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Rautenbach SP, Whittles LK, Meyer-Rath G, Jamieson L, Chidarikire T, Johnson LF, Imai-Eaton JW. Future HIV epidemic trajectories in South Africa and projected long-term consequences of reductions in general population HIV testing: a mathematical modelling study. Lancet Public Health 2024; 9:e218-e230. [PMID: 38553141 PMCID: PMC11000585 DOI: 10.1016/s2468-2667(24)00020-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/16/2024] [Accepted: 01/25/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND After successful intensive interventions to rapidly increase HIV awareness, coverage of antiretroviral therapy (ART), and viral suppression, HIV programmes in eastern and southern Africa are considering scaling back of some interventions, such as widespread general population HIV testing. We aimed to model whether scaling back of general population HIV testing in South Africa could result in a resurgence of the HIV epidemic or substantial slowing of declines in HIV incidence, resulting in increased long-term ART. METHODS In this modelling study, we used the Thembisa 4.5 model (a deterministic compartmental model of HIV transmission in South Africa) to project the South African HIV epidemic to 2100 assuming the continuation of 2022 epidemiological conditions and HIV programme implementation. We assessed how implementing reductions in general population HIV testing services in 2025 (while maintaining antenatal, symptom-based, and risk-based testing modalities and other HIV prevention services at 2022 levels) would affect HIV incidence and prevalence among people aged 15-49 years, the year in which incidence would reach one per 1000 people aged 15-49 years (the threshold for virtual elimination of HIV), and associated costs, as well as numbers of additional new HIV infections and AIDS-related deaths. We also modelled the effects of delaying reductions in general population testing services by 5-year increments. Additionally, we modelled the potential effects of reductions in general population testing services in combination with increases or decreases in ART interruption rates (ie, the annual rate at which people who are on ART discontinue ART) and condom usage in 2025-35. FINDINGS If general population HIV testing services and the HIV risk environment of 2022 were maintained, we projected that HIV incidence would steadily decline from 4·95 (95% CI 4·40-5·34) per 1000 population in 2025 to 0·14 (0·05-0·31) per 1000 in 2100, and that the so-called virtual elimination threshold of less than one new infection per 1000 population per year would be reached in 2055 (95% CI 2051-2060). Scaling back of general population HIV testing services by 25%, 50%, or 75% in 2025 delayed time to reaching the virtual elimination threshold by 5, 13, or 35 years, respectively, whereas complete cessation of general population testing would result in the threshold not being attained by 2100. Although the incidence of HIV continued to fall when general HIV testing services were reduced, our modelling suggested that, with reductions of between 25% and 100%, between 396 000 (95% CI 299 000-474 000) and 2·50 million (1·97 million-2·98 million) additional HIV infections and between 115 000 (94 000-135 000) and 795 000 (670 000-926 000) additional AIDS-related deaths would occur between 2025 and 2075, depending on the extent of reduction in testing. Delaying reductions in general population HIV testing services for 5-25 years mitigated some of these effects. HIV testing accounted for only 5% of total programmatic costs at baseline; reducing testing moderately reduced short-term total annual costs, but increased annual costs after 25 years. Increases in ART interruption and reductions in condom usage were projected to slow the decline in incidence and increase the coverage of general HIV testing services required to control transmission but did not cause rapid resurgence in HIV infections. INTERPRETATION Our modelling suggests that scaling back of general population HIV testing would not result in a resurgence of HIV infections, but would delay attainment of incidence-reduction targets and result in long-term increases in HIV infections, AIDS-related deaths, and costs (via increased need for ART provision). HIV programmes need to balance short-term potential resource savings with long-term epidemic control objectives. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Stefan P Rautenbach
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK.
| | - Lilith K Whittles
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Global Health, School of Public Health, Boston University, Boston, MA, USA; South African Department of Science and Innovation and National Research Foundation Centre of Excellence in Epidemiological Modelling and Analysis, Stellenbosch University, Stellenbosch, South Africa
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; South African Department of Science and Innovation and National Research Foundation Centre of Excellence in Epidemiological Modelling and Analysis, Stellenbosch University, Stellenbosch, South Africa
| | - Thato Chidarikire
- HIV and AIDS and STI Unit, National Department of Health, Johannesburg, South Africa
| | - Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Jeffrey W Imai-Eaton
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK; Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
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Thinking clearly about social aspects of infectious disease transmission. Nature 2021; 595:205-213. [PMID: 34194045 DOI: 10.1038/s41586-021-03694-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 06/04/2021] [Indexed: 02/06/2023]
Abstract
Social and cultural forces shape almost every aspect of infectious disease transmission in human populations, as well as our ability to measure, understand, and respond to epidemics. For directly transmitted infections, pathogen transmission relies on human-to-human contact, with kinship, household, and societal structures shaping contact patterns that in turn determine epidemic dynamics. Social, economic, and cultural forces also shape patterns of exposure, health-seeking behaviour, infection outcomes, the likelihood of diagnosis and reporting of cases, and the uptake of interventions. Although these social aspects of epidemiology are hard to quantify and have limited the generalizability of modelling frameworks in a policy context, new sources of data on relevant aspects of human behaviour are increasingly available. Researchers have begun to embrace data from mobile devices and other technologies as useful proxies for behavioural drivers of disease transmission, but there is much work to be done to measure and validate these approaches, particularly for policy-making. Here we discuss how integrating local knowledge in the design of model frameworks and the interpretation of new data streams offers the possibility of policy-relevant models for public health decision-making as well as the development of robust, generalizable theories about human behaviour in relation to infectious diseases.
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Avanceña ALV, Hutton DW. Optimization Models for HIV/AIDS Resource Allocation: A Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:1509-1521. [PMID: 33127022 DOI: 10.1016/j.jval.2020.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 07/23/2020] [Accepted: 08/07/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE This study reviews optimization models for human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) resource allocation. METHODS We searched 2 databases for peer-reviewed articles published from January 1985 through August 2019 that describe optimization models for resource allocation in HIV/AIDS. We included models that consider 2 or more competing HIV/AIDS interventions. We extracted data on selected characteristics and identified similarities and differences across models. We also assessed the quality of mathematical disease transmission models based on the best practices identified by a 2010 task force. RESULTS The final qualitative synthesis included 23 articles that used 14 unique optimization models. The articles shared several characteristics, including the use of dynamic transmission modeling to estimate health benefits and the inclusion of specific high-risk groups in the study population. The models explored similar HIV/AIDS interventions that span primary and secondary prevention and antiretroviral treatment. Most articles were focused on sub-Saharan African countries (57%) and the United States (39%). There was notable variation in the types of optimization objectives across the articles; the most common was minimizing HIV incidence or maximizing infections averted (87%). Articles that utilized mathematical modeling of HIV disease and transmission displayed variable quality. CONCLUSIONS This systematic review of the literature identified examples of optimization models that have been applied in different settings, many of which displayed similar features. There were similarities in objective functions across optimization models, but they did not align with global HIV/AIDS goals or targets. Future work should be applied in countries facing the largest declines in HIV/AIDS funding.
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Affiliation(s)
- Anton L V Avanceña
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA.
| | - David W Hutton
- Department of Health Management and Policy and Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI, USA
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Onoya D, Sineke T, Hendrickson C, Mokhele I, Maskew M, Long LC, Fox M. Impact of the test and treat policy on delays in antiretroviral therapy initiation among adult HIV positive patients from six clinics in Johannesburg, South Africa: results from a prospective cohort study. BMJ Open 2020; 10:e030228. [PMID: 32213514 PMCID: PMC7170559 DOI: 10.1136/bmjopen-2019-030228] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES To assess delays to antiretroviral therapy (ART) initiation before and after the Universal Test and Treat (UTT) and the same-day initiation (SDI) of ART policy periods in Johannesburg, South Africa. DESIGN Prospective cohort study. SETTING Patients were recruited from six primary health clinics in Johannesburg. PARTICIPANTS Overall, 1029 newly diagnosed HIV positive adults (≥18 years) were consecutively enrolled by referral from the testing counsellor between April and December 2015 (pre-UTT n=146), July and August 2017 (UTT, n=141) and October 2017 and August 2018 (SDI, n=742). MAIN OUTCOME MEASURES Cox proportional hazards regression was used to assess predictors of 30 days ART initiation. Additionally, predictors of immediate ART initiation were evaluated using Poisson regression. RESULTS Overall, 30 days ART proportions were 71.9% overall, 36.9% pre-UTT (44.3% of those eligible), 65.9% under UTT and 79.9% under the SDI policy. The median days to ART initiation declined from 21 pre-UTT (IQR: 15-30) to 8 (IQR: 6-16) under UTT and 5 days (IQR: 0-8) under the SDI policy. However, only 150 (20.2%) of the SDI cohort-initiated ART immediately after HIV diagnosis. Living in a two-adult home (adjusted HR (aHR) 1.2 vs living alone, 95% CI 1.0 to 1.5) increased the likelihood of 30-day ART. Missing baseline cluster of differentiation four (CD4) data decreased the likelihood of 30 days ART by 40% (aHR 0.6 vs CD4 <350 cells/µL, 95% CI 0.5 to 0.7). More women took up immediate ART (adjusted relative risk (aRR) 1.3, 95% CI 1.0 to 1.9). Participants ≥40 years (aRR 0.6 vs 18-24 years, 95% CI 0.4 to 0.9) were less likely to start ART immediately after HIV diagnosis. However, immediate ART rates increased with longer policy implementation time (aRR 0.2 for <3 months vs >10 months, 95% CI 0.1 to 0.4). CONCLUSIONS The study results highlight a positive move towards earlier ART initiation during the UTT and SDI periods and emphasise a need to increase same-day ART implementation further.
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Affiliation(s)
- Dorina Onoya
- Health Economics & Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Tembeka Sineke
- Health Economics & Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Cheryl Hendrickson
- Health Economics & Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Idah Mokhele
- Health Economics & Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Mhairi Maskew
- Health Economics & Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence C Long
- Health Economics & Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Matthew Fox
- Health Economics & Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, USA
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts, USA
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Abstract
The HIV Prevention Trials Network 052 study (HPTN 052) was a clinical trial designed to determine whether early treatment for HIV infection prevented transmission of the virus in couples where one partner was infected with HIV and the other was not, referred to as HIV serodiscordant or serodifferent couples. The study enrolled 1,763 couples at 13 sites in 9 countries in Asia, Africa, and the Americas. HPTN 052 demonstrated a minimum of 96% reduction of HIV in heterosexual couples ascribed to antiretroviral treatment; early treatment of HIV significantly reduced other infections in the HIV-infected subjects. This study, in conjunction with similar research, led to significant changes in international HIV treatment guidelines and the concept of treatment as prevention (TasP). This article provides the scientific background and history of how HPTN 052 came into being, the challenges it faced, and the ultimate impact it had on the fields of HIV treatment and prevention.
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Affiliation(s)
- Myron S Cohen
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina 27516, USA;
- Science Facilitation Department, HIV Prevention Trials Network (HPTN) Leadership and Operations Center, FHI 360, Durham, North Carolina 27701, USA; ,
| | - Theresa Gamble
- Science Facilitation Department, HIV Prevention Trials Network (HPTN) Leadership and Operations Center, FHI 360, Durham, North Carolina 27701, USA; ,
| | - Marybeth McCauley
- Science Facilitation Department, HIV Prevention Trials Network (HPTN) Leadership and Operations Center, FHI 360, Durham, North Carolina 27701, USA; ,
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Cohen MS, Council OD, Chen JS. Sexually transmitted infections and HIV in the era of antiretroviral treatment and prevention: the biologic basis for epidemiologic synergy. J Int AIDS Soc 2019; 22 Suppl 6:e25355. [PMID: 31468737 PMCID: PMC6715951 DOI: 10.1002/jia2.25355] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 06/26/2019] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION HIV is a unique sexually transmitted infection (STI) that is greatly affected by other concomitant "classical" bacterial and viral STIs that cause genital ulcers and/or mucosal inflammation. STIs also serve as a marker for risky sexual behaviours. STIs increase infectiousness of people living with HIV by increasing the viral concentration in the genital tract, and by increasing the potential for HIV acquisition in people at risk for HIV. In addition, some STIs can increase blood HIV concentration and promote progression of disease. This review is designed to investigate the complex relationship between HIV and classical STIs. DISCUSSION Treatment of STIs with appropriate antibiotics reduces HIV in blood, semen and female genital secretions. However, community-based trials could not reliably reduce the spread of HIV by mass treatment of STIs. Introduction of antiretroviral agents for the treatment and prevention of HIV has led to renewed interest in the complex relationship between STIs and HIV. Antiretroviral treatment (ART) reduces the infectiousness of HIV and virtually eliminates the transmission of HIV in spite of concomitant or acquired STIs. However, while ART interrupts HIV transmission, it does not stop intermittent shedding of HIV in genital secretions. Such shedding of HIV is increased by STIs, although the viral copies are not likely replication competent or infectious. Pre-exposure prophylaxis (PrEP) of HIV with the combination of tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) prevents HIV acquisition in spite of concomitant STIs. CONCLUSIONS STIs remain pandemic, and the availability of ART may have led to an increase in STIs, as fear of HIV has diminished. Classical STIs present a huge worldwide health burden that cannot be separated from HIV, and they deserve far more attention than they currently receive.
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Affiliation(s)
- Myron S Cohen
- UNC School of MedicineInstitute for Global Health & Infectious DiseasesChapel HillNCUSA
| | | | - Jane S Chen
- Department of EpidemiologyGillings School of Global Public HealthUNCChapel HillNCUSA
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Lemos MP, Lazarus E, Isaacs A, Dietrich J, Morgan C, Huang Y, Grove D, Andrasik M, Laher F, Hural J, Chung E, Dragavon J, Puren A, Gulati RK, Coombs R, McElrath MJ, Gray G, Kublin JG. Daily Vaginal Swabs and Mobile Phone Sex Report for Assessing HIV Virion Exposure Prospectively Among a Cohort of Young Sexually Active Women in South Africa (HVTN 915). J Acquir Immune Defic Syndr 2019; 81:e39-e48. [PMID: 31095007 PMCID: PMC6743720 DOI: 10.1097/qai.0000000000002015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Measurements of HIV exposure could help identify subpopulations at highest risk of acquisition and improve the design of HIV prevention efficacy trials and public health interventions. The HVTN 915 study evaluated the feasibility of self-administered vaginal swabs for detection of HIV virions to assess exposure. METHODS Fifty 18- to 25-year-old sexually active HIV-seronegative women using contraception were enrolled in Soweto, South Africa. Participants self-administered daily vaginal swabs and answered sexual behavior questions through mobile phone for 90 days. Clinician-administered vaginal swabs, behavioral questionnaires, HIV diagnostic testing, and counseling were performed at 8 clinic visits. Glycogen concentrations assessed adherence to swabbing. Y-chromosome DNA (Yc-DNA) assessed the accuracy of reported condom use. HIV exposure was measured by virion polymerase chain reaction in swabs from 41 women who reported unprotected vaginal sex during follow-up. RESULTS Glycogen was detected in 315/336 (93.8%) participant-collected and in all clinician-collected swabs. Approximately 20/39 daily swabs (51.3%) linked to mobile reports of unprotected sex tested positive for Yc-DNA, whereas 10/187 swabs collected after 3 days of abstinence or protected sex (5.3%) had detectable Yc-DNA. No participant became HIV infected during the study; yet, exposure to HIV was detected by nucleic acids in 2 vaginal swabs from 1 participant, collected less than 1 hour after coitus. CONCLUSION There was high adherence to daily vaginal swabbing. Daily mobile surveys had accurate reporting of unprotected sex. Detection of HIV in self-collected vaginal swabs from an uninfected participant demonstrated it was possible to measure HIV exposure, but the detection rate was lower than expected.
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Affiliation(s)
- Maria P Lemos
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Erica Lazarus
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Abby Isaacs
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Janan Dietrich
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Cecilia Morgan
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Yunda Huang
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Doug Grove
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Michele Andrasik
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Fatima Laher
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - John Hural
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Eva Chung
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Joan Dragavon
- Department of Laboratory Medicine, University of Washington, Seattle, WA
| | - Adrian Puren
- Centre of HIV and Sexually Transmitted Infections, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Reena K Gulati
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Robert Coombs
- Department of Laboratory Medicine, University of Washington, Seattle, WA
| | - Margaret Juliana McElrath
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Laboratory Medicine, University of Washington, Seattle, WA
- Global Health, University of Washington, Seattle, WA
| | - Glenda Gray
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- South African Medical Research Council, Cape Town, South Africa
| | - James G Kublin
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
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Kimmel AD, Bono RS, Keiser O, Sinayobye JD, Estill J, Mujwara D, Tymejczyk O, Nash D. Mathematical modelling to inform 'treat all' implementation in sub-Saharan Africa: a scoping review. J Virus Erad 2018; 4:47-54. [PMID: 30515314 PMCID: PMC6248854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE Despite widespread uptake, only half of sub-Saharan African countries have fully implemented the World Health Organization's 'treat all' policy, hindering achievement of global HIV targets. We examined literature on mathematical modelling studies that sought to inform scale-up and implementation of 'treat all' in sub-Saharan Africa. METHODS We conducted a scoping review, a research synthesis to assess emerging evidence and identify gaps, of peer-reviewed literature, extracting study characteristics on 'treat all' policies and assumptions, setting, key populations, outcomes and findings. Studies were narratively summarised and potential gaps characterised. RESULTS We identified 16 studies examining 'treat all' alone (n=12) or with expanded testing (n=7) and/or care continuum improvements (n=6). Twelve studies examined 'treat all' for Southern African countries, while none did so for Central Africa. Four included the role of resistance; one evaluated any key population. A range of health and economic outcomes were reported, although fewer studies formally assessed budget impact. Fourteen studies involved co-authors with any in-country affiliation; one study also had co-authors with local government affiliation. Overall, 'treat all' improves health outcomes and is cost-effective compared to deferred HIV treatment; 'treat all' with expanded testing or care continuum improvements may provide further health benefits. However, studies generally used optimistic assumptions about the implementation of expanded testing or care continuum improvements. CONCLUSIONS The modelling literature demonstrates improved health and economic benefits of 'treat all'. Using mathematical modelling to inform real-world implementation of 'treat all' requires realistic assumptions about expanded testing and care continuum interventions across a wide range of settings and populations.
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Affiliation(s)
- April D Kimmel
- Department of Health Behavior and Policy, Virginia Commonwealth University,
Richmond VA,
USA
| | - Rose S Bono
- Department of Health Behavior and Policy, Virginia Commonwealth University,
Richmond VA,
USA
| | - Olivia Keiser
- Institute of Global Health, University of Geneva,
Switzerland
| | - Jean D Sinayobye
- Research and Clinical Education Division, Rwanda Military Hospital,
Kigali,
Rwanda
| | | | - Deo Mujwara
- Department of Health Behavior and Policy, Virginia Commonwealth University,
Richmond VA,
USA
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Kimmel AD, Bono RS, Keiser O, Sinayobye JD, Estill J, Mujwara D, Tymejczyk O, Nash D. Mathematical modelling to inform ‘treat all’ implementation in sub-Saharan Africa: a scoping review. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30345-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Kumi Smith M, Jewell BL, Hallett TB, Cohen MS. Treatment of HIV for the Prevention of Transmission in Discordant Couples and at the Population Level. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1075:125-162. [PMID: 30030792 DOI: 10.1007/978-981-13-0484-2_6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The scientific breakthrough proving that antiretroviral therapy (ART) can halt heterosexual HIV transmission came in the form of a landmark clinical trial conducted among serodiscordant couples. Study findings immediately informed global recommendations for the use of treatment as prevention in serodiscordant couples. The extent to which these findings are generalizable to other key populations or to groups exposed to HIV through nonsexual transmission routes (i.e., anal intercourse or unsafe injection of drugs) has since driven a large body of research. This review explores the history of HIV research in serodiscordant couples, the implications for management of couples, subsequent research on treatment as prevention in other key populations, and challenges in community implementation of these strategies.
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Affiliation(s)
- M Kumi Smith
- University of North Carolina Chapel Hill, Chapel Hill, NC, USA.
| | | | | | - Myron S Cohen
- University of North Carolina Chapel Hill, Chapel Hill, NC, USA
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Ruggles KV, Patel AR, Schensul S, Schensul J, Nucifora K, Zhou Q, Bryant K, Braithwaite RS. Betting on the fastest horse: Using computer simulation to design a combination HIV intervention for future projects in Maharashtra, India. PLoS One 2017; 12:e0184179. [PMID: 28873452 PMCID: PMC5584966 DOI: 10.1371/journal.pone.0184179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 08/18/2017] [Indexed: 11/18/2022] Open
Abstract
Objective To inform the design of a combination intervention strategy targeting HIV-infected unhealthy alcohol users in Maharashtra, India, that could be tested in future randomized control trials. Methods Using probabilistic compartmental simulation modeling we compared intervention strategies targeting HIV-infected unhealthy alcohol users on antiretroviral therapy (ART) in Maharashtra, India. We tested interventions targeting four behaviors (unhealthy alcohol consumption, risky sexual behavior, depression and antiretroviral adherence), in three formats (individual, group based, community) and two durations (shorter versus longer). A total of 5,386 possible intervention combinations were tested across the population for a 20-year time horizon and intervention bundles were narrowed down based on incremental cost-effectiveness analysis using a two-step probabilistic uncertainty analysis approach. Results Taking into account uncertainty in transmission variables and intervention cost and effectiveness values, we were able to reduce the number of possible intervention combinations to be used in a randomized control trial from over 5,000 to less than 5. The most robust intervention bundle identified was a combination of three interventions: long individual alcohol counseling; weekly Short Message Service (SMS) adherence counseling; and brief sex risk group counseling. Conclusions In addition to guiding policy design, simulation modeling of HIV transmission can be used as a preparatory step to trial design, offering a method for intervention pre-selection at a reduced cost.
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Affiliation(s)
- Kelly V. Ruggles
- Department of Medicine, New York University School of Medicine, New York, NY, United States of America
- * E-mail:
| | - Anik R. Patel
- Department of Experimental Medicine, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
| | - Stephen Schensul
- Department of Community Medicine and Health Care, University of Connecticut Health Center, Farmington, CT, United States of America
| | - Jean Schensul
- Institute for Community Research, Hartford, CT, United States of America
| | - Kimberly Nucifora
- Department of Population Health, New York University School of Medicine, New York, NY, United States of America
| | - Qinlian Zhou
- Department of Population Health, New York University School of Medicine, New York, NY, United States of America
| | - Kendall Bryant
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, United States of America
| | - R. Scott Braithwaite
- Department of Population Health, New York University School of Medicine, New York, NY, United States of America
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Fatti G, Shaikh N, Jackson D, Goga A, Nachega JB, Eley B, Grimwood A. Low HIV incidence in pregnant and postpartum women receiving a community-based combination HIV prevention intervention in a high HIV incidence setting in South Africa. PLoS One 2017; 12:e0181691. [PMID: 28750070 PMCID: PMC5531482 DOI: 10.1371/journal.pone.0181691] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 07/04/2017] [Indexed: 12/21/2022] Open
Abstract
Background Young Southern African women have the highest HIV incidence globally. Pregnancy doubles the risk of HIV acquisition further, and maternal HIV acquisition contributes significantly to the paediatric HIV burden. Little data on combination HIV prevention interventions during pregnancy and lactation are available. We measured HIV incidence amongst pregnant and postpartum women receiving a community-based combination HIV prevention intervention in a high HIV incidence setting in South Africa. Methods A cohort study that included HIV-uninfected pregnant women was performed. Lay community-based workers provided individualized HIV prevention counselling and performed three-monthly home and clinic-based individual and couples HIV testing. Male partners were referred for circumcision, sexually transmitted infections or HIV treatment as appropriate. Kaplan-Meier analyses and Cox’s regression were used to estimate HIV incidence and factors associated with HIV acquisition. Results The 1356 women included (median age 22.5 years) received 5289 HIV tests. Eleven new HIV infections were detected over 828.3 person-years (PY) of follow-up, with an HIV incidence rate of 1.33 infections/100 PY (95% CI: 0.74–2.40). Antenatally, the HIV incidence rate was 1.49 infections/100 PY (95% CI: 0.64–2.93) and postnatally the HIV incidence rate was 1.03 infections/100 PY (95% CI: 0.33–3.19). 53% of male partners received HIV testing and 66% of eligible partners received referral for circumcision. Women within known serodiscordant couples, and women with newly diagnosed HIV-infected partners, adjusted hazard ratio (aHR) = 32.7 (95% CI: 3.8–282.2) and aHR = 126.4 (95% CI: 33.8–472.2) had substantially increased HIV acquisition, respectively. Women with circumcised partners had a reduced risk of incident HIV infection, aHR = 0.22 (95% CI: 0.03–1.86). Conclusions Maternal HIV incidence was substantially lower than previous regional studies. Community-based combination HIV prevention interventions may reduce high maternal HIV incidence in resource-poor settings. Expanded roll-out of home-based couples HIV testing and initiating pre-exposure prophylaxis for pregnant women within serodiscordant couples is needed in Southern Africa.
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Affiliation(s)
- Geoffrey Fatti
- Kheth'Impilo, Cape Town, South Africa.,South African Centre for Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | | | - Debra Jackson
- UNICEF, New York, New York, United States of America.,School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Ameena Goga
- Health Systems Research Unit, South African Medical Research Council, Pretoria, South Africa.,Department of Paediatrics, University of Pretoria, Pretoria, South Africa
| | - Jean B Nachega
- Departments of Epidemiology, Infectious Diseases and Microbiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, United States of America.,Department of Medicine and Centre for Infectious Diseases, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Departments of Epidemiology and International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Brian Eley
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
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Blaizot S, Huerga H, Riche B, Ellman T, Shroufi A, Etard JF, Ecochard R. Combined interventions to reduce HIV incidence in KwaZulu-Natal: a modelling study. BMC Infect Dis 2017; 17:522. [PMID: 28747167 PMCID: PMC5530541 DOI: 10.1186/s12879-017-2612-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 07/18/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Combined prevention interventions, including early antiretroviral therapy initiation, may substantially reduce HIV incidence in hyperendemic settings. Our aim was to assess the potential short-term impact of combined interventions on HIV spreading in the adult population of Mbongolwane and Eshowe (KwaZulu-Natal, South Africa) using sex- and age-specific scenarios, and age-targeted interventions. METHODS A mathematical model was used with data on adults (15-59 years) from the Mbongolwane and Eshowe HIV Impact in Population Survey to compare the effects of various interventions on the HIV incidence rate. These interventions included increase in antiretroviral therapy (ART) coverage with extended eligibility criteria, increase in voluntary medical male circumcision (VMMC), and implementation of pre-exposure prophylaxis (PrEP) among women. RESULTS With no additional interventions to the ones in place at the time of the survey (ART at CD4 < 350 and VMMC), incidence will decrease by 24% compared to the baseline rate. The implementation of "ART at CD4<500" or "ART for all" would reduce further the incidence rate by additional 8% and 15% respectively by 4 years and 20% and 34% by 10 years. Impacts would be higher with age-targeted scenarios than without. CONCLUSIONS In Mbongolwane and Eshowe, implementation of the new South African guidelines, recommending ART initiation regardless of CD4 count, would accelerate incidence reduction. In this setting, combining these guidelines, VMMC, and PrEP among young women could be an effective strategy in reducing the incidence to low levels.
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Affiliation(s)
- Stéphanie Blaizot
- Service de Biostatistique, Hospices Civils de Lyon, F-69003 Lyon, France
- Université de Lyon, F-69000 Lyon, France
- Université Lyon 1, F-69100 Villeurbanne, France
- CNRS UMR 5558, Equipe Biostatistique-Santé, Laboratoire de Biométrie et Biologie Evolutive, F-69100 Villeurbanne, France
| | | | - Benjamin Riche
- Service de Biostatistique, Hospices Civils de Lyon, F-69003 Lyon, France
- Université de Lyon, F-69000 Lyon, France
- Université Lyon 1, F-69100 Villeurbanne, France
- CNRS UMR 5558, Equipe Biostatistique-Santé, Laboratoire de Biométrie et Biologie Evolutive, F-69100 Villeurbanne, France
| | - Tom Ellman
- Médecins Sans Frontières, Cape Town, South Africa
| | - Amir Shroufi
- Médecins Sans Frontières, Cape Town, South Africa
| | - Jean-François Etard
- Epicentre, F-75011 Paris, France
- IRD UMI 233, INSERM U1175, Université de Montpellier, Unité TransVIHMI, F-34000 Montpellier, France
| | - René Ecochard
- Service de Biostatistique, Hospices Civils de Lyon, F-69003 Lyon, France
- Université de Lyon, F-69000 Lyon, France
- Université Lyon 1, F-69100 Villeurbanne, France
- CNRS UMR 5558, Equipe Biostatistique-Santé, Laboratoire de Biométrie et Biologie Evolutive, F-69100 Villeurbanne, France
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14
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Zuma T, Wight D, Rochat T, Moshabela M. Traditional health practitioners' management of HIV/AIDS in rural South Africa in the era of widespread antiretroviral therapy. Glob Health Action 2017; 10:1352210. [PMID: 28771116 PMCID: PMC5645651 DOI: 10.1080/16549716.2017.1352210] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 07/05/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Traditional health practitioners (THPs) have been identified as a key local resource in the fight against human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) in South Africa. However, their approaches to the treatment of people living with HIV (PLHIV) have been met with scepticism by some biomedical practitioners amid increasing access to antiretroviral therapy (ART). OBJECTIVE In light of this ambivalence, this study aims to document and identify treatment approaches of THPs to the management of illness among PLHIV in the current era of widespread access to ART. METHODS The study was conducted as part of a larger trial of Treatment as Prevention (TasP) in rural northern Kwa-Zulu Natal, intended to treat PLHIV regardless of CD4 count. Nine THPs were enrolled using purposive and snowballing techniques. Repeat group discussions, triangulated with community walks and photovoice techniques, were conducted. A thematic analysis approach was used to analyse the data. RESULTS Eight of the nine THPs had received training in biomedical aspects of HIV. THPs showed a multilayered decision-making process in managing illness among PLHIV, influenced by the attributes and choices of the THPs. THPs assessed and managed illness among PLHIV based on THP training in HIV/AIDS, THP type, as well as knowledge and experience in the traditional healing practice. Management of illness depended on the patients' report of their HIV status or willingness to test for HIV. CONCLUSIONS THPs' approaches to illness in PLHIV appear to be shifting in light of increasing exposure to HIV/AIDS-related information. Importantly, disclosure of HIV status plays a major role in THPs' management of illness among PLHIV, as well as linkage to HIV testing and care for their patients. Therefore, THPs can potentially enhance the success of ART for PLHIV when HIV status is known.
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Affiliation(s)
- Thembelihle Zuma
- Africa Health Research Institute, Mtubatuba, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Daniel Wight
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Tamsen Rochat
- Human Sciences Research Council/Human and Social Development (HSD) and MRC Developmental Pathways to Health Research Unit, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Mosa Moshabela
- Africa Health Research Institute, Mtubatuba, South Africa
- Discipline of Rural Health, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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