1
|
Rapaport SF, Peer AD, Viswasam N, Hahn E, Ryan S, Turpin G, Lyons CE, Baral S, Hansoti B. Implementing HIV Prevention in Sub-Saharan Africa: A Systematic Review of Interventions Targeting Systems, Communities, and Individuals. AIDS Behav 2023; 27:150-160. [PMID: 35913588 PMCID: PMC9851926 DOI: 10.1007/s10461-022-03751-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 01/29/2023]
Abstract
HIV remains a threat to global public health, disproportionately affecting countries across Sub-Saharan Africa. Although treatment and access to care have improved, prevention remains critical to ending new HIV infections by 2030. A variety of prevention strategies exist, yet their effectiveness is difficult to measure and variable due to the nature of the interventions and vulnerability of the intervention during implementation. This systematic review of 51 studies synthesizes data on the implementation and evaluation of evidence-based HIV prevention interventions across Sub-Saharan Africa. Studies were included if they occurred between January 1, 2008, and December 31, 2019, inclusive in Sub-Saharan Africa, were written in English, implemented an HIV prevention intervention in the field, and had reportable results. Using a modified social-ecological model for HIV prevention, we divided studies into three categories: interventions targeting health systems (n = 16), communities (n = 8), and individuals (n = 27). Across all categories, the data emphasized preventing mother-to-child transmission (PMTCT), medical interventions, and psychosocial interventions. The most successful programs bundled several interventions that were integrated into the health system. There is a notable lack of interventions targeting key populations and there are significant rates of loss to follow up (LTFU) across many studies. This review provides insight into the prioritization of evidence-based HIV prevention interventions across Sub-Saharan Africa.
Collapse
Affiliation(s)
- Sarah F. Rapaport
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Austin D. Peer
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Nikita Viswasam
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elizabeth Hahn
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sophia Ryan
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Gnilane Turpin
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Carrie E. Lyons
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Stefan Baral
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Department of International Health, Bloomberg School of Public Health, Baltimore, Maryland, USA
| |
Collapse
|
2
|
Chen JS, Pettifor AE, Nelson JAE, Phiri S, Pasquale DK, Kumwenda W, Kamanga G, Cottrell ML, Sykes C, Kashuba ADM, Tegha G, Krysiak R, Thengolose I, Cohen MS, Hoffman IF, Miller WC, Rutstein SE. Brief Report: Blood and Genital Fluid Viral Load Trajectories Among Treated and Untreated Persons With Acute HIV Infection in Malawi. J Acquir Immune Defic Syndr 2022; 90:56-61. [PMID: 35044991 PMCID: PMC8986564 DOI: 10.1097/qai.0000000000002917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/06/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Persons with acute HIV infection (AHI) are highly infectious and responsible for a disproportionate share of incident infections. Immediate antiretroviral therapy (ART) rapidly reduces blood viral loads (VLs), but genital VLs after ART initiation during AHI are less well described. SETTING Lilongwe, Malawi, 2012-2014. METHODS HIV-seronegative and HIV-serodiscordant persons aged ≥18 years were screened for AHI (RNA positive) and randomized to standard of care, behavioral intervention, or behavioral intervention plus short-term ART (raltegravir/emtricitabine/tenofovir) (1:2:2). Persons who were ART eligible under Malawi guidelines could receive first-line therapy. Blood and genital VLs were assessed at weeks 1, 4, 8, and 12. Fisher's Exact test was used to compare viral suppression by ART status. RESULTS Overall, 46 persons with AHI were enrolled; of whom, 17 started ART within 12 weeks. Median blood VL at AHI diagnosis was 836,115 copies/mL. At week 12, 7% (1/14) of those who initiated ART had a blood VL of ≥400 copies/mL, compared with 100% (23/23; P < 0.0001) of those who did not initiate ART (median VL: 61,605 copies/mL). Median genital VL at week 1 was 772 copies/mL, with 13 of 22 (59%) having VL of ≥400 copies/mL. At week 12, 0 of 10 (0%) of those who initiated ART had genital VL of ≥400 copies/mL, compared with 7 of 15 (47%) of those who did not initiate ART (P = 0.02). CONCLUSION Although highly correlated, VLs in blood and genital fluids occupy discrete biological compartments with distinct virologic dynamics. Our results corroborate the dramatic reduction in both compartments after ART initiation. Increasing AHI screening and rapidly initiating treatment is key to interrupting transmission.
Collapse
Affiliation(s)
- Jane S Chen
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Audrey E Pettifor
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Julie A E Nelson
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Dana K Pasquale
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | | | - Gift Kamanga
- UNC Project, Lilongwe, Malawi
- FHI 360, Lilongwe, Malawi
- Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, IN
| | - Mackenzie L Cottrell
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Craig Sykes
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Angela D M Kashuba
- Clinical Pharmacology and Analytical Chemistry Core, UNC Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | - Myron S Cohen
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Irving F Hoffman
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - William C Miller
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Division of Epidemiology, Ohio State University, Columbus, OH; and
| | - Sarah E Rutstein
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| |
Collapse
|
3
|
Amatavete S, Lujintanon S, Teeratakulpisarn N, Thitipatarakorn S, Seekaew P, Hanaree C, Sripanjakun J, Prabjuntuek C, Suwannarat L, Phattanathawornkool T, Photisan N, Suriwong S, Avery M, Mills S, Phanuphak P, Phanuphak N, Ramautarsing RA. Evaluation of the integration of telehealth into the same-day antiretroviral therapy initiation service in Bangkok, Thailand in response to COVID-19: a mixed-method analysis of real-world data. J Int AIDS Soc 2021; 24 Suppl 6:e25816. [PMID: 34713623 PMCID: PMC8554221 DOI: 10.1002/jia2.25816] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 08/19/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Same‐day antiretroviral therapy (SDART) initiation has been implemented at the Thai Red Cross Anonymous Clinic (TRCAC) in Bangkok, Thailand, since 2017. HIV‐positive, antiretroviral therapy (ART)‐naïve clients who are willing and clinically eligible start ART on the day of HIV diagnosis. In response to the first wave of the coronavirus disease 2019 (COVID‐19) outbreak in March 2020, telehealth follow‐up was established to comply with COVID‐19 preventive measures and allow service continuation. Here, we evaluate its implementation. Methods Pre‐COVID‐19 (until February 2020) clients who initiated SDART received a 2‐week ART supply and returned to the clinic for evaluation before being referred to long‐term ART maintenance facilities. If no adverse events (AEs) occurred, another 8‐week ART supply was provided while referral was arranged. During the first wave of COVID‐19 (March–May 2020), clients received a 4‐week ART supply and the option of conducting follow‐up consultation and physical examination via video call. Clients with severe AEs were required to return to TRCAC; those without received another 6‐week ART supply by courier to bridge transition to long‐term facilities. This adaptation continued post‐first wave (May–August 2020). Routine service data were analysed using data from March to August 2019 for the pre‐COVID‐19 period. Interviews and thematic analysis were conducted to understand experiences of clients and providers, and gain feedback for service improvement. Results Of 922, 183 and 321 eligible clients from the three periods, SDART reach [89.9%, 96.2% and 92.2% (p = 0.018)] and ART initiation rates [88.1%, 90.9% and 94.9% (p<0.001)] were high. ART uptake, time to ART initiation and rates of follow‐up completion improved over time. After the integration, 35.3% received the telehealth follow‐up. The rates of successful referral to a long‐term facility (91.8% vs. 95.3%, p = 0.535) and retention in care at months 3 (97.5% vs. 98.0%, p = 0.963) and 6 (94.1% vs. 98.4%, p = 0.148) were comparable for those receiving in‐person and telehealth follow‐up. Six clients and nine providers were interviewed; six themes on service experience and feedback were identified. Conclusions Telehealth follow‐up with ART delivery for SDART clients is a feasible option to differentiate ART initiation services at TRCAC, which led to its incorporation into routine service.
Collapse
Affiliation(s)
| | | | | | | | - Pich Seekaew
- Institute of HIV Research and Innovation, Bangkok, Thailand.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Rutstein SE, Chen JS, Nelson JAE, Phiri S, Miller WC, Hosseinipour MC. High rates of transmitted NNRTI resistance among persons with acute HIV infection in Malawi: implications for first-line dolutegravir scale-up. AIDS Res Ther 2019; 16:5. [PMID: 30795780 PMCID: PMC6385432 DOI: 10.1186/s12981-019-0220-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 02/07/2019] [Indexed: 11/10/2022] Open
Abstract
High rates of non-nucleoside reverse transcriptase inhibitors (NNRTI) resistance was a key consideration in the WHO policies transitioning first-line regimens to include integrase inhibitors (dolutegravir [DTG]). However, recent data suggests a relationship between DTG and neural tube defects among women exposed during conception, giving providers and policymakers pause regarding the planned regimen changes. We examined HIV drug resistance among a cohort of 46 acutely infected persons in Malawi. Our data demonstrates high levels of transmitted resistance, 11% using standard resistance surveillance mutations and 20% when additional NNRTI polymorphisms that may affect treatment response are included. High resistance rates in this treatment-naïve patient population reinforces the critical nature of DTG-based options in the context of public-health driven treatment programs.
Collapse
Affiliation(s)
- Sarah E. Rutstein
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC USA
| | - Jane S. Chen
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC USA
| | - Julie A. E. Nelson
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC USA
- Department of Microbiology and Immunology, University of North Carolina, Chapel Hill, NC USA
| | | | | | - Mina C. Hosseinipour
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC USA
- UNC Project, Lilongwe, Malawi
| |
Collapse
|
5
|
Miller WC, Rutstein SE, Phiri S, Kamanga G, Nsona D, Pasquale DK, Rucinski KB, Chen JS, Golin CE, Powers KA, Dennis AM, Hosseinipour MC, Eron JJ, Chege W, Hoffman IF, Pettifor AE. Randomized Controlled Pilot Study of Antiretrovirals and a Behavioral Intervention for Persons With Acute HIV Infection: Opportunity for Interrupting Transmission. Open Forum Infect Dis 2018; 6:ofy341. [PMID: 30648131 PMCID: PMC6329906 DOI: 10.1093/ofid/ofy341] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 12/18/2018] [Indexed: 01/03/2023] Open
Abstract
Background Persons with acute HIV infection (AHI) have heightened transmission risk. We evaluated potential transmission reduction using behavioral and biomedical interventions in a randomized controlled pilot study in Malawi. Methods Persons were randomized 1:2:2 to standard counseling (SC), 5-session behavioral intervention (BI), or behavioral intervention plus 12 weeks of antiretrovirals (ARVs; BIA). All were followed for 26–52 weeks and, regardless of arm, referred for treatment according to Malawi-ARV guidelines. Participants were asked to refer partners for testing. Results Among 46 persons (9 SC, 18 BI, 19 BIA), the average age was 28; 61% were male. The median viral load (VL) was 5.9 log copies/mL at enrollment. 67% (10/15) of BIA participants were suppressed (<1000 copies/mL) at week 12 vs 25% BI and 50% SC (P = .07). Although the mean number of reported condomless sexual acts in the past week decreased from baseline across all arms (1.5 vs 0.3 acts), 36% experienced incident sexually transmitted infection by 52 weeks (12% SC, 28% BI, 18% BIA). Forty-one percent (19/46) of participants referred partners (44% SC, 44% BI, 37% BIA); 15 of the partners were HIV-infected. Conclusions Diagnosis of AHI facilitates behavioral and biomedical risk reduction strategies during a high-transmission period that begins years before people are typically identified and started on ARVs. Sexually transmitted infection incidence in this cohort suggests ongoing risk behaviors, reinforcing the importance of early intervention with ARVs to reduce transmission. Early diagnosis coupled with standard AHI counseling and early ARV referral quickly suppresses viremia, may effectively change behavior, and could have tremendous public health benefit in reducing onward transmission.
Collapse
Affiliation(s)
- William C Miller
- Division of Epidemiology, The Ohio State University, Columbus, Ohio.,Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Sarah E Rutstein
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | | | | | - Dana K Pasquale
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Katherine B Rucinski
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jane S Chen
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Carol E Golin
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kimberly A Powers
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ann M Dennis
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mina C Hosseinipour
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Joseph J Eron
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Wairimu Chege
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Irving F Hoffman
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Audrey E Pettifor
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| |
Collapse
|