. Conclusion Key stakeholders co-created a comprehensive health education program tailored to men, which integrates education about health beliefs, HIV/AIDS and HIVST. Further studies to assess the effectiveness of the program are needed. It is anticipated that the intervention will improve the uptake of HIVST among men in Kigali, Rwanda.
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Affiliation(s)
- Tafadzwa Dzinamarira
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa
| | | | - Tivani Phosa Mashamba-Thompson
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa.,CIHR Canadian HIV Trials Network, Vancouver, BC, Canada.,Department of Public Health, University of Limpopo, Polokwane, Limpopo Province, South Africa
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10
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A pilot randomized trial of incentive strategies to promote HIV retesting in rural Uganda. PLoS One 2020; 15:e0233600. [PMID: 32470089 PMCID: PMC7259772 DOI: 10.1371/journal.pone.0233600] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 05/07/2020] [Indexed: 11/24/2022] Open
Abstract
Background Retesting for HIV is critical to identifying newly-infected persons and reinforcing prevention efforts among at-risk adults. Incentives can increase one-time HIV testing, but their role in promoting retesting is unknown. We sought to test feasibility and acceptability of incentive strategies, including commitment contracts, to promote HIV retesting among at-risk adults in rural Uganda. Methods At-risk HIV-negative adults were enrolled in a pilot trial assessing feasibility and acceptability of incentive strategies to promote HIV retesting three months after enrollment. Participants were randomized (1:1:3) to: 1) no incentive; 2) standard cash incentive (~US$4); and 3) commitment contract: participants could voluntarily make a low- or high-value deposit that would be returned with added interest (totaling ~US$4 including the deposit) upon retesting or lost if participants failed to retest. Contracts sought to promote retesting by leveraging loss aversion and addressing present bias via pre-commitment. Outcomes included acceptability of trial enrollment, contract feasibility (proportion of participants making deposits), and HIV retesting uptake. Results Of 130 HIV-negative eligible adults, 123 (95%) enrolled and were randomized: 74 (60%) to commitment contracts, 25 (20%) to standard incentives, and 24 (20%) to no incentive. Of contract participants, 69 (93%) made deposits. Overall, 93 (76%) participants retested for HIV: uptake was highest in the standard incentive group (22/25 [88%]) and lowest in high-value contract (26/36 [72%]) and no incentive (17/24 [71%]) groups. Conclusion In a randomized trial of strategies to promote HIV retesting among at-risk adults in Uganda, incentive strategies, including commitment contracts, were feasible and had high acceptability. Our findings suggest use of incentives for HIV retesting merits further comparison in a larger trial. Trial registration ClinicalTrials.gov identifier: NCT:02890459
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11
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Horter S, Seeley J, Bernays S, Kerschberger B, Lukhele N, Wringe A. Dissonance of Choice: Biomedical and Lived Perspectives on HIV Treatment-Taking. Med Anthropol 2020; 39:675-688. [PMID: 32078396 DOI: 10.1080/01459740.2020.1720981] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Treat-all recommends prompt treatment initiation for those diagnosed HIV positive, requiring adaptations to individuals' behavior and practice. Drawing on data from a longitudinal qualitative study in Eswatini, we examine the choice to initiate treatment when asymptomatic, the dissonance between the biomedical logic surrounding Treat-all and individuals' conceptions of treatment necessity, and the navigation over time of ongoing engagement with care. We reflect on the perspectives of healthcare workers, responsible for implementing Treat-all and holding a duty of care for their patients. We explore how the potentially differing needs and priorities of individuals and the public health agenda are navigated and reconciled. Rationalities regarding treatment-taking extend beyond the biomedical realm, requiring adjustments to sense of self and identity, and decision-making that is situated and socially embedded. Sense of choice and ownership for this process is important for individuals' engagement with treatment and care.
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Affiliation(s)
- Shona Horter
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine , London, UK.,Research Department, Medecins Sans Frontieres , Nhlangano, Swaziland
| | - Janet Seeley
- Global Health and Development, London School of Hygiene and Tropical Medicine , London, UK.,MRC/UVRI Uganda Research Unit On AIDS , Entebbe, Uganda
| | - Sarah Bernays
- The University of Sydney School of Public Health , Sydney, Australia
| | | | | | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine , London, UK
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12
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Falling Short of the First 90: HIV Stigma and HIV Testing Research in the 90-90-90 Era. AIDS Behav 2020; 24:357-362. [PMID: 31907675 DOI: 10.1007/s10461-019-02771-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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13
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Krishnaratne S, Bond V, Stangl A, Pliakas T, Mathema H, Lilleston P, Hoddinott G, Bock P, Ayles H, Fidler S, Hargreaves JR. Stigma and Judgment Toward People Living with HIV and Key Population Groups Among Three Cadres of Health Workers in South Africa and Zambia: Analysis of Data from the HPTN 071 (PopART) Trial. AIDS Patient Care STDS 2020; 34:38-50. [PMID: 31944852 DOI: 10.1089/apc.2019.0131] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Stigma and judgment by health workers toward people living with HIV (PLHIV) and key populations can undermine the uptake of HIV services. In 2014, we recruited health workers delivering HIV services from 21 urban communities in South Africa and Zambia participating in the first year of the HPTN 071 (PopART) cluster-randomized trial. We analyzed self-reported levels of stigma and judgment toward (1) PLHIV, (2) women who sell sex, (3) men who have sex with men (MSM), and (4) young women who become pregnant before marriage. Using logistic regression, we compared responses between three health worker cadres and explored risk factors for stigmatizing attitudes. Highest levels of stigma and judgment were in relation to women who sell sex and MSM, especially in Zambia. Heath workers did not generally think that clients should be denied services, although this was reported slightly more commonly by community health workers. Higher education levels were associated with lower judgmental beliefs, whereas higher perceptions of coworker stigmatizing behaviors toward PLHIV and each key population were associated with holding judgmental beliefs. Training experience was not associated with judgmental attitudes for any of the key populations. Our findings confirm a high prevalence of judgmental attitudes toward key population groups but lower levels in relation to PLHIV, among all cadres of health workers in both countries. Planning and implementing targeted stigma reduction interventions within health settings are critical to meet the needs of vulnerable populations that face more stigmatizing attitudes from health workers.
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Affiliation(s)
- Shari Krishnaratne
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Virginia Bond
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Zambart, The School of Medicine, University of Zambia, Lusaka, Zambia
| | - Anne Stangl
- International Centre for Research on Women, Washington, District of Columbia
| | - Triantafyllos Pliakas
- Department of Public Health Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Hlengani Mathema
- Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Pamela Lilleston
- International Centre for Research on Women, Washington, District of Columbia
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Helen Ayles
- Zambart, The School of Medicine, University of Zambia, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sarah Fidler
- Department of Medicine, Imperial College London, London, United Kingdom
| | - James R. Hargreaves
- Department of Public Health Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
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14
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Perriat D, Balzer L, Hayes R, Lockman S, Walsh F, Ayles H, Floyd S, Havlir D, Kamya M, Lebelonyane R, Mills LA, Okello V, Petersen M, Pillay D, Sabapathy K, Wirth K, Orne-Gliemann J, Dabis F. Comparative assessment of five trials of universal HIV testing and treatment in sub-Saharan Africa. J Int AIDS Soc 2019; 21. [PMID: 29314658 PMCID: PMC5810333 DOI: 10.1002/jia2.25048] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 11/27/2017] [Indexed: 02/03/2023] Open
Abstract
Design Universal voluntary HIV counselling and testing followed by prompt initiation of antiretroviral therapy (ART) for all those diagnosed HIV‐infected (universal test and treat, UTT) is now a global health standard. However, its population‐level impact, feasibility and cost remain unknown. Five community‐based trials have been implemented in sub‐Saharan Africa to measure the effects of various UTT strategies at population level: BCPP/YaTsie in Botswana, MaxART in Swaziland, HPTN 071 (PopART) in South Africa and Zambia, SEARCH in Uganda and Kenya and ANRS 12249 TasP in South Africa. This report describes and contrasts the contexts, research methodologies, intervention packages, themes explored, evolution of study designs and interventions related to each of these five UTT trials. Methods We conducted a comparative assessment of the five trials using data extracted from study protocols and collected during baseline studies, with additional input from study investigators. We organized differences and commonalities across the trials in five categories: trial contexts, research designs, intervention packages, trial themes and adaptations. Results All performed in the context of generalized HIV epidemics, the trials highly differ in their social, demographic, economic, political and health systems settings. They share the common aim of assessing the impact of UTT on the HIV epidemic but differ in methodological aspects such as study design and eligibility criteria for trial populations. In addition to universal ART initiation, the trials deliver a wide range of biomedical, behavioural and structural interventions as part of their UTT strategies. The five studies explore common issues, including the uptake rates of the trial services and individual health outcomes. All trials have adapted since their initiation to the evolving political, economic and public health contexts, including adopting the successive national recommendations for ART initiation. Conclusions We found substantial commonalities but also differences between the five UTT trials in their design, conduct and multidisciplinary outputs. As empirical literature on how UTT may improve efficiency and quality of HIV care at population level is still scarce, this article provides a foundation for more collaborative research on UTT and supports evidence‐based decision making for HIV care in country and internationally.
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Affiliation(s)
- Delphine Perriat
- Inserm, Bordeaux Population Health Research Center, UMR 1219, University Bordeaux, Bordeaux, France.,Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France.,Africa Health Research Institute, Somkhele, KwaZulu-Natal, South Africa (ANRS TasP trial)
| | - Laura Balzer
- University of California San Francisco, San Francisco, CA, USA (SEARCH trial).,University of Massachusetts Amherst, Amherst, MA, USA
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom (PopART trial)
| | - Shahin Lockman
- Harvard School of Public Health, Boston, MA, USA (BCPP trial).,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana (BCPP trial).,Brigham and Women's Hospital, Boston, MA, USA (BCPP trial)
| | - Fiona Walsh
- Clinton Health Access Initiative, Boston, MA, USA (MaxART trial)
| | - Helen Ayles
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom (PopART trial).,Zambart, Lusaka, Zambia
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom (PopART trial)
| | - Diane Havlir
- University of California San Francisco, San Francisco, CA, USA (SEARCH trial)
| | - Moses Kamya
- Makerere University School of Medicine, Uganda (SEARCH trial)
| | | | - Lisa A Mills
- Centers for Disease Control, Gaborone, Botswana (BCPP trial)
| | - Velephi Okello
- Ministry of Health, Kingdom of Swaziland, Mbabane, Swaziland (MaxART trial)
| | - Maya Petersen
- University of California Berkeley School of Public Health, Berkeley, CA, USA (SEARCH trial)
| | - Deenan Pillay
- Africa Health Research Institute, Somkhele, KwaZulu-Natal, South Africa (ANRS TasP trial).,Department of Infection, University College London, London, United Kingdom (ANRS TasP trial)
| | - Kalpana Sabapathy
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom (PopART trial)
| | - Kathleen Wirth
- Department of Infection, University College London, London, United Kingdom (ANRS TasP trial)
| | - Joanna Orne-Gliemann
- Inserm, Bordeaux Population Health Research Center, UMR 1219, University Bordeaux, Bordeaux, France.,Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France.,Africa Health Research Institute, Somkhele, KwaZulu-Natal, South Africa (ANRS TasP trial)
| | - François Dabis
- Inserm, Bordeaux Population Health Research Center, UMR 1219, University Bordeaux, Bordeaux, France.,Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France.,Africa Health Research Institute, Somkhele, KwaZulu-Natal, South Africa (ANRS TasP trial)
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15
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Correlates of Undiagnosed HIV Infection and Retesting Among Voluntary HIV Testing Clients at Mildmay Clinic, Uganda. AIDS Behav 2019; 23:820-834. [PMID: 30255386 DOI: 10.1007/s10461-018-2274-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Increasing HIV diagnosis is important for combatting HIV. We invited individuals aged ≥ 13 years seeking voluntary HIV testing at Mildmay Clinic in Uganda to undertake a computer or audio-computer-assisted self-interview to facilitate post-test counseling. We evaluated first-visit data from 12,233 consenting individuals between January 2011 and October 2013. HIV prevalence was 39.0%. Of those with HIV, 37.2% already knew they were infected. Undiagnosed infection was associated with not being single, screening positive for depression (aOR 1.16, 95% CI 1.04-1.28), and screening for harmful drinking behavior (aOR 1.23, 95% CI 1.10-1.39). The odds of retesting subsequent to HIV diagnosis were lower for males (aOR 0.80, 95% CI 0.70-0.92) and those screening positive for harmful drinking behavior (aOR 0.77, 95% CI 0.66-0.88). Retesting was also associated with higher education and perceived social status below 'better off'. Our findings reiterate the value of population-based HIV surveys to provide estimates of testing coverage.
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16
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Harichund C, Kunene P, Simelane S, Abdool Karim Q, Moshabela M. Repeat HIV testing practices in the era of HIV self-testing among adults in KwaZulu-Natal, South Africa. PLoS One 2019; 14:e0212343. [PMID: 30794580 PMCID: PMC6386490 DOI: 10.1371/journal.pone.0212343] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 01/31/2019] [Indexed: 11/30/2022] Open
Abstract
Repeat HIV testing is important in high HIV burden communities to enable sustainability of prevention initiatives; however, an understanding of repeat testing practices is limited. Additional HIV testing approaches may be required to increase testing. HIV self-testing is an additional testing approach, but knowledge on its potential for repeat testing is limited. This study explored repeat HIV testing practices and uptake of HIV self-testing among repeat testers, following exposure to HIV self-testing. HIV testing practices were explored at two time points. During Phase 1, eighty in-depth interviews were conducted among 40 consenting adults, and 30 telephonic contacts were completed during Phase 2. Framework analysis was used to analyse the transcripts from the in-depth interviews. The practice of repeat HIV testing is primarily influenced by HIV status awareness and risk exposure. Thirteen regular testers and one HIV naïve tester at baseline had undergone repeat testing through the use of a traditional testing approach such as HIV counselling and testing as reported in Phase 2. HIV self-testing has a role among repeat testers, but affordability and access are barriers.
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Affiliation(s)
- Charlene Harichund
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- * E-mail:
| | - Pinky Kunene
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | | | - Quarraisha Abdool Karim
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- Department of Epidemiology, Columbia University, New York, New York, United States of America
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Mosa Moshabela
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Africa Health Research Institute, KwaZulu-Natal, South Africa
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17
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Horter S, Bernays S, Thabede Z, Dlamini V, Kerschberger B, Pasipamire M, Rusch B, Wringe A. "I don't want them to know": how stigma creates dilemmas for engagement with Treat-all HIV care for people living with HIV in Eswatini. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2019; 18:27-37. [PMID: 30782082 DOI: 10.2989/16085906.2018.1552163] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
"Treat-all" programmes aim to improve clinical outcomes and to reduce HIV transmission through regular HIV testing and immediate offer of antiretroviral therapy (ART) for those diagnosed HIV-positive, irrespective of immunological status and symptoms of disease. Global narratives on the benefits of Treat-all anticipate reduced HIV-related stigma and increased "normalisation" of HIV with Treat-all implementation, whereby HIV is remoulded as a manageable, chronic condition where stigmatising symptoms can be concealed. Drawing on Goffman's stigma work, we aimed to investigate how stigma may influence the engagement of clinically asymptomatic people living with HIV (PLHIV) with Treat-all HIV care in Shiselweni, Eswatini (formerly Swaziland). This longitudinal research comprised 106 interviews conducted from August 2016 to September 2017, including repeated interviews with 30 PLHIV, and one-off interviews with 20 healthcare workers. Data were analysed thematically using NVivo 11, drawing upon principles of grounded theory to generate findings inductively from participants' accounts. Stigma was pervasive within the narratives of PLHIV, framing their engagement with treatment and care. Many asymptomatic PLHIV were motivated to initiate ART in order to maintain a "discreditable" status, by preventing the development of visible and exposing symptoms. However, engagement with treatment and care services could itself be exposing. PLHIV described the ways in which these "invisibilising" benefits and exposing risks of ART were continually assessed and navigated over time. Where the risk of exposure was deemed too great, this could lead to intermittent treatment-taking, and disengagement from care. Addressing HIV related stigma is crucial to the success of Treat-all, and should thus be a core component of HIV responses.
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Affiliation(s)
- Shona Horter
- a London School of Hygiene and Tropical Medicine , London , UK.,b Médecins sans Frontières/Doctors Without Borders , Nhlangano , Eswatini
| | - Sarah Bernays
- c Sydney School of Public Health , University of Sydney , Sydney , Australia
| | - Zanele Thabede
- b Médecins sans Frontières/Doctors Without Borders , Nhlangano , Eswatini
| | - Velibanti Dlamini
- b Médecins sans Frontières/Doctors Without Borders , Nhlangano , Eswatini
| | | | - Munyaradzi Pasipamire
- d Swaziland National AIDS Programme , Swaziland Ministry of Health , Mbabane , Eswatini
| | - Barbara Rusch
- e Médecins sans Frontières/Doctors without Borders , Geneva , Switzerland
| | - Alison Wringe
- a London School of Hygiene and Tropical Medicine , London , UK
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18
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Performance of self-reported HIV status in determining true HIV status among older adults in rural South Africa: a validation study. J Int AIDS Soc 2017; 20:21691. [PMID: 28782333 PMCID: PMC5577734 DOI: 10.7448/ias.20.1.21691] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Introduction: In South Africa, older adults make up a growing proportion of people living with HIV. HIV programmes are likely to reach older South Africans in home-based interventions where testing is not always feasible. We evaluate the accuracy of self-reported HIV status, which may provide useful information for targeting interventions or offer an alternative to biomarker testing. Methods: Data were taken from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) baseline survey, which was conducted in rural Mpumalanga province, South Africa. A total of 5059 participants aged ≥40 years were interviewed from 2014 to 2015. Self-reported HIV status and dried bloodspots for HIV biomarker testing were obtained during at-home interviews. We calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for self-reported status compared to “gold standard” biomarker results. Log-binomial regression explored associations between demographic characteristics, antiretroviral therapy (ART) status and sensitivity of self-report. Results: Most participants (93%) consented to biomarker testing. Of those with biomarker results, 50.9% reported knowing their HIV status and accurately reported it. PPV of self-report was 94.1% (95% confidence interval (CI): 92.0–96.0), NPV was 87.2% (95% CI: 86.2–88.2), sensitivity was 51.2% (95% CI: 48.2–54.3) and specificity was 99.0% (95% CI: 98.7–99.4). Participants on ART were more likely to report their HIV-positive status, and participants reporting false-negatives were more likely to have older HIV tests. Conclusions: The majority of participants were willing to share their HIV status. False-negative reports were largely explained by lack of testing, suggesting HIV stigma is retreating in this setting, and that expansion of HIV testing and retesting is still needed in this population. In HIV interventions where testing is not possible, self-reported status should be considered as a routine first step to establish HIV status.
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19
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Beyrer C, Shisana O, Baral SD, Milsana K, Mayer KH, Pozniak A, Walker BD, Mboup S, Sohn AH, Serwadda D, Rees H, Dvoriak S, Warren M, Thiam S, El-Sadr WM, Hospital X, Ryan O, Thomson N, Bekker LG. The science of Durban, AIDS 2016. J Int AIDS Soc 2017; 20:21781. [PMID: 28692209 PMCID: PMC5515038 DOI: 10.7448/ias.20.1.21781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 04/25/2017] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION The science presented at the 21st International AIDS Conference in Durban, South Africa, in July 2016, addressed the state of the field across basic, clinical, prevention, law and policy and implementation science. METHODS AND RESULTS The AIDS response has seen remarkable achievements in scientific advances, in translation of those advances into prevention, treatment and care for affected individuals and communities, and in large scale implementation - reaching 18 million people with antiviral therapy by mid-year 2016. Yet incident HIV infections in adults remain stubbornly stable and are increasing in some regions and among adolescents and adults in some key populations, challenging current science, policy and programming. There have been important advances in both preventive vaccines and in cure research, but both areas require ongoing investment and innovation. Clinical research has flourished with new agents, regimens, delivery modes and diagnostics but has been challenged by aging and increasingly complex patient populations, long-term adherence challenges, co-infections and co-morbidities, and unresolved issues in TB management and epidemic control. It is an extraordinary period of innovation in prevention, yet the promise of new tools and combination approaches have yet to deliver epidemic HIV control. CONCLUSIONS Proven interventions, most notably pre-exposure prophylaxis, PrEP, have been limited in rollout and impact. Treatment as prevention has the promise to improve clinical outcomes but remains uncertain as a prevention tool to reduce population-level HIV incidence. The improvement of legal, policy and human rights environments for those most at risk for HIV acquisition and most at risk for lack of access to essential services; sexual and gender minorities, sex workers of all genders, people who inject drugs, and prisoners and detainees remain among the greatest unmet needs in HIV/AIDS. Failure to do better for these individuals and communities could undermine the HIV response.
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Affiliation(s)
- Chris Beyrer
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- International AIDS Society, Geneva, Switzerland
| | | | - Stefan D. Baral
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Koleka Milsana
- Department of Medicine, University of KwaZulua Natal, Durban, South Africa
| | - Kenneth H. Mayer
- Department of Medicine, Harvard Medical School, Fenway Community Health Center, Boston, USA
| | - Anton Pozniak
- Department of Medicine, Chelsea and Westminster Hospital, London, UK
| | - Bruce D. Walker
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA
| | - Souleman Mboup
- Institut de Recherche en Santé, de Surveillance Epidemiologique et de Formations, Dakar, Senegal
| | - Annette H. Sohn
- TREAT Asia, amfAR – The Foundation for AIDS Research, Bangkok, Thailand
| | - David Serwadda
- Department of Epidemiology, Makerere University School of Public Health Kampala, Uganda
| | - Helen Rees
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Sergii Dvoriak
- Ukrainian Institute on Public Health Policy, Kiev, Ukraine
| | | | - Safiatou Thiam
- Department of Health, National AIDS Council of Senegal, Dakar
| | - Wafaa M. El-Sadr
- Mailman School of Public Health, ICAP at Columbia University, New York, NY, USA
| | - Xavier Hospital
- Department of Health, UNESCO Regional Office in Dakar, Dakar, Senegal
| | - Owen Ryan
- International AIDS Society, Geneva, Switzerland
| | - Nicolas Thomson
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Linda-Gail Bekker
- International AIDS Society, Geneva, Switzerland
- Desmond Tutu HIV Research Foundation, University of Cape Town, Cape Town, South Africa
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20
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Reynolds LJ, Camlin CS, Ware NC, Seeley J. Exploring critical questions for the implementation of "universal test and treat" approaches to HIV prevention and care. AIDS Care 2016; 28 Suppl 3:1-6. [PMID: 27421046 DOI: 10.1080/09540121.2016.1178960] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Lindsey J Reynolds
- a Population Studies and Training Center , Brown University , Providence , RI , USA.,b Department of Sociology and Social Anthropology , Stellenbosch University , Stellenbosch , South Africa
| | - Carol S Camlin
- c Department of Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health, and Center for AIDS Prevention Studies , University of California , San Francisco , CA , USA
| | - Norma C Ware
- d Department of Global Health & Social Medicine , Harvard Medical School , Boston , MA , USA.,e Department of Medicine , Brigham and Women's Hospital , Boston , MA , USA
| | - Janet Seeley
- f Department of Global Health and Development , London School of Hygiene and Tropical Medicine , London , UK
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21
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Chikovore J, Gillespie N, McGrath N, Orne-Gliemann J, Zuma T. Men, masculinity, and engagement with treatment as prevention in KwaZulu-Natal, South Africa. AIDS Care 2016; 28 Suppl 3:74-82. [PMID: 27421054 PMCID: PMC5096677 DOI: 10.1080/09540121.2016.1178953] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Men's poorer engagement with healthcare generally and HIV care specifically, compared to women, is well-described. Within the HIV public health domain, interest is growing in universal test and treat (UTT) strategies. UTT strategies refer to the expansion of antiretroviral therapy (ART) in order to reduce onward transmission and incidence of HIV in a population, through a "treatment as prevention" (TasP). This paper focuses on how masculinity influences engagement with HIV care in the context of an on-going TasP trial. Data were collected in January-November 2013 using 20 in-depth interviews, 10 of them repeated thrice, and 4 focus group discussions, each repeated four times. Analysis combined inductive and deductive approaches for coding and the review and consolidation of emerging themes. The accounts detailed men's unwillingness to engage with HIV testing and care, seemingly tied to their pursuit of valued masculinity constructs such as having strength and control, being sexually competent, and earning income. Articulated through fears regarding getting an HIV-positive diagnosis, observations that men preferred traditional medicine and that primary health centres were not welcoming to men, descriptions that men used lay measures to ascertain HIV status, and insinuations by men that they were removed from HIV risk, the indisposition to HIV care contrasted markedly with an apparent readiness to test among women. Gendered tensions thus emerged which were amplified in the context where valued masculinity representations were constantly threatened. Amid the tensions, men struggled with disclosing their HIV status, and used various strategies to avoid or postpone disclosing, or disclose indirectly, while women's ability to access care readily, use condoms, or communicate about HIV appeared similarly curtailed. UTT and TasP promotion should heed and incorporate into policy and health service delivery models the intrapersonal tensions, and the conflict, and poor and indirect communication at the micro-relational levels of couples and families.
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Affiliation(s)
- Jeremiah Chikovore
- HIV/AIDS, STIs and TB Programme, Human Sciences Research Council (HSRC), Durban, South Africa
| | | | - Nuala McGrath
- Faculty of Medicine, University of Southampton, Southampton, UK
- Faculty of Social, Human and Mathematical Sciences, University of Southampton, Southampton, UK
- Africa Centre for Population Health, University of KwaZulu Natal, Mtubatuba, South Africa
- Research Department of Infection and Population Health, University College London, London, UK
| | - Joanna Orne-Gliemann
- INSERM, ISPED, Centre INSERM U1219 - Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
| | - Thembelihle Zuma
- Africa Centre for Population Health, University of KwaZulu Natal, Mtubatuba, South Africa
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