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Gareta D, Baisley K, Mngomezulu T, Smit T, Khoza T, Nxumalo S, Dreyer J, Dube S, Majozi N, Ording-Jesperson G, Ehlers E, Harling G, Shahmanesh M, Siedner M, Hanekom W, Herbst K. Cohort Profile Update: Africa Centre Demographic Information System (ACDIS) and population-based HIV survey. Int J Epidemiol 2021; 50:33-34. [PMID: 33437994 PMCID: PMC7938501 DOI: 10.1093/ije/dyaa264] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2020] [Indexed: 12/18/2022] Open
Affiliation(s)
- Dickman Gareta
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Kathy Baisley
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, UK
| | | | - Theresa Smit
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Thandeka Khoza
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | | | - Jaco Dreyer
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Sweetness Dube
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | | | | | - Eugene Ehlers
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Guy Harling
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,Institute for Global Health, University College London, London, UK.,MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology & Harvard Centre for Population and Development Studies, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Maryam Shahmanesh
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,Institute for Global Health, University College London, London, UK
| | - Mark Siedner
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,Harvard Medical School, Boston, MA, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Willem Hanekom
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Kobus Herbst
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,SAPRIN, South African Medical Research Council, Cape Town, South Africa
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Gregson S, Nyamukapa C. Did sexual behaviour differences between HIV infection and treatment groups offset the preventative biological effects of ART roll-out in Zimbabwe? Population Studies 2021; 75:457-476. [PMID: 33559537 DOI: 10.1080/00324728.2021.1874043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Declines in HIV incidence have been slower than expected during the roll-out of antiretroviral treatment (ART) services in sub-Saharan African populations suffering generalized epidemics. Using data from a population-based, open cohort HIV sero-survey (2004-13), we found evidence for initial reductions in sexual activity and multiple sexual partnerships, followed by increases during the period of ART scale-up in areas of high HIV prevalence in Manicaland, east Zimbabwe. Recent population-level increases in condom use were also recorded, but largely reflected high use by the rapidly growing proportion of HIV-infected individuals on treatment. Sexual risk behaviour increased in susceptible uninfected individuals and in untreated (and therefore more infectious) HIV-infected men, which may have slowed the decline in HIV incidence in this area. Intensified primary HIV prevention programmes, together with strengthened risk screening, referral, and support services following HIV testing, could help to maximize the impact of 'test-and-treat' programmes in reducing new infections.
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Affiliation(s)
- Simon Gregson
- Imperial College London.,Biomedical Research and Training Institute
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Houle B, Yu ST, Angotti N, Schatz E, Kabudula CW, Gómez-Olivé FX, Clark SJ, Menken J, Mojola SA. Clusters of HIV Risk and Protective Sexual Behaviors in Agincourt, Rural South Africa: Findings from the Ha Nakekela Population-Based Study of Ages 15 and Older. ARCHIVES OF SEXUAL BEHAVIOR 2020; 49:2057-2068. [PMID: 32232623 PMCID: PMC7321875 DOI: 10.1007/s10508-020-01663-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 02/12/2020] [Accepted: 02/14/2020] [Indexed: 06/10/2023]
Abstract
Understanding how sexual behaviors cluster in distinct population subgroups along the life course is critical for effective targeting and tailoring of HIV prevention messaging and intervention activities. We examined interrelatedness of sexual behaviors and variation between men and women across a wide age range in a rural South African setting with a high HIV burden. Data come from the Ha Nakekela population-based survey of people aged 15-85-plus drawn from the Agincourt Health and Socio-Demographic Surveillance System. We used latent class analysis of six sexual behavior indicators to identify distinct subgroup sexual behavior clusters. We then examined associations between class membership and sociodemographic and other behavioral risk factors and assessed the accuracy of a reduced set of sexual behavior indicators to classify individuals into latent classes. We identified three sexual behavior classes: (1) single with consistent protective behaviors; (2) risky behaviors; and (3) in union with lack of protective behaviors. Patterns of sexual behaviors varied by gender. Class membership was also associated with age, HIV status, nationality, and alcohol use. With only two sexual behavior indicators (union status and multiple sexual partners), individuals were accurately assigned to their most likely predicted class. There were distinct multidimensional sexual behavior clusters in population subgroups that varied by sex, age, and HIV status. In this population, only two brief questions were needed to classify individuals into risk classes. Replication in other situations is needed to confirm these findings.
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Affiliation(s)
- Brian Houle
- School of Demography, The Australian National University, #9 Fellows Road, Acton, Canberra, ACT, 2601, Australia.
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
- Institute of Behavioral Science, University of Colorado Boulder, Boulder, CO, USA.
| | - Shao-Tzu Yu
- School of Demography, The Australian National University, #9 Fellows Road, Acton, Canberra, ACT, 2601, Australia
| | - Nicole Angotti
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Institute of Behavioral Science, University of Colorado Boulder, Boulder, CO, USA
- Department of Sociology and Center on Health, Risk and Society, American University, Washington, DC, USA
| | - Enid Schatz
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Institute of Behavioral Science, University of Colorado Boulder, Boulder, CO, USA
- Department of Public Health, University of Missouri, Columbia, MO, USA
| | - Chodziwadziwa W Kabudula
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | - Francesc Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | - Samuel J Clark
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Sociology, The Ohio State University, Columbus, OH, USA
| | - Jane Menken
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Institute of Behavioral Science, University of Colorado Boulder, Boulder, CO, USA
| | - Sanyu A Mojola
- Department of Sociology and Woodrow Wilson School of Public and International Affairs, and Office of Population Research, Princeton University, Princeton, NJ, USA
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Kim H, Harling G, Vandormael A, Tomita A, Cuadros DF, Bärnighausen T, Tanser F. HIV seroconcordance among heterosexual couples in rural KwaZulu-Natal, South Africa: a population-based analysis. J Int AIDS Soc 2020; 23:e25432. [PMID: 31916420 PMCID: PMC6949466 DOI: 10.1002/jia2.25432] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 11/08/2019] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION High levels of HIV seroconcordance at the population level reduce the potential for effective HIV transmission. However, the level of HIV seroconcordance is largely unknown among heterosexual couples in sub-Saharan Africa. We aimed to quantify the population level HIV seroconcordance in stable heterosexual couples in rural South Africa. METHODS We followed adults (≥15 years old) using a population-based, longitudinal and open surveillance system in KwaZulu-Natal, South Africa, from 2003 to 2016. Sexual partnerships and HIV status were confirmed via household surveys and annual HIV surveillance. We calculated the proportions of HIV seroconcordance and serodiscordance in stable sexual partnerships and compared them to the expected proportions under the assumption of random mixing using individual-based microsimulation models. Among unpartnered individuals, we estimated the incidence rates and hazard of sexual partnership formation with HIV-positive or HIV-negative partners by participants' own time-varying HIV status. Competing risks survival regressions were fitted adjusting for sociodemographic and clinical factors. We also calculated Newman's assortativity coefficients. RESULTS A total of 18,341 HIV-negative and 11,361 HIV-positive individuals contributed 154,469 person-years (PY) of follow-up. Overall, 28% of the participants were in stable sexual partnerships. Of the 677 newly formed stable sexual partnerships, 7.7% (95% CI: 5.8 to 10.0) were HIV-positive seroconcordant (i.e. both individuals in the partnership were HIV-positive), which was three times higher than the expected proportion (2.3%) in microsimulation models based on random mixing. The incidence rates of sexual partnership formation were 0.54/1000PY with HIV-positive, 1.12/1000PY with HIV-negative and 2.65/1000PY with unknown serostatus partners. HIV-positive individuals had 2.39 (95% CI: 1.43 to 3.99) times higher hazard of forming a sexual partnership with an HIV-positive partner than did HIV-negative individuals after adjusting for age, opposite-sex HIV prevalence (by 5-years age groups), HIV prevalence in the surrounding community, ART coverage and other sociodemographic factors. Similarly, forming a sexual partnership with an HIV-negative partner was 1.47 (95% CI: 1.01 to 2.14) times higher in HIV-negative individuals in the adjusted model. Newman's coefficient also showed that assortativity by participant and partner HIV status was moderate (r = 0.35). CONCLUSIONS A high degree of population level HIV seroconcordance (both positive and negative) was observed at the time of forming new sexual partnerships. Understanding factors driving these patterns may help the development of strategies to bring the HIV epidemic under control.
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Affiliation(s)
- Hae‐Young Kim
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- KwaZulu‐Natal Research Innovation and Sequencing Platform (KRISP)KwaZulu‐NatalSouth Africa
- Department of Population HealthNew York University Grossman School of MedicineNew YorkNYUSA
| | - Guy Harling
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Institute for Global HealthUniversity College LondonLondonUK
- Department of Epidemiology & Harvard Center for Population and Development StudiesHarvard T.H. Chan School of Public HealthBostonMAUSA
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt)University of the WitwatersrandJohannesburgSouth Africa
| | - Alain Vandormael
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- KwaZulu‐Natal Research Innovation and Sequencing Platform (KRISP)KwaZulu‐NatalSouth Africa
- School of Nursing and Public HealthUniversity of KwaZulu‐NatalDurbanSouth Africa
- Heidelberg Institute of Global HealthFaculty of MedicineUniversity of HeidelbergHeidelbergGermany
| | - Andrew Tomita
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- KwaZulu‐Natal Research Innovation and Sequencing Platform (KRISP)KwaZulu‐NatalSouth Africa
- Centre for Rural HealthSchool of Nursing and Public HealthUniversity of KwaZulu‐NatalDurbanSouth Africa
| | - Diego F Cuadros
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Department of Geography and Geographic Information ScienceUniversity of CincinnatiCincinnatiOHUSA
| | - Till Bärnighausen
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Heidelberg Institute of Global HealthFaculty of MedicineUniversity of HeidelbergHeidelbergGermany
- Department of Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonMAUSA
| | - Frank Tanser
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Department of Epidemiology & Harvard Center for Population and Development StudiesHarvard T.H. Chan School of Public HealthBostonMAUSA
- Lincoln Institute for HealthUniversity of LincolnLincolnUK
- Centre for the AIDS Programme of Research in South Africa (CAPRISA)University of KwaZulu‐NatalKwaZulu‐NatalSouth Africa
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Mashaphu S, Wyatt GE, Zhang M, Mthiyane T, Liu H, Gomo E. Effectiveness of an HIV-risk reduction intervention to reduce HIV transmission among serodiscordant couples in Durban, South Africa. A randomized controlled trial. AIDS Care 2019; 32:537-545. [PMID: 31269801 DOI: 10.1080/09540121.2019.1634785] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Lack of condom use by married or cohabiting couples in populations with high rates of HIV infection has become a significant public health issue. This study investigated whether an HIV risk-reduction intervention (RRI) would increase condom use when delivered to serodiscordant couples as a unit. Of the 62 couples that were screened, 30 serodiscordant couples were enrolled in the study, and randomized 2:1 to an immediate intervention-waitlist control study. The 12-week intervention focused on communication, problem-solving, and negotiation skills. Participants were assessed at baseline, three and six months after the intervention. The main outcome measures were consistent condom use, HIV seroconversion and fidelity to the programme. The use of condoms increased for both the intervention and control groups after receiving a 12-week RRI. Group comparisons showed a significant difference at three months, with a significantly higher mean proportion of condom-protected sex acts (p = 0.0119) between the control and intervention groups, the later showing an increase in condom use. No seroconversion was detected, and the overall retention rate of participants was 83.33%. Counselling heterosexual couples as a unit prompted an increase in condom use, but sustained condom use remains a challenge.
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Affiliation(s)
- Sibongile Mashaphu
- School of Clinical Medicine, University of KwaZulu-Natal, College of Health Sciences, Durban, South Africa
| | - Gail E Wyatt
- Department of Psychiatry and Bio-Behavioural, Sciences University of California, Los Angeles, CA, USA
| | - Muyu Zhang
- Department of Psychiatry and Bio-Behavioural, Sciences University of California, Los Angeles, CA, USA
| | - Thuli Mthiyane
- South African Medical Research Council, Pretoria, South Africa
| | - Honghu Liu
- Department of Psychiatry and Bio-Behavioural, Sciences University of California, Los Angeles, CA, USA
| | - Exnevia Gomo
- School of Nursing and Public Health, University of KwaZulu-Natal, College of Health Sciences, Durban, South Africa
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6
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Abstract
CONTEXT Within the community-randomized ANRS 12249 Treatment-as-Prevention trial conducted in rural South Africa, we analysed sexual behaviours stratified by sex over time, comparing immediate antiretroviral therapy irrespective of CD4+ cell count vs. CD4+-guided antiretroviral therapy (start at CD4+ cell count > 350 cells/μl then >500 cells/μl) arms. METHODS As part of the 6-monthly home-based trial rounds, a sexual behaviour individual questionnaire was administered to all residents at least 16 years. We considered seven indicators: sexual intercourse in the past month; at least one regular sexual partner in the past 6 months; at least one casual sexual partner in the past 6 months and more than one sexual partner in the past 6 months; condom use at last sex (CLS) with regular partner, CLS with casual partner, and point prevalence estimate of concurrency. We conducted repeated cross-sectional analyses, stratified by sex. Generalized Estimating Equations models were used, including trial arm, trial time, calendar time and interaction between trial arm and trial time. RESULTS CLS with regular partner varied between 29-51% and 23-46% for men and women, respectively, with significantly lower odds among women in the control vs. intervention arm by trial end (P < 0.001). CLS with casual partner among men showed a significant interaction between arm and trial round, with no consistent pattern. Women declared more than one partner in the past 6 months in less than 1% of individual questionnaires; among men, rates varied between 5-12%, and odds significantly and continuously declined between calendar rounds 1 and 7 [odds ratio = 4.2 (3.24-5.45)]. CONCLUSION Universal Test and Treat was not associated with increased sexual risk behaviours.
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Harling G, Gumede D, Shahmanesh M, Pillay D, Bärnighausen TW, Tanser F. Sources of social support and sexual behaviour advice for young adults in rural South Africa. BMJ Glob Health 2018; 3:e000955. [PMID: 30498588 PMCID: PMC6254751 DOI: 10.1136/bmjgh-2018-000955] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 09/18/2018] [Accepted: 09/22/2018] [Indexed: 11/25/2022] Open
Abstract
Introduction While young people in sub-Saharan Africa (SSA) are at greatest risk of HIV acquisition, uptake of HIV prevention interventions among them has been limited. Interventions delivered through social connections have changed behaviour in many settings, but not to date in SSA. There is little systematic evidence on whom young SSA adults turn to for advice. We therefore conducted an exploratory cross-sectional study from whom young rural South Africans received support and sexual behaviour-specific advice. Methods We asked 119 18–34 year olds in rural KwaZulu-Natal about the important people in their lives who provided emotional, informational, financial, physical, social or other support. We also asked whether they had discussed sex or HIV prevention with each contact named. We used descriptive statistics and logistic regression to analyse support and advice provision patterns. Results Respondents named 394 important contacts, each providing a mean of 1.7 types of support. Most contacts were relatives, same-gender friends or romantic partners. Relatives provided most informational, financial and physical support; friends and partners more social support and sexual advice. Respondents reported discussing sexual matters with 60% of contacts. Sources of support changed with age, from friends and parents, towards siblings and partners. Discussion Sexual health interventions for young adults in rural South Africa may be able to harness friend and same-generation kin social ties through which sex is already discussed, and parental ties through which other forms of support are transmitted. The gender-segregated nature of social connections may require separate interventions for men and women.
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Affiliation(s)
- Guy Harling
- Institute for Global Health, University College London, London, UK.,Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
| | - Dumile Gumede
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
| | - Maryam Shahmanesh
- Institute for Global Health, University College London, London, UK.,Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
| | - Deenan Pillay
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa.,Division of Infection and Immunity, University College London, London, UK
| | - Till W Bärnighausen
- Institute for Global Health, University College London, London, UK.,Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa.,Department of Global Health and Development, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - Frank Tanser
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,Centre for the AIDS Programme of Research in South Africa - CAPRISA, University of KwaZulu-Natal, Congella, South Africa
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Huerga H, Van Cutsem G, Ben Farhat J, Puren A, Bouhenia M, Wiesner L, Dlamini L, Maman D, Ellman T, Etard JF. Progress towards the UNAIDS 90-90-90 goals by age and gender in a rural area of KwaZulu-Natal, South Africa: a household-based community cross-sectional survey. BMC Public Health 2018; 18:303. [PMID: 29499668 PMCID: PMC5833029 DOI: 10.1186/s12889-018-5208-0] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 02/23/2018] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The Joint United Nations Programme on HIV/AIDS (UNAIDS) has developed an ambitious strategy to end the AIDS epidemic. After eight years of antiretroviral therapy (ART) program we assessed progress towards the UNAIDS 90-90-90 targets in Mbongolwane and Eshowe, KwaZulu-Natal, South Africa. METHODS We conducted a cross-sectional household-based community survey using a two-stage stratified cluster probability sampling strategy. Persons aged 15-59 years were eligible. We used face-to-face interviewer-administered questionnaires to collect information on history of HIV testing and care. Rapid HIV testing was performed on site and venous blood specimens collected from HIV-positive participants for antiretroviral drug presence test, CD4 count and viral load. At the time of the survey the CD4 threshold for ART initiation was 350 cells/μL. We calculated progression towards the 90-90-90 UNAIDS targets by estimating three proportions: HIV positive individuals who knew their status (first 90), those diagnosed who were on ART (second 90), and those on ART who were virally suppressed (third 90). RESULTS We included 5649/6688 (84.5%) individuals. Median age was 26 years (IQR: 19-40), 62.3% were women. HIV prevalence was 25.2% (95% CI: 23.6-26.9): 30.9% (95% CI: 29.0-32.9) in women; 15.9% (95% CI: 14.0-18.0) in men. Overall progress towards the 90-90-90 targets was as follows: 76.4% (95% CI: 74.1-78.6) knew their status, 69.9% (95% CI: 67.0-72.7) of those who knew their status were on ART and 93.1% (95% CI: 91.0-94.8) of those on ART were virally suppressed. By sex, progress towards the 90-90-90 targets was: 79%-71%-93% among women; and 68%-68%-92% among men (p-values of women and men comparisons were < 0.001, 0.443 and 0.584 respectively). By age, progress was: 83%-75%-95% among individuals aged 30-59 years and 64%-58%-89% among those aged 15-29 years (p-values of age groups comparisons were < 0.001, < 0.001 and 0.011 respectively). CONCLUSIONS In this context of high HIV prevalence, significant progress has been achieved with regards to reaching the UNAIDS 90-90-90 targets. The third 90, viral suppression in people on ART, was achieved among women and men. However, gaps persist in HIV diagnosis and ART coverage particularly in men and individuals younger than 30 years. Achieving 90-90-90 is feasible but requires additional investment to reach youth and men.
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Affiliation(s)
- Helena Huerga
- Clinical Research, Epicentre, 8 rue Saint-Sabin, 75011 Paris, France
| | - Gilles Van Cutsem
- Medical Department, Médecins Sans Frontières, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Jihane Ben Farhat
- Clinical Research, Epicentre, 8 rue Saint-Sabin, 75011 Paris, France
| | - Adrian Puren
- National Institute for Communicable Diseases of the NHLS, Johannesburg, South Africa
| | - Malika Bouhenia
- Clinical Research, Epicentre, 8 rue Saint-Sabin, 75011 Paris, France
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Linda Dlamini
- Department of Health, District, Empangeni, Uthungulu, South Africa
| | - David Maman
- Clinical Research, Epicentre, 8 rue Saint-Sabin, 75011 Paris, France
| | - Tom Ellman
- Medical Department, Médecins Sans Frontières, Cape Town, South Africa
| | - Jean-François Etard
- Clinical Research, Epicentre, 8 rue Saint-Sabin, 75011 Paris, France
- IRD UMI 233, INSERM U1175, Université de Montpellier, Unité TransVIHMI, Montpellier, France
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9
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Reis RK, Melo ES, Gir E. Factors associated with inconsistent condom use among people living with HIV/Aids. Rev Bras Enferm 2017; 69:40-6. [PMID: 26871214 DOI: 10.1590/0034-7167.2016690106i] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to analyze the prevalence and factors associated with inconsistent use of condoms among people living with HIV/ Aids (PLWHA). METHOD it is a cross-sectional study with 228, with individual interviews conducted in 2011. A multivariate analysis was performed with a logistic regression model. RESULTS 143 participants met the inclusion criteria, and the prevalence of inconsistent condom use was 28.7%. However, there was greater adherence among men (79.3%). In the multivariate analysis, the independent variable daily use of alcohol (OR=11.02; 95% CI 1.84, 65.92; p = 0.021) was associated with inconsistent condom use. The chance of men making consistent condom use was higher than women (OR = 0.36, 95% CI 0.15, 0.81; p = 0.015). CONCLUSION the prevalence of inconsistent condom male use among PLWHA was low, however, evidenced greater compliance among men over women with a statistically significant difference and the daily use of alcohol was associated with inconsistent condom use.
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Affiliation(s)
- Renata Karina Reis
- Programa de Pos-Graduacao em Enfermagem Fundamental, Escola de Enfermagem de Ribeirao Preto, Universidade de Sao Paulo, Ribeirao Preto, SP, Brasil
| | - Elizabete Santos Melo
- Programa de Pos-Graduacao em Enfermagem Fundamental, Escola de Enfermagem de Ribeirao Preto, Universidade de Sao Paulo, Ribeirao Preto, SP, Brasil
| | - Elucir Gir
- Programa de Pos-Graduacao em Enfermagem Fundamental, Escola de Enfermagem de Ribeirao Preto, Universidade de Sao Paulo, Ribeirao Preto, SP, Brasil
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10
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Harling G, Gumede D, Mutevedzi T, McGrath N, Seeley J, Pillay D, Bärnighausen TW, Herbst AJ. The impact of self-interviews on response patterns for sensitive topics: a randomized trial of electronic delivery methods for a sexual behaviour questionnaire in rural South Africa. BMC Med Res Methodol 2017; 17:125. [PMID: 28818053 PMCID: PMC5561578 DOI: 10.1186/s12874-017-0403-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 08/02/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Self-interviews, where the respondent rather than the interviewer enters answers to questions, have been proposed as a way to reduce social desirability bias associated with interviewer-led interviews. Computer-assisted self-interviews (CASI) are commonly proposed since the computer programme can guide respondents; however they require both language and computer literacy. We evaluated the feasibility and acceptability of using electronic methods to administer quantitative sexual behaviour questionnaires in the Somkhele demographic surveillance area (DSA) in rural KwaZulu-Natal, South Africa. METHODS We conducted a four-arm randomized trial of paper-and-pen-interview, computer-assisted personal-interview (CAPI), CASI and audio-CASI with an age-sex-urbanicity stratified sample of 504 adults resident in the DSA in 2015. We compared respondents' answers to their responses to the same questions in previous surveillance rounds. We also conducted 48 cognitive interviews, dual-coding responses using the Framework approach. RESULTS Three hundred forty (67%) individuals were interviewed and covariates and participation rates were balanced across arms. CASI and audio-CASI were significantly slower than interviewer-led interviews. Item non-response rates were higher in self-interview arms. In single-paper meta-analysis, self-interviewed individuals reported more socially undesirable sexual behaviours. Cognitive interviews found high acceptance of both self-interviews and the use of electronic methods, with some concerns that self-interview methods required more participant effort and literacy. CONCLUSIONS Electronic data collection methods, including self-interview methods, proved feasible and acceptable for completing quantitative sexual behaviour questionnaires in a poor, rural South African setting. However, each method had both benefits and costs, and the choice of method should be based on context-specific criteria.
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Affiliation(s)
- Guy Harling
- Academic Unit of Primary Care and Population Sciences and Department of Social Statistics and Demography, University of Southampton, Southampton, UK
- Africa Health Research Institute, School of Nursing & Public Health, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
- Research Department of Epidemiology & Public Health, University College London, London, UK
| | - Dumile Gumede
- Academic Unit of Primary Care and Population Sciences and Department of Social Statistics and Demography, University of Southampton, Southampton, UK
| | - Tinofa Mutevedzi
- Academic Unit of Primary Care and Population Sciences and Department of Social Statistics and Demography, University of Southampton, Southampton, UK
| | - Nuala McGrath
- Academic Unit of Primary Care and Population Sciences and Department of Social Statistics and Demography, University of Southampton, Southampton, UK
- University of Southampton, Southampton, UK
| | - Janet Seeley
- Academic Unit of Primary Care and Population Sciences and Department of Social Statistics and Demography, University of Southampton, Southampton, UK
- London School of Hygiene & Tropical Medicine, London, UK
| | - Deenan Pillay
- Academic Unit of Primary Care and Population Sciences and Department of Social Statistics and Demography, University of Southampton, Southampton, UK
- Division of Infection and Immunity, University College London, London, UK
| | - Till W. Bärnighausen
- Academic Unit of Primary Care and Population Sciences and Department of Social Statistics and Demography, University of Southampton, Southampton, UK
- Research Department of Epidemiology & Public Health, University College London, London, UK
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - Abraham J. Herbst
- Academic Unit of Primary Care and Population Sciences and Department of Social Statistics and Demography, University of Southampton, Southampton, UK
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11
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Legemate EM, Hontelez JAC, Looman CWN, de Vlas SJ. Behavioural disinhibition in the general population during the antiretroviral therapy roll-out in Sub-Saharan Africa: systematic review and meta-analysis. Trop Med Int Health 2017; 22:797-806. [PMID: 28449332 DOI: 10.1111/tmi.12885] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Improved life expectancy and reduced transmission probabilities due to ART may result in behavioural disinhibition - that is an increase in sexual risk behaviour in response to a perceived lower risk of HIV. We examined trends in sexual risk behaviour in the general population of sub-Saharan African countries 1999-2015. METHODS We systematically reviewed scientific literature of sexual behaviour and reviewed trends in Demographic and Health Surveys. A meta-analysis on four indicators of sexual risk behaviour was performed: unprotected sex, multiple sexual partners, commercial sex and prevalence of sexually transmitted infections. RESULTS Only two peer-reviewed studies met our inclusion criteria, while our review of DHS data spanned 18 countries and 16 years (1999-2015). We found conflicting trends in sexual risk behaviour. Reported unprotected sex decreased consistently across the 18 countries, for both sexes. In contrast, reporting multiple partners was decreasing over the period 1999 to the mid-2000s, yet has been consistently increasing thereafter. Similar trends were found for reported sexually transmitted infections and commercial sex (men only). CONCLUSIONS In conclusion, we found no clear evidence of behavioural disinhibition due to expanded access to ART in sub-Saharan Africa. Substantial increases in condom use coincided with increases in reported multiple partners, commercial sex and sexually transmitted infections, especially during the period of ART scale-up. Further research is needed into how these changes might affect HIV transmission.
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Affiliation(s)
- Eva M Legemate
- Department of Public Health, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jan A C Hontelez
- Department of Public Health, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Caspar W N Looman
- Department of Public Health, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sake J de Vlas
- Department of Public Health, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands
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12
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Delva W, Helleringer S. Beyond Risk Compensation: Clusters of Antiretroviral Treatment (ART) Users in Sexual Networks Can Modify the Impact of ART on HIV Incidence. PLoS One 2016; 11:e0163159. [PMID: 27657492 PMCID: PMC5033240 DOI: 10.1371/journal.pone.0163159] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 09/02/2016] [Indexed: 11/19/2022] Open
Abstract
Introduction Concerns about risk compensation—increased risk behaviours in response to a perception of reduced HIV transmission risk—after the initiation of ART have largely been dispelled in empirical studies, but other changes in sexual networking patterns may still modify the effects of ART on HIV incidence. Methods We developed an exploratory mathematical model of HIV transmission that incorporates the possibility of ART clusters, i.e. subsets of the sexual network in which the density of ART patients is much higher than in the rest of the network. Such clusters may emerge as a result of ART homophily—a tendency for ART patients to preferentially form and maintain relationships with other ART patients. We assessed whether ART clusters may affect the impact of ART on HIV incidence, and how the influence of this effect-modifying variable depends on contextual variables such as HIV prevalence, HIV serosorting, coverage of HIV testing and ART, and adherence to ART. Results ART homophily can modify the impact of ART on HIV incidence in both directions. In concentrated epidemics and generalized epidemics with moderate HIV prevalence (≈ 10%), ART clusters can enhance the impact of ART on HIV incidence, especially when adherence to ART is poor. In hyperendemic settings (≈ 35% HIV prevalence), ART clusters can reduce the impact of ART on HIV incidence when adherence to ART is high but few people living with HIV (PLWH) have been diagnosed. In all contexts, the effects of ART clusters on HIV epidemic dynamics are distinct from those of HIV serosorting. Conclusions Depending on the programmatic and epidemiological context, ART clusters may enhance or reduce the impact of ART on HIV incidence, in contrast to serosorting, which always leads to a lower impact of ART on HIV incidence. ART homophily and the emergence of ART clusters should be measured empirically and incorporated into more refined models used to plan and evaluate ART programmes.
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Affiliation(s)
- Wim Delva
- The South African Department of Science and Technology-National Research Foundation (DST-NRF) Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium
- Center for Statistics, Hasselt University, Diepenbeek, Belgium
- Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
- Institute of Integrative Biology, ETH Zurich, Zurich, Switzerland
- * E-mail:
| | - Stéphane Helleringer
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
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Assessment of epidemic projections using recent HIV survey data in South Africa: a validation analysis of ten mathematical models of HIV epidemiology in the antiretroviral therapy era. LANCET GLOBAL HEALTH 2016; 3:e598-608. [PMID: 26385301 DOI: 10.1016/s2214-109x(15)00080-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 05/06/2015] [Accepted: 06/12/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND Mathematical models are widely used to simulate the effects of interventions to control HIV and to project future epidemiological trends and resource needs. We aimed to validate past model projections against data from a large household survey done in South Africa in 2012. METHODS We compared ten model projections of HIV prevalence, HIV incidence, and antiretroviral therapy (ART) coverage for South Africa with estimates from national household survey data from 2012. Model projections for 2012 were made before the publication of the 2012 household survey. We compared adult (age 15-49 years) HIV prevalence in 2012, the change in prevalence between 2008 and 2012, and prevalence, incidence, and ART coverage by sex and by age groups between model projections and the 2012 household survey. FINDINGS All models projected lower prevalence estimates for 2012 than the survey estimate (18·8%), with eight models' central projections being below the survey 95% CI (17·5-20·3). Eight models projected that HIV prevalence would remain unchanged (n=5) or decline (n=3) between 2008 and 2012, whereas prevalence estimates from the household surveys increased from 16·9% in 2008 to 18·8% in 2012 (difference 1·9, 95% CI -0·1 to 3·9). Model projections accurately predicted the 1·6 percentage point prevalence decline (95% CI -0·3 to 3·5) in young adults aged 15-24 years, and the 2·2 percentage point (0·5 to 3·9) increase in those aged 50 years and older. Models accurately represented the number of adults on ART in 2012; six of ten models were within the survey 95% CI of 1·54-2·12 million. However, the differential ART coverage between women and men was not fully captured; all model projections of the sex ratio of women to men on ART were lower than the survey estimate of 2·22 (95% CI 1·73-2·71). INTERPRETATION Projections for overall declines in HIV epidemics during the ART era might have been optimistic. Future treatment and HIV prevention needs might be greater than previously forecasted. Additional data about service provision for HIV care could help inform more accurate projections. FUNDING Bill & Melinda Gates Foundation.
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14
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Sex Differences in HIV Prevalence Persist over Time: Evidence from 18 Countries in Sub-Saharan Africa. PLoS One 2016; 11:e0148502. [PMID: 26841112 PMCID: PMC4739589 DOI: 10.1371/journal.pone.0148502] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 01/19/2016] [Indexed: 01/07/2023] Open
Abstract
Objective The aim of this study was to examine changes over time in the female: male HIV prevalence ratio in 18 countries in Sub-Saharan Africa, overall and when stratified by area of residence, educational attainment and marital status. Methodology We used data from the Demographic and Health Surveys, which are nationally representative household surveys. By using data from 18 countries with at least two survey rounds with HIV testing, and dividing the countries into three regions (Western/Central, Eastern and Southern) we were able to examine cross-country and regional changes in the female: male HIV prevalence ratio over time. Logistic regression was used to estimate female: male HIV prevalence ratios in urban versus rural areas and for different categories of education and marital status. To assess changes over time, we compared the confidence intervals of the prevalence ratios. Results The female: male HIV prevalence ratio was above one in all countries in at least one survey round for both ages 15–24 years and 25–49 years. In 13 out of 18 countries the prevalence ratio was higher for the younger age group compared to the age group 25–49 years (3 significant) and this difference in prevalence ratios between the age groups did not change over time. Overall, there was a higher frequency of increasing than decreasing prevalence ratios. The gender disparity was greater among those who were married/living together than among the never-married, and over time, the ratio was more stable among the married/living together. The study found no clear differential changes by education. Conclusion Women continue to carry the greater burden of HIV in Sub-Saharan Africa and there is no clear pattern of change in the gap between men and women as the direction and magnitude of change in the prevalence ratios varied greatly.
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15
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Lancaster KE, Powers KA, Lungu T, Mmodzi P, Hosseinipour MC, Chadwick K, Go VF, Pence BW, Hoffman IF, Miller WC. The HIV Care Continuum among Female Sex Workers: A Key Population in Lilongwe, Malawi. PLoS One 2016; 11:e0147662. [PMID: 26808043 PMCID: PMC4726447 DOI: 10.1371/journal.pone.0147662] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 01/06/2016] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE The HIV care continuum among female sex workers (FSW), a key population, has not been well characterized, especially within the generalized epidemics of sub-Saharan Africa. This was the first study to characterize the HIV care continuum among FSW in Lilongwe, Malawi. METHODS From July through September 2014, we used venue-based sampling to enroll 200 adult FSW in Lilongwe, Malawi into a cross-sectional evaluation assessing HIV care continuum outcomes. Seropositive FSW, identified using HIV rapid testing, received rapid CD4 counts in addition to viral loads using dried blood spots. We calculated proportions of HIV-infected FSW who had history of care, were on ART, and had suppressed viral load and we used Poisson regression to estimate the associations of demographic characteristics and transmission risk behaviors with each outcome. RESULTS HIV seroprevalence was 69% (n = 138). Among all FSW the median age was 24 years (IQR: 22-28). Among the 20% who were newly diagnosed and reported previously testing negative, the median time since last HIV test was 11 months (interquartile range: 3-17). The majority (69%) of HIV-infected FSW had a history of HIV care, 52% reported current ART use, and 45% were virally suppressed. Of the FSW who reported current ART use, 86% were virally suppressed. Transmission risk behaviors were not associated with continuum outcomes. CONCLUSIONS FSW in Lilongwe were predominately young and have a high HIV prevalence. Only half of HIV-infected FSW reported current ART use, but the majority of those on ART were virally suppressed. To reduce ongoing transmission and improve health outcomes, increased HIV testing, care engagement, and ART coverage is urgently needed among FSW. Universal testing and treatment strategies for all FSW in Malawi must be strongly considered.
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Affiliation(s)
- Kathryn Elizabeth Lancaster
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | - Kimberly A. Powers
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Thandie Lungu
- UNC Project Malawi, University of North Carolina at Chapel Hill, Lilongwe, Malawi
| | - Pearson Mmodzi
- UNC Project Malawi, University of North Carolina at Chapel Hill, Lilongwe, Malawi
| | - Mina C. Hosseinipour
- UNC Project Malawi, University of North Carolina at Chapel Hill, Lilongwe, Malawi
- Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | - Vivian F. Go
- Department of Health Behavior, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Brian W. Pence
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Irving F. Hoffman
- UNC Project Malawi, University of North Carolina at Chapel Hill, Lilongwe, Malawi
- Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - William C. Miller
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Iwuji CC, McGrath N, de Oliveira T, Porter K, Pillay D, Fisher M, Newport M, Newell ML. The Art of HIV Elimination: Past and Present Science. JOURNAL OF AIDS & CLINICAL RESEARCH 2015; 6:525. [PMID: 27774350 PMCID: PMC5072486 DOI: 10.4172/2155-6113.1000525] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Remarkable strides have been made in controlling the HIV epidemic, although not enough to achieve epidemic control. More recently, interest in biomedical HIV control approaches has increased, but substantial challenges with the HIV cascade of care hinder successful implementation. We summarise all available HIV prevention methods and make recommendations on how to address current challenges. DISCUSSION In the early days of the epidemic, behavioural approaches to control the HIV dominated, and the few available evidence-based interventions demonstrated to reduce HIV transmission were applied independently from one another. More recently, it has become clear that combination prevention strategies targeted to high transmission geographies and people at most risk of infections are required to achieve epidemic control. Biomedical strategies such as male medical circumcision and antiretroviral therapy for treatment in HIV-positive individuals and as pre-exposure prophylaxis in HIV-negative individuals provide immense promise for the future of HIV control. In resource-rich settings, the threat of HIV treatment optimism resulting in increased sexual risk taking has been observed and there are concerns that as ART roll-out matures in resource-poor settings and the benefits of ART become clearly visible, behavioural disinhibition may also become a challenge in those settings. Unfortunately, an efficacious vaccine, a strategy which could potentially halt the HIV epidemic, remains elusive. CONCLUSION Combination HIV prevention offers a logical approach to HIV control, although what and how the available options should be combined is contextual. Therefore, knowledge of the local or national drivers of HIV infection is paramount. Problems with the HIV care continuum remain of concern, hindering progress towards the UNAIDS target of 90-90-90 by 2020. Research is needed on combination interventions that address all the steps of the cascade as the steps are not independent of each other. Until these issues are addressed, HIV elimination may remain an unattainable goal.
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Affiliation(s)
- Collins C. Iwuji
- Africa Centre for Health and Population Studies, University of KwaZulu Natal, South Africa
- Research Department of Infection and Population Health, University College London, UK
| | - Nuala McGrath
- Africa Centre for Health and Population Studies, University of KwaZulu Natal, South Africa
- Academic Unit of Primary Care and Population Sciences, and Department of Social statistics and Demography, University of Southampton, UK
| | - Tulio de Oliveira
- Africa Centre for Health and Population Studies, University of KwaZulu Natal, South Africa
| | | | - Deenan Pillay
- Africa Centre for Health and Population Studies, University of KwaZulu Natal, South Africa
- Research Department of Infection and Immunity, University College London, UK
| | - Martin Fisher
- Division of Medicine, Brighton and Sussex Medical School, UK
| | - Melanie Newport
- Department of Infectious Diseases and Global Health, Brighton and Sussex Medical School, UK
| | - Marie-Louise Newell
- Faculty of Medicine and Faculty of Social and Human Sciences, University of Southampton, UK
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Implementation of couples' voluntary HIV counseling and testing services in Durban, South Africa. BMC Public Health 2015; 15:601. [PMID: 26136116 PMCID: PMC4489128 DOI: 10.1186/s12889-015-1959-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 06/22/2015] [Indexed: 01/21/2023] Open
Abstract
Background Couples’ voluntary HIV counseling and testing (CVCT) is an evidence-based intervention that significantly reduces HIV incidence in couples. Despite the high prevalence of HIV and HIV couple serodiscordance in South Africa, there are few CVCT services. Methods From February-June 2013, The Rwanda Zambia HIV Research Group provided support, training, and technical assistance for local counselors and promoters to pilot CVCT services in five hospital-based clinics in Durban, South Africa. Client-level data (age, gender, years cohabiting, pregnancy status, previous testing, antiretroviral treatment (ART) status, neighborhood, and test site) collected as a component of routine CVCT service operation is presented stratified by couple serostatus. Results Twenty counselors and 28 promoters completed training. Of 907 couples (1,814 individuals) that underwent CVCT, prevalence of HIV was 41.8 % and prevalence of HIV serodiscordance was 29.5 % (19.3 % M-F+, 10.3 % M + F-). Most participants were 25–34 years of age, and this group had the highest prevalence. Previous individual HIV testing was low (50 % for men, 63 % for women). Only 4 % of couples reported previous CVCT. Most (75 %) HIV+ partners were not on ART, and HIV+ individuals in discordant couples were more likely to be on ART than those in concordant positive couples. Pregnancy among HIV+ women was not associated with previous HIV testing or ART use. Conclusions Implementation of standard CVCT services was found to be feasible in Durban. The burden of HIV and couple serodiscordance in Durban was extremely high. CVCT would greatly benefit couples in Durban as an HIV prevention strategy.
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McGrath N, Eaton JW, Newell ML, Hosegood V. Migration, sexual behaviour, and HIV risk: a general population cohort in rural South Africa. Lancet HIV 2015; 2:e252-9. [PMID: 26280016 PMCID: PMC4533230 DOI: 10.1016/s2352-3018(15)00045-4] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Increased sexual risk behaviour and HIV prevalence have been reported in migrants compared with nonmigrants in sub-Saharan Africa. We investigated the association of residential and migration patterns with sexual HIV risk behaviours and HIV prevalence in an open, general population cohort in rural KwaZulu-Natal, South Africa. METHODS In a mainly rural demographic surveillance area in northern KwaZulu-Natal, South Africa, we collected longitudinal demographic, migration, sexual behaviour, and HIV status data through household surveillance twice per year and individual surveillance once per year. All resident household members and a sample of non-resident household members (stratified by sex and migration patterns) were eligible for participation. Participants reported sexual risk behaviours, including data for multiple, concurrent, and casual sexual partners and condom use, and gave a dried blood spot sample via fingerprick for HIV testing. We investigated population-level differences in sexual HIV risk behaviours and HIV prevalence with respect to migration indicators using logistic regression models. FINDINGS Between Jan 1, 2005, and Dec 31, 2011, the total eligible population at each surveillance round ranged between 21 129 and 22 726 women (aged 17-49 years) and between 20 399 and 22 100 men (aged 17-54 years). The number of eligible residents in any round ranged from 24 395 to 26 664 and the number of eligible non-residents ranged from 17 002 to 18 891 between rounds. The stratified sample of non-residents included between 2350 and 3366 individuals each year. Sexual risk behaviours were significantly more common in non-residents than in residents for both men and women. Estimated differences in sexual risk behaviours, but not HIV prevalence, varied between the migration indicators: recent migration, mobility, and migration type. HIV prevalence was significantly increased in current residents with a recent history of migration compared with other residents in the study area in men(adjusted odds ratio 1·19, 95% CI 1·07-1·33) and in women (1·18, 1·10-1·26). INTERPRETATION Local information about migrants and highly mobile individuals could help to target intervention strategies that are based on the identification of transmission hotspots.Funding Wellcome Trust.
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Affiliation(s)
- Nuala McGrath
- Academic Unit of Primary Care and Population Sciences, University of Southampton, Southampton, UK
- Department of Social Statistics and Demography, University of Southampton, Southampton, UK
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
| | - Jeffrey W Eaton
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Marie-Louise Newell
- Department of Social Statistics and Demography, University of Southampton, Southampton, UK
- Academic Unit of Human Development and Health, University of Southampton, Southampton, UK
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
| | - Victoria Hosegood
- Department of Social Statistics and Demography, University of Southampton, Southampton, UK
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
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Fladseth K, Gafos M, Newell ML, McGrath N. The impact of gender norms on condom use among HIV-positive adults in KwaZulu-Natal, South Africa. PLoS One 2015; 10:e0122671. [PMID: 25853870 PMCID: PMC4390283 DOI: 10.1371/journal.pone.0122671] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 02/24/2015] [Indexed: 11/18/2022] Open
Abstract
Critical to preventing the spread of HIV is promoting condom use among HIV-positive individuals. Previous studies suggest that gender norms (social and cultural constructions of the ways that women and men are expected to behave) may be an important determinant of condom use. However, the relationship has not been evaluated among HIV-positive women and men in South Africa. We examined gender norms and condom use at last sex among 550 partnerships reported by 530 sexually-active HIV-positive women (372) and men (158) who had sought care, but not yet initiated antiretroviral therapy in a high HIV-prevalence rural setting in KwaZulu-Natal, South Africa between January 2009 and March 2011. Participants enrolled in the cohort study completed a baseline questionnaire that detailed their socio-demographic characteristics, socio-economic circumstances, religion, HIV testing history and disclosure of HIV status, stigma, social capital, gender norms and self-efficacy. Gender norms did not statistically differ between women and men (p = 0.18). Overall, condoms were used at last sex in 58% of partnerships. Although participants disclosed their HIV status in 66% of the partnerships, 60% did not have knowledge of their partner's HIV status. In multivariable logistic regression, run separately for each sex, women younger than 26 years with more equitable gender norms were significantly more likely to have used a condom at last sex than those of the same age group with inequitable gender norms (OR = 8.88, 95% CI 2.95-26.75); the association between condom use and gender norms among women aged 26+ years and men of all ages was not statistically significant. Strategies to address gender inequity should be integrated into positive prevention interventions, particularly for younger women, and supported by efforts at a societal level to decrease gender inequality.
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Affiliation(s)
- Kristin Fladseth
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mitzy Gafos
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
| | - Marie Louise Newell
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa
- Faculty of Medicine and of Social and Human Sciences, University of Southampton, Southampton, United Kingdom
| | - Nuala McGrath
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa
- Faculty of Medicine and of Social and Human Sciences, University of Southampton, Southampton, United Kingdom
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20
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Orne-Gliemann J, Larmarange J, Boyer S, Iwuji C, McGrath N, Bärnighausen T, Zuma T, Dray-Spira R, Spire B, Rochat T, Lert F, Imrie J. Addressing social issues in a universal HIV test and treat intervention trial (ANRS 12249 TasP) in South Africa: methods for appraisal. BMC Public Health 2015; 15:209. [PMID: 25880823 PMCID: PMC4351958 DOI: 10.1186/s12889-015-1344-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 01/02/2015] [Indexed: 12/21/2022] Open
Abstract
Background The Universal HIV Test and Treat (UTT) strategy represents a challenge for science, but is also a challenge for individuals and societies. Are repeated offers of provider-initiated HIV testing and immediate antiretroviral therapy (ART) socially-acceptable and can these become normalized over time? Can UTT be implemented without potentially adding to individual and community stigma, or threatening individual rights? What are the social, cultural and economic implications of UTT for households and communities? And can UTT be implemented within capacity constraints and other threats to the overall provision of HIV services? The answers to these research questions will be critical for routine implementation of UTT strategies. Methods/design A social science research programme is nested within the ANRS 12249 Treatment-as-Prevention (TasP) cluster-randomised trial in rural South Africa. The programme aims to inform understanding of the (i) social, economic and environmental factors affecting uptake of services at each step of the continuum of HIV prevention, treatment and care and (ii) the causal impacts of the TasP intervention package on social and economic factors at the individual, household, community and health system level. We describe a multidisciplinary, multi-level, mixed-method research protocol that includes individual, household, community and clinic surveys, and combines quantitative and qualitative methods. Discussion The UTT strategy is changing the overall approach to HIV prevention, treatment and care, and substantial social consequences may be anticipated, such as changes in social representations of HIV transmission, prevention, HIV testing and ART use, as well as changes in individual perceptions and behaviours in terms of uptake and frequency of HIV testing and ART initiation at high CD4. Triangulation of social science studies within the ANRS 12249 TasP trial will provide comprehensive insights into the acceptability and feasibility of the TasP intervention package at individual, community, patient and health system level, to complement the trial’s clinical and epidemiological outcomes. It will also increase understanding of the causal impacts of UTT on social and economic outcomes, which will be critical for the long-term sustainability and routine UTT implementation. Trial registration Clinicaltrials.gov: NCT01509508; South African Trial Register: DOH-27-0512-3974. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-1344-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Joanna Orne-Gliemann
- INSERM/University of Bordeaux, ISPED, Centre Inserm U897- Épidemiologie-Biostatistique, Bordeaux, France.
| | - Joseph Larmarange
- Centre Population et Développement (CEPED UMR 196 Université Paris Descartes Ined IRD), Paris, France. .,Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Durban, South Africa.
| | - Sylvie Boyer
- INSERM-IRD-Aix-Marseille University, Faculty of Medicine, Aix-Marseille School of Economics (AMSE), SESSTIM-UMR 912, 13006, Marseille, France.
| | - Collins Iwuji
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Durban, South Africa.
| | - Nuala McGrath
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Durban, South Africa. .,Academic Unit of Primary Care and Population Sciences, and Department of Social statistics and Demography, University of Southampton, Southampton, UK.
| | - Till Bärnighausen
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Durban, South Africa. .,Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, USA.
| | - Thembelile Zuma
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Durban, South Africa.
| | - Rosemary Dray-Spira
- INSERM, UMR_S1136, Pierre Louis Institute of Epidemiology and Public Health, Research Team in social epidemiology, F-75013, Paris, France. .,Sorbonne Universités, UPMC Univ Paris 06, UMR_S1136, Pierre Louis Institute of Epidemiology and Public Health, Team Research in social epidemiology, F-75013, Paris, France.
| | - Bruno Spire
- INSERM-IRD-Aix-Marseille University, Faculty of Medicine, Aix-Marseille School of Economics (AMSE), SESSTIM-UMR 912, 13006, Marseille, France.
| | - Tamsen Rochat
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Durban, South Africa.
| | - France Lert
- Centre de recherche en Épidémiologie et Santé des Populations (CESP, Inserm Unité 1018), Villejuif, France.
| | - John Imrie
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Durban, South Africa. .,Centre for Sexual Health and HIV Research, Research Department of Infection and Population Health, Faculty of Population Health Sciences, University College London, London, UK.
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Abstract
Southern Africa, home to about 20 % of the global burden of infection continues to experience high rates of new HIV infection despite substantial programmatic scale-up of treatment and prevention interventions. While several countries in the region have had substantial reductions in HIV infection, almost half a million new infections occurred in this region in 2012. Sexual transmission remains the dominant mode of transmission. A recent national household survey in Swaziland revealed an HIV prevalence of 14.3 % among 18-19 year old girls, compared to 0.8 % among their male peers. Expanded ART programmes in Southern Africa have resulted in dramatically decreased HIV incidence and HIV mortality rates. In South Africa alone, it is estimated that more than 2.1 million of the 6.1 million HIV-positive people were receiving ART by the end of 2012, and that this resulted in more than 2.7 million life-years saved, and hundreds of thousands of HIV infections averted. Biological, behavioural and structural factors all contribute to the ongoing high rates of new HIV infection; however, as the epidemic matures and mortality is reduced from increased ART coverage, epidemiological trends become hard to quantify. What is clear is that a key driver of the Southern African epidemic is the high incidence rate of infection in young women, a vulnerable population with limited prevention options. Moreover, whilst ongoing trials of combination prevention, microbicides and behavioural economics hold promise for further epidemic control, an AIDS-free generation will not be realised unless incident infections in key populations are reduced.
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Knight L, McGrath N, van Rooyen H, Humphries H, van Heerden A, Richter L. Characteristics of sexually experienced HIV testers aged 18 to 32 in rural South Africa: baseline results from a community-based trial, NIMH Project Accept (HPTN 043). BMC Public Health 2014; 14:1164. [PMID: 25392204 PMCID: PMC4234824 DOI: 10.1186/1471-2458-14-1164] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 10/17/2014] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Young people in South Africa are at high risk of HIV infection and yet may have more limited access to prevention and treatment services than others in the population. Testing facilitates the sharing of prevention messages but also enables the linkage to care and treatment of those who test positive and therefore has wider public health implications. METHODS This baseline survey conducted in 2005 for a community randomized trial in rural KwaZulu-Natal explored factors associated with a history of ever, repeat and recent testing amongst sexually debuted men and women aged 18 to 32 years. RESULTS Over 35% of this rural population ever tested for HIV, with men less likely to ever (unadjusted OR 0.26, 95% CI: 0.21-0.32) and repeatedly test than women (adjusted OR (aOR) 0.68, 95% CI: 0.48-0.97). Men aged 24-28 years (aOR 2.02, 95% CI: 1.10-3.71) and 29-32 years (aOR 2.69, 95% CI: 1.46-4.94) were more likely to ever test than those <20 years. Those who reported having discussed HIV with others had significantly greater odds of reporting ever (men's aOR 2.83, 95% CI: 1.63-4.89; women's aOR 3.36, 95% CI: 2.50-4.53), recent (irrespective of sex, aOR 2.87, 95% CI: 2.02-4.09) and repeat testing (aOR 2.02, 95% CI: 1.28-3.19). CONCLUSION These findings highlight the need for novel youth- and men-friendly testing services and emphasises the importance of discussions about HIV in the home and community to encourage testing.
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Affiliation(s)
- Lucia Knight
- />School of Public Health, University of the Western Cape, P Bag X17, Bellville, 7535 South Africa
| | - Nuala McGrath
- />Academic Unit of Primary Care and Population Sciences, and Department of Social Statistics and Demography, Mailpoint 805, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD UK
- />Africa Centre for Health and Population Studies, University of KwaZulu-Natal, PO Box 198, Mtubatuba, KZN 3935 South Africa
| | - Heidi van Rooyen
- />HIV/AIDS STIs and TB Programme, Human Sciences Research Council, P.O Box 90, Msunduzi, 3200 South Africa
| | - Hilton Humphries
- />HIV/AIDS STIs and TB Programme, Human Sciences Research Council, P.O Box 90, Msunduzi, 3200 South Africa
| | - Alastair van Heerden
- />HIV/AIDS STIs and TB Programme, Human Sciences Research Council, P.O Box 90, Msunduzi, 3200 South Africa
- />Developmental Pathways of Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Linda Richter
- />Developmental Pathways of Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- />HIV/AIDS STIs and TB Programme, Human Sciences Research Council, 750 Francois Road, Cato Manor, Durban, 4001 South Africa
- />DST-NRF Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa
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Decrease in sexual risk behaviours after early initiation of antiretroviral therapy: a 24-month prospective study in Côte d'Ivoire. J Int AIDS Soc 2014; 17:18977. [PMID: 24985779 PMCID: PMC4078101 DOI: 10.7448/ias.17.1.18977] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 04/23/2014] [Accepted: 05/01/2014] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Whether early antiretroviral therapy (ART) initiation could impact sexual risk behaviours remains to be documented. We aimed to investigate changes in sexual behaviours within the 24 months following an early versus standard ART initiation in HIV-positive adults with high CD4 counts. METHODS We used data from a prospective behavioural study nested in a randomized controlled trial of early ART (Temprano-ANRS12136). Time trends in sexual behaviours from enrolment in the trial (M0) to 12-month (M12) and 24-month (M24) visits were measured and compared, using Generalized Estimating Equations models, between participants randomly assigned either to initiate ART immediately (early ART) or to defer ART initiation until on-going WHO starting criteria are met (standard ART). Indicators of sexual behaviours included 1) sexual activity in the past year, 2) multiple partnership in the past year, 3) unprotected sex at last intercourse and 4) risky sex (i.e. unprotected sex with a partner of HIV negative/unknown status) at last intercourse. RESULTS Analyses included 1952 participants (975 with early ART and 977 with standard ART; overall median baseline CD4 count: 469/mm(3)). Among participants with early ART, significant decreases were found between M0 and M24 in sexual activity (Odds Ratio [OR] 0.72, 95% Confidence Interval [95% CI] 0.57-0.92), multiple partnership (OR 0.57, 95% CI 0.41-0.79), unprotected sex (OR 0.59, 95% CI 0.47-0.75) and risky sex (OR 0.58, 95% CI 0.45-0.76). Among participants with standard ART, sexual behaviours showed similar trends over time. These decreases mostly occurred within the 12 months following enrolment in the trial in both groups and prior to ART initiation in participants with standard ART. For unprotected sex and risky sex, decreases were or tended to be more pronounced among patients reporting that their last sexual partner was non-cohabiting. CONCLUSIONS In these sub-Saharan adults with high CD4 counts, entry into HIV care, rather than ART initiation, resulted in decreased sexual activity and risky sexual behaviours. We did not observe any evidence of a risk compensation phenomenon associated with early ART initiation. These results illustrate the potential behavioural preventive effect of early entry into care, which goes hand in hand with early ART initiation.
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Mutevedzi PC, Newell ML. Review: [corrected] The changing face of the HIV epidemic in sub-Saharan Africa. Trop Med Int Health 2014; 19:1015-28. [PMID: 24976370 DOI: 10.1111/tmi.12344] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The widespread roll-out of antiretroviral therapy (ART) has substantially changed the face of human immunodeficiency virus (HIV). Timely initiation of ART in HIV-infected individuals dramatically reduces mortality and improves employment rates to levels prior to HIV infection. Recent findings from several studies have shown that ART reduces HIV transmission risk even with modest ART coverage of the HIV-infected population and imperfect ART adherence. While condoms are highly effective in the prevention of HIV acquisition, they are compromised by low and inconsistent usage; male medical circumcision substantially reduces HIV transmission but uptake remains relatively low; ART during pregnancy, delivery and breastfeeding can virtually eliminate mother-to-child transmission but implementation is challenging, especially in resource-limited settings. The current HIV prevention recommendations focus on a combination of preventions approach, including ART as treatment or pre- or post-exposure prophylaxis together with condoms, circumcision and sexual behaviour modification. Improved survival in HIV-infected individuals and reduced HIV transmission risk is beginning to result in limited HIV incidence decline at population level and substantial increases in HIV prevalence. However, achievements in HIV treatment and prevention are threatened by the challenges of lifelong adherence to preventive and therapeutic methods and by the ageing of the HIV-infected cohorts potentially complicating HIV management. Although current thinking suggests prevention of HIV transmission through early detection of infection immediately followed by ART could eventually result in elimination of the HIV epidemic, controversies remain as to whether we can treat our way out of the HIV epidemic.
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Affiliation(s)
- Portia C Mutevedzi
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
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25
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Darbes LA, van Rooyen H, Hosegood V, Ngubane T, Johnson MO, Fritz K, McGrath N. Uthando Lwethu ('our love'): a protocol for a couples-based intervention to increase testing for HIV: a randomized controlled trial in rural KwaZulu-Natal, South Africa. Trials 2014; 15:64. [PMID: 24552199 PMCID: PMC3936910 DOI: 10.1186/1745-6215-15-64] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Accepted: 02/03/2014] [Indexed: 11/29/2022] Open
Abstract
Background Couples-based HIV counseling and testing (CHCT) is a proven strategy to reduce the risk of HIV transmission between partners, but uptake of CHCT is low. We describe the study design of a randomized controlled trial (RCT) aimed to increase participation in CHCT and reduce sexual risk behavior for HIV among heterosexual couples in rural KwaZulu-Natal, South Africa. We hypothesize that the rate of participation in CHCT will be higher and sexual risk behavior will be lower in the intervention group as compared to the control. Methods/design Heterosexual couples (N = 350 couples, 700 individuals) are being recruited to participate in a randomized trial of a couples-based intervention comprising two group sessions (one mixed gender, one single gender) and four couples’ counseling sessions. Couples must have been in a relationship together for at least 6 months. Quantitative assessments are conducted via mobile phones by gender-matched interviewers at baseline, 3, 6, and 9 months post-randomization. Intervention content is aimed to improve relationship dynamics, and includes communication skills and setting goals regarding CHCT. Discussion The Uthando Lwethu (‘our love’) intervention is the first couples-based intervention to have CHCT as its outcome. We are also targeting reductions in unprotected sex. CHCT necessitates the testing and mutual disclosure of both partners, conditions that are essential for improving subsequent outcomes such as disclosure of HIV status, sexual risk reduction, and improving treatment outcomes. Thus, improving rates of CHCT has the potential to improve health outcomes for heterosexual couples in a rural area of South Africa that is highly impacted by HIV. The results of our ongoing clinical trial will provide much needed information regarding whether a relationship-focused approach is effective in increasing rates of participation in CHCT. Our intervention represents an attempt to move away from individual-level conceptualizations, to a more integrated approach for HIV prevention. Trial registration Study Name: Couples in Context: An RCT of a Couples-based HIV Prevention Intervention ClinicalTrials.gov identifier: NCT01953133. South African clinical trial registration number: DOH-27-0212-3937
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Affiliation(s)
- Lynae A Darbes
- Center for AIDS Prevention Studies, University of California, 50 Beale Street, San Francisco, CA 94105, USA.
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26
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Eaton JW, Menzies NA, Stover J, Cambiano V, Chindelevitch L, Cori A, Hontelez JAC, Humair S, Kerr CC, Klein DJ, Mishra S, Mitchell KM, Nichols BE, Vickerman P, Bakker R, Bärnighausen T, Bershteyn A, Bloom DE, Boily MC, Chang ST, Cohen T, Dodd PJ, Fraser C, Gopalappa C, Lundgren J, Martin NK, Mikkelsen E, Mountain E, Pham QD, Pickles M, Phillips A, Platt L, Pretorius C, Prudden HJ, Salomon JA, van de Vijver DAMC, de Vlas SJ, Wagner BG, White RG, Wilson DP, Zhang L, Blandford J, Meyer-Rath G, Remme M, Revill P, Sangrujee N, Terris-Prestholt F, Doherty M, Shaffer N, Easterbrook PJ, Hirnschall G, Hallett TB. Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models. Lancet Glob Health 2013; 2:23-34. [PMID: 25083415 PMCID: PMC4114402 DOI: 10.1016/s2214-109x(13)70172-4] [Citation(s) in RCA: 153] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND New WHO guidelines recommend ART initiation for HIV-positive persons with CD4 cell counts ≤500 cells/µL, a higher threshold than was previously recommended. Country decision makers must consider whether to further expand ART eligibility accordingly. METHODS We used multiple independent mathematical models in four settings-South Africa, Zambia, India, and Vietnam-to evaluate the potential health impact, costs, and cost-effectiveness of different adult ART eligibility criteria under scenarios of current and expanded treatment coverage, with results projected over 20 years. Analyses considered extending eligibility to include individuals with CD4 ≤500 cells/µL or all HIV-positive adults, compared to the previous recommendation of initiation with CD4 ≤350 cells/µL. We assessed costs from a health system perspective, and calculated the incremental cost per DALY averted ($/DALY) to compare competing strategies. Strategies were considered 'very cost-effective' if the $/DALY was less than the country's per capita gross domestic product (GDP; South Africa: $8040, Zambia: $1425, India: $1489, Vietnam: $1407) and 'cost-effective' if $/DALY was less than three times per capita GDP. FINDINGS In South Africa, the cost per DALY averted of extending ART eligibility to CD4 ≤500 cells/µL ranged from $237 to $1691/DALY compared to 2010 guidelines; in Zambia, expanded eligibility ranged from improving health outcomes while reducing costs (i.e. dominating current guidelines) to $749/DALY. Results were similar in scenarios with substantially expanded treatment access and for expanding eligibility to all HIV-positive adults. Expanding treatment coverage in the general population was therefore found to be cost-effective. In India, eligibility for all HIV-positive persons ranged from $131 to $241/DALY and in Vietnam eligibility for CD4 ≤500 cells/µL cost $290/DALY. In concentrated epidemics, expanded access among key populations was also cost-effective. INTERPRETATION Earlier ART eligibility is estimated to be very cost-effective in low- and middle-income settings, although these questions should be revisited as further information becomes available. Scaling-up ART should be considered among other high-priority health interventions competing for health budgets. FUNDING The Bill and Melinda Gates Foundation and World Health Organization.
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Affiliation(s)
- Jeffrey W Eaton
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Nicolas A Menzies
- Center for Health Decision Science, Harvard School of Public Health, Boston, MA, USA
| | | | - Valentina Cambiano
- Research Department of Infection and Population Health, University College London, London, UK
| | - Leonid Chindelevitch
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA
| | - Anne Cori
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Jan A C Hontelez
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa
- Nijmegen International Center for Health System Analysis and Education (NICHE), Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Salal Humair
- Harvard School of Public Health, Boston, MA, USA
| | - Cliff C Kerr
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Daniel J Klein
- Epidemiological Modeling Group, Intellectual Ventures Laboratory, Bellevue, WA, USA
| | - Sharmistha Mishra
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
- Division of Infectious Diseases, St. Michael’s Hospital, University of Toronto, Canada
| | - Kate M Mitchell
- Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Brooke E Nichols
- Department of Virology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Peter Vickerman
- Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Roel Bakker
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Till Bärnighausen
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa
- Harvard School of Public Health, Boston, MA, USA
| | - Anna Bershteyn
- Epidemiological Modeling Group, Intellectual Ventures Laboratory, Bellevue, WA, USA
| | | | - Marie-Claude Boily
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Stewart T Chang
- Epidemiological Modeling Group, Intellectual Ventures Laboratory, Bellevue, WA, USA
| | - Ted Cohen
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
| | - Peter J Dodd
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Christophe Fraser
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | | | - Jens Lundgren
- Copenhagen University Hospital/Rigshospitalet, Copenhagen, Denmark
- University of Copenhagen, Copenhagen, Denmark
| | - Natasha K Martin
- Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Evelinn Mikkelsen
- Nijmegen International Center for Health System Analysis and Education (NICHE), Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Elisa Mountain
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Quang D Pham
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Michael Pickles
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Andrew Phillips
- Research Department of Infection and Population Health, University College London, London, UK
| | - Lucy Platt
- Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Holly J Prudden
- Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Joshua A Salomon
- Center for Health Decision Science, Harvard School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA
| | | | - Sake J de Vlas
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Bradley G Wagner
- Epidemiological Modeling Group, Intellectual Ventures Laboratory, Bellevue, WA, USA
| | - Richard G White
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - David P Wilson
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Lei Zhang
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - John Blandford
- U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Gesine Meyer-Rath
- Center for Global Health and Development, Boston University, Boston, MA, USA
- Health Economics and Epidemiology Research Office, Department of Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Michelle Remme
- Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | | | - Fern Terris-Prestholt
- Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Meg Doherty
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Nathan Shaffer
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | | | | - Timothy B Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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Tanser F, Bärnighausen T, Grapsa E, Zaidi J, Newell ML. High coverage of ART associated with decline in risk of HIV acquisition in rural KwaZulu-Natal, South Africa. Science 2013; 339:966-71. [PMID: 23430656 PMCID: PMC4255272 DOI: 10.1126/science.1228160] [Citation(s) in RCA: 600] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The landmark HIV Prevention Trials Network (HPTN) 052 trial in HIV-discordant couples demonstrated unequivocally that treatment with antiretroviral therapy (ART) substantially lowers the probability of HIV transmission to the HIV-uninfected partner. However, it has been vigorously debated whether substantial population-level reductions in the rate of new HIV infections could be achieved in "real-world" sub-Saharan African settings where stable, cohabiting couples are often not the norm and where considerable operational challenges exist to the successful and sustainable delivery of treatment and care to large numbers of patients. We used data from one of Africa's largest population-based prospective cohort studies (in rural KwaZulu-Natal, South Africa) to follow up a total of 16,667 individuals who were HIV-uninfected at baseline, observing individual HIV seroconversions over the period 2004 to 2011. Holding other key HIV risk factors constant, individual HIV acquisition risk declined significantly with increasing ART coverage in the surrounding local community. For example, an HIV-uninfected individual living in a community with high ART coverage (30 to 40% of all HIV-infected individuals on ART) was 38% less likely to acquire HIV than someone living in a community where ART coverage was low (<10% of all HIV-infected individuals on ART).
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Affiliation(s)
- Frank Tanser
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, South Africa.
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