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Ayieko J, Thorp M, Getahun M, Gandhi M, Maeri I, Gutin SA, Okiring J, Kamya MR, Bukusi EA, Charlebois ED, Petersen M, Havlir DV, Camlin CS, Murnane PM. Geographic Mobility and HIV Care Engagement among People Living with HIV in Rural Kenya and Uganda. Trop Med Infect Dis 2023; 8:496. [PMID: 37999615 PMCID: PMC10675546 DOI: 10.3390/tropicalmed8110496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 10/31/2023] [Accepted: 11/08/2023] [Indexed: 11/25/2023] Open
Abstract
INTRODUCTION Human mobility is a critical aspect of existence and survival, but may compromise care engagement among people living with HIV (PLHIV). We examined the association between various forms of human mobility with retention in HIV care and antiretroviral treatment (ART) interruptions. METHODS In a cohort of adult PLHIV in Kenya and Uganda, we collected surveys in 2016 about past 6-month travel and lifetime migration histories, including reasons and locations, and engagement in HIV care defined as (1) discontinuation of care, and (2) history of a treatment interruption among those who remained in care. We estimated associations between mobility and these care engagement outcomes via logistic regression, adjusted for sex, prior mobility, age, region, marital status, household wealth, and education. RESULTS Among 1081 participants, 56 (5%) reported having discontinued care; among those in care, 104 (10%) reported treatment interruption. Past-year migration was associated with a higher risk of discontinuation of care (adjusted odds ratio [aOR] 1.98, 95% CI 1.08-3.63). In sex-stratified models, the association was somewhat attenuated in women, but remained robust among men. Past-year migration was associated with reduced odds of having a treatment interruption among men (aOR 0.51, 95% CI 0.34-0.77) but not among women (aOR 2.67, 95% CI 0.78, 9.16). Travel in the past 6 months was not associated with discontinuation of care or treatment interruptions. CONCLUSIONS We observed both negative and protective effects of recent migration on care engagement and ART use that were most pronounced among men in this cohort. Migration can break ties to ongoing care, but for men, who have more agency in the decision to migrate, may foster new care and treatment strategies. Strategies that enable health facilities to support individuals throughout the process of transferring care could alleviate the risk of care disengagement.
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Affiliation(s)
- James Ayieko
- Kenya Medical Research Institute, Center for Microbiology Research, Nairobi 00200, Kenya
| | - Marguerite Thorp
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90024, USA
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA 94143, USA
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, CA 94143, USA
| | - Irene Maeri
- Kenya Medical Research Institute, Center for Microbiology Research, Nairobi 00200, Kenya
| | - Sarah A. Gutin
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, CA 94143, USA
| | - Jaffer Okiring
- Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, Kampala P.O. Box 7072, Uganda
| | - Moses R. Kamya
- School of Medicine, Makerere University, Kampala P.O. Box 7072, Uganda
| | - Elizabeth A. Bukusi
- Kenya Medical Research Institute, Center for Microbiology Research, Nairobi 00200, Kenya
| | - Edwin D. Charlebois
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA 94143, USA
| | - Maya Petersen
- Division of Biostatistics, University of California, Berkeley, CA 94720, USA
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, CA 94143, USA
| | - Carol S. Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA 94143, USA
| | - Pamela M. Murnane
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA 94143, USA
- Institute for Global Health Sciences, University of California, San Francisco, CA 94143, USA
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Thorp M, Ayieko J, Hoffman RM, Balakasi K, Camlin CS, Dovel K. Mobility and HIV care engagement: a research agenda. J Int AIDS Soc 2023; 26:e26058. [PMID: 36943731 PMCID: PMC10029995 DOI: 10.1002/jia2.26058] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 01/10/2023] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION Mobility is common and an essential livelihood strategy in sub-Saharan Africa (SSA). Mobile people suffer worse outcomes at every stage of the HIV care cascade compared to non-mobile populations. Definitions of mobility vary widely, and research on the role of temporary mobility (as opposed to permanent migration) in HIV treatment outcomes is often lacking. In this article, we review the current landscape of mobility and HIV care research to identify what is already known, gaps in the literature, and recommendations for future research. DISCUSSION Mobility in SSA is closely linked to income generation, though caregiving, climate change and violence also contribute to the need to move. Mobility is likely to increase in the coming decades, both due to permanent migration and increased temporary mobility, which is likely much more common. We outline three central questions regarding mobility and HIV treatment outcomes in SSA. First, it is unclear what aspects of mobility matter most for HIV care outcomes and if high-risk mobility can be identified or predicted, which is necessary to facilitate targeted interventions for mobile populations. Second, it is unclear what groups are most vulnerable to mobility-associated treatment interruption and other adverse outcomes. And third, it is unclear what interventions can improve HIV treatment outcomes for mobile populations. CONCLUSIONS Mobility is essential for people living with HIV in SSA. HIV treatment programmes and broader health systems must understand and adapt to human mobility, both to promote the rights and welfare of mobile people and to end the HIV pandemic.
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Affiliation(s)
- Marguerite Thorp
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - James Ayieko
- Center for Microbiology ResearchKenya Medical Research InstituteKisumuKenya
| | - Risa M. Hoffman
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | | | - Carol S. Camlin
- Department of ObstetricsGynecology & Reproductive SciencesUniversity of California San FranciscoSan FranciscoCaliforniaUSA
- Center for AIDS Prevention StudiesDepartment of MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Kathryn Dovel
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
- Partners in HopeLilongweMalawi
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Maeri I, Eyul P, Getahun M, Hatchett K, Owino L, Akatukwasa C, Itiakorit H, Gutin SA, Johnson-Peretz J, Ssali S, Cohen CR, Bukusi EA, Kamya MR, Charlebois ED, Camlin CS. Nothing about us without us: Community-based participatory research to improve HIV care for mobile patients in Kenya and Uganda. Soc Sci Med 2023; 318:115471. [PMID: 36628879 PMCID: PMC10184576 DOI: 10.1016/j.socscimed.2022.115471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 09/11/2022] [Accepted: 10/20/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Population mobility is prevalent and complex in sub-Saharan Africa, and can disrupt HIV care and fuel onward transmission. While differentiated care models show promise for meeting the needs of mobile populations by addressing care cascade gaps, the voices of mobile populations need to be included when designing care delivery models. We assessed the unmet needs of mobile populations and engaged mobile stakeholders in the design and implementation of service delivery to improve care outcomes for mobile people living with HIV (PLHIV). METHODS CBPR was conducted in 12 rural communities in Kenya and Uganda participating in a mobility study within the Sustainable East Africa Research in Community Health (SEARCH) test-and-treat trial (NCT# 01864603) from 2016 to 2019. Annual gender-balanced meetings with between 17 and 33 mobile community stakeholders per meeting were conducted in local languages to gather information on mobility and its influence on HIV-related outcomes. Discussions were audio-recorded, transcribed and translated into English. Findings were shared at subsequent meetings to engage mobile stakeholders in interpretation. At year three, intervention ideas to address mobile populations' needs were elicited. After refinement, these intervention options were presented to the same communities for prioritization the following year, using a participatory ranking approach. RESULTS Transit hubs, trading centers, and beach sites were identified as desirable service locations. Communities prioritized mobile health 'cards' with electronic medical records and peer-delivered home-based services. Mobile health clinics, longer antiretroviral refills, and 24/7 (after service) were less desirable options. Care challenges included: lack of transfer letters to other clinics; inability to adhere to scheduled appointments, medication regimens, and monitoring of treatment outcomes while mobile amongst others. CONCLUSIONS Iterative discussions with mobile community stakeholders elicited communities' health priorities and identified challenges to achieving HIV care cascade outcomes. Understanding the mobility patterns and unique needs of mobile populations through responsive community engagement is critical.
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Affiliation(s)
- Irene Maeri
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya.
| | - Patrick Eyul
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, USA
| | - Khalela Hatchett
- Department of Community Health Sciences, University of California Los Angeles, Los Angeles, USA
| | - Lawrence Owino
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | - Sarah A Gutin
- Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, USA
| | - Jason Johnson-Peretz
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, USA
| | - Sarah Ssali
- School of Women and Gender Studies, Makerere University, Kampala, Uganda
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, USA
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda; School of Medicine, Makerere University, Kampala, Uganda
| | - Edwin D Charlebois
- Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, USA
| | - Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, USA; Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, USA
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Coomes D, Green D, Barnabas R, Sharma M, Barr-DiChiara M, Jamil MS, Baggaley R, Owiredu MN, Macdonald V, Nguyen VTT, Vo SH, Taylor M, Wi T, Johnson C, Drake AL. Cost-effectiveness of implementing HIV and HIV/syphilis dual testing among key populations in Viet Nam: a modelling analysis. BMJ Open 2022; 12:e056887. [PMID: 35953255 PMCID: PMC9379490 DOI: 10.1136/bmjopen-2021-056887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Key populations, including sex workers, men who have sex with men, and people who inject drugs, have a high risk of HIV and sexually transmitted infections. We assessed the health and economic impacts of different HIV and syphilis testing strategies among three key populations in Viet Nam using a dual HIV/syphilis rapid diagnostic test (RDT). SETTING We used the spectrum AIDS impact model to simulate the HIV epidemic in Viet Nam and evaluated five testing scenarios among key populations. We used a 15-year time horizon and a provider perspective for costs. PARTICIPANTS We simulate the entire population of Viet Nam in the model. INTERVENTIONS We modelled five testing scenarios among key populations: (1) annual testing with an HIV RDT, (2) annual testing with a dual RDT, (3) biannual testing using dual RDT and HIV RDT, (4) biannual testing using HIV RDT and (5) biannual testing using dual RDT. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome is incremental cost-effectiveness ratios. Secondary outcomes include HIV and syphilis cases. RESULTS Annual testing using a dual HIV/syphilis RDT was cost-effective (US$10 per disability-adjusted life year (DALY)) and averted 3206 HIV cases and treated 27 727 syphilis cases compared with baseline over 15 years. Biannual testing using one dual test and one HIV RDT (US$1166 per DALY), or two dual tests (US$5672 per DALY) both averted an additional 875 HIV cases, although only the former scenario was cost-effective. Annual or biannual HIV testing using HIV RDTs and separate syphilis tests were more costly and less effective than using one or two dual RDTs. CONCLUSIONS Annual HIV and syphilis testing using dual RDT among key populations is cost-effective in Vietnam and similar settings to reach global reduction goals for HIV and syphilis.
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Affiliation(s)
- David Coomes
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Dylan Green
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Ruanne Barnabas
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Magdalena Barr-DiChiara
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Muhammad S Jamil
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - R Baggaley
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Morkor Newman Owiredu
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Virginia Macdonald
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | | | - Son Hai Vo
- Viet Nam Authority for HIV/AIDS Prevention and Control, Government of Viet Nam Ministry of Health, Hanoi, Viet Nam
| | - Melanie Taylor
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Teodora Wi
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Cheryl Johnson
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Alison L Drake
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
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Hakim AJ, Tippett Barr BA, Kinchen S, Musuka G, Manjengwa J, Munyati S, Gwanzura L, Mugurungi O, Ncube G, Saito S, Parekh BS, Patel H, Duong YT, Gonese E, Sleeman K, Ruangtragool L, Justman J, Herman-Roloff A, Radin E. Progress Toward the 90-90-90 HIV Targets in Zimbabwe and Identifying Those Left Behind. J Acquir Immune Defic Syndr 2021; 88:272-281. [PMID: 34321414 PMCID: PMC8526397 DOI: 10.1097/qai.0000000000002772] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 06/17/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We present findings from the nationally representative Zimbabwe Population-based HIV Impact Assessment that characterize Zimbabwe's progress toward the Joint United Nations Programme on HIV/AIDS 90-90-90 targets. DESIGN We conducted a cross-sectional household survey. METHODS Consenting adults and children in the household were eligible to participate in Zimbabwe Population-based HIV Impact Assessment (October 2015-August 2016). Participants completed face-to-face interviews and provided blood for HIV, CD4, viral load, and syphilis testing. Viral load suppression (VLS) was defined as HIV RNA <1000 copies/mL. HIV-positive specimens were tested for the presence of selected antiretroviral drugs. Data were weighted. Analysis was restricted to HIV-positive adults aged 15-64 years. RESULTS We enrolled 11,098 men and 14,033 women aged 15-64 years. HIV prevalence was 14.1%. Of those living with HIV, 76.8% (95% confidence interval [CI]: 74.9 to 78.7) were aware of their HIV status or had detectable antiretroviral levels. Of these, 88.4% (95% CI: 87.1 to 89.7) were receiving antiretroviral therapy (ART), and of these people, 85.3% (95% CI: 83.4 to 87.1) had VLS. Male sex age 15-34 years and having 1 or more sexual partners were associated with being unaware of one's HIV-positive status. Age <50 years and not taking cotrimoxazole were associated with being less likely to be being both aware and taking ART. Male sex, age <50 years, and taking cotrimoxazole were associated with being on ART but not having VLS. CONCLUSIONS Zimbabwe has made great strides toward epidemic control. Focusing resources on case finding, particularly among men, people aged <35 years, and sexually active individuals can help Zimbabwe attain 90-90-90 targets.
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Affiliation(s)
- Avi J Hakim
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Atlanta, GA
| | - Beth A Tippett Barr
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Harare, Zimbabwe
| | - Steven Kinchen
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Atlanta, GA
| | - Godfrey Musuka
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, NY
| | - Julius Manjengwa
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, NY
| | - Shungu Munyati
- Biomedical Research & Training Institute, Harare, Zimbabwe
| | - Lovemore Gwanzura
- Biomedical Research & Training Institute, Harare, Zimbabwe
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Owen Mugurungi
- Ministry of Health and Child Care, Harare, Zimbabwe ; and
| | - Getrude Ncube
- Ministry of Health and Child Care, Harare, Zimbabwe ; and
| | - Suzue Saito
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, NY
| | - Bharat S Parekh
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Atlanta, GA
| | - Hetal Patel
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Atlanta, GA
| | - Yen T Duong
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, NY
| | - Elizabeth Gonese
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Harare, Zimbabwe
| | - Katrina Sleeman
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Atlanta, GA
| | - Leala Ruangtragool
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Harare, Zimbabwe
- ASPPH/CDC Allan Rosenfield Global Health Fellow, Centers for Disease Control and Prevention, Harare, Zimbabwe
| | - Jessica Justman
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, NY
| | - Amy Herman-Roloff
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Harare, Zimbabwe
| | - Elizabeth Radin
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, NY
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Jewell BL, BALZER LB, CLARK TD, CHARLEBOIS ED, KWARISIIMA D, KAMYA MR, HAVLIR DV, PETERSEN ML, BERSHTEYN A. Predicting HIV Incidence in the SEARCH Trial: A Mathematical Modeling Study. J Acquir Immune Defic Syndr 2021; 87:1024-1031. [PMID: 33770065 PMCID: PMC8217115 DOI: 10.1097/qai.0000000000002684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/16/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The SEARCH study provided community-based HIV and multidisease testing and antiretroviral therapy (ART) to 32 communities in East Africa and reported no statistically significant difference in 3-year HIV incidence. We used mathematical modeling to estimate the effect of control arm viral suppression and community mixing on SEARCH trial outcomes. SETTING Uganda and Kenya. METHODS Using the individual-based HIV modeling software EMOD-HIV, we configured a new model of SEARCH communities. The model was parameterized using demographic, HIV prevalence, male circumcision, and viral suppression data and calibrated to HIV prevalence, ART coverage, and population size. Using assumptions about ART scale-up in the control arm, degree of community mixing, and effect of baseline testing, we estimated comparative HIV incidence under multiple scenarios. RESULTS Before the trial results, we predicted that SEARCH would report a 4%-40% reduction between arms, depending on control arm ART linkage rates and community mixing. With universal baseline testing followed by rapidly expanded ART eligibility and uptake, modeled effect sizes were smaller than the study was powered to detect. Using interim viral suppression data, we estimated 3-year cumulative incidence would have been reduced by up to 27% in the control arm and 43% in the intervention arm compared with a counterfactual without universal baseline testing. CONCLUSIONS Our model suggests that the active control arm substantially reduced expected effect size and power of the SEARCH study. However, compared with a counterfactual "true control" without increased ART linkage because of baseline testing, SEARCH reduced HIV incidence by up to 43%.
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Affiliation(s)
- Britta L. Jewell
- University of California, Berkeley, Berkeley, USA
- Institute for Disease Modeling, Bellevue, USA
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Bonsall D, Golubchik T, de Cesare M, Limbada M, Kosloff B, MacIntyre-Cockett G, Hall M, Wymant C, Ansari MA, Abeler-Dörner L, Schaap A, Brown A, Barnes E, Piwowar-Manning E, Eshleman S, Wilson E, Emel L, Hayes R, Fidler S, Ayles H, Bowden R, Fraser C. A Comprehensive Genomics Solution for HIV Surveillance and Clinical Monitoring in Low-Income Settings. J Clin Microbiol 2020; 58:e00382-20. [PMID: 32669382 PMCID: PMC7512176 DOI: 10.1128/jcm.00382-20] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 07/10/2020] [Indexed: 01/01/2023] Open
Abstract
Viral genetic sequencing can be used to monitor the spread of HIV drug resistance, identify appropriate antiretroviral regimes, and characterize transmission dynamics. Despite decreasing costs, next-generation sequencing (NGS) is still prohibitively costly for routine use in generalized HIV epidemics in low- and middle-income countries. Here, we present veSEQ-HIV, a high-throughput, cost-effective NGS sequencing method and computational pipeline tailored specifically to HIV, which can be performed using leftover blood drawn for routine CD4 cell count testing. This method overcomes several major technical challenges that have prevented HIV sequencing from being used routinely in public health efforts; it is fast, robust, and cost-efficient, and generates full genomic sequences of diverse strains of HIV without bias. The complete veSEQ-HIV pipeline provides viral load estimates and quantitative summaries of drug resistance mutations; it also exploits information on within-host viral diversity to construct directed transmission networks. We evaluated the method's performance using 1,620 plasma samples collected from individuals attending 10 large urban clinics in Zambia as part of the HPTN 071-2 study (PopART Phylogenetics). Whole HIV genomes were recovered from 91% of samples with a viral load of >1,000 copies/ml. The cost of the assay (30 GBP per sample) compares favorably with existing VL and HIV genotyping tests, proving an affordable option for combining HIV clinical monitoring with molecular epidemiology and drug resistance surveillance in low-income settings.
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Affiliation(s)
- David Bonsall
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
| | - Tanya Golubchik
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Mariateresa de Cesare
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
| | - Mohammed Limbada
- ZAMBART, University of Zambia, Lusaka, Zambia
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Barry Kosloff
- ZAMBART, University of Zambia, Lusaka, Zambia
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - George MacIntyre-Cockett
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Matthew Hall
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Chris Wymant
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - M Azim Ansari
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
- Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, United Kingdom
| | - Lucie Abeler-Dörner
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Ab Schaap
- ZAMBART, University of Zambia, Lusaka, Zambia
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anthony Brown
- Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, United Kingdom
| | - Eleanor Barnes
- Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, United Kingdom
| | | | - Susan Eshleman
- Dept. of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ethan Wilson
- Statistical Centre for HIV/AIDS Research, Fred Hutchinson Cancer Research Centre, Seattle, Washington, USA
| | - Lynda Emel
- Statistical Centre for HIV/AIDS Research, Fred Hutchinson Cancer Research Centre, Seattle, Washington, USA
| | - Richard Hayes
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sarah Fidler
- Department of Infectious Disease, Imperial College London, Imperial College NIHR BRC, London, United Kingdom
| | - Helen Ayles
- ZAMBART, University of Zambia, Lusaka, Zambia
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rory Bowden
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
| | - Christophe Fraser
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
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Mobility and its Effects on HIV Acquisition and Treatment Engagement: Recent Theoretical and Empirical Advances. Curr HIV/AIDS Rep 2020; 16:314-323. [PMID: 31256348 DOI: 10.1007/s11904-019-00457-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW We reviewed literature across multiple disciplines to describe issues with the measurement of population mobility in HIV research and to summarize evidence of causal pathways linking mobility to HIV acquisition risks and treatment engagement, with a focus on sub-Saharan Africa. RECENT FINDINGS While the literature on mobility and HIV remains hampered by problems and inconsistency in measures of mobility, the recent research reveals a turn towards a greater attentiveness to measurement and gender. Theoretical and heuristic models for the study of mobility and HIV acquisition and treatment outcomes have been published, but few studies have used longitudinal designs with clear ascertainment of exposures and outcomes for measurement of causal pathways. Notwithstanding these limitations, evidence continues to accumulate that mobility is linked to higher HIV incidence, and that it challenges optimal treatment engagement. Gender continues to be important: while men are more mobile than women, women's mobility particularly heightens their HIV acquisition risks. Recent large-scale efforts to find, test, and treat the individuals in communities who are most at risk of sustaining local HIV transmission have been severely challenged by mobility. Novel interventions, policies, and health systems improvements are urgently needed to fully engage mobile individuals in HIV care and prevention. Interventions targeting the HIV prevention and care needs of mobile populations remain few in number and urgently needed.
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Tanser F, Kim HY, Vandormael A, Iwuji C, Bärnighausen T. Opportunities and Challenges in HIV Treatment as Prevention Research: Results from the ANRS 12249 Cluster-Randomized Trial and Associated Population Cohort. Curr HIV/AIDS Rep 2020; 17:97-108. [PMID: 32072468 PMCID: PMC7072051 DOI: 10.1007/s11904-020-00487-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The ANRS 12249 treatment as prevention (TasP) trial investigated the impact of a universal test and treat (UTT) approach on reducing HIV incidence in one of the regions of the world most severely affected by the HIV epidemic-KwaZulu-Natal, South Africa. We summarize key findings from this trial as well as recent findings from controlled studies conducted in the linked population cohort quantifying the long-term effects of expanding ART on directly measured HIV incidence (2004-2017). RECENT FINDINGS The ANRS TasP trial did not-and could not-demonstrate a reduction in HIV incidence, because the offer of UTT in the intervention communities did not increase ART coverage and population viral suppression compared to the standard of care in the control communities. Ten controlled studies from the linked population cohort-including several quasi-experimental study designs-exploit heterogeneity in ART exposure to show a consistent and substantial impact of expanding provision of ART and population viral suppression on reduction in HIV incidence at the couple, household, community, and population levels. In this setting, all of the evidence from large, population-based studies (inclusive of the ANRS TasP trial) is remarkably coherent and consistent-i.e., higher ART coverage and population viral suppression were repeatedly associated with clear, measurable decreases in HIV incidence. Thus, the expanded provision of ART has plausibly contributed in a major way toward the dramatic 43% decline in population-level HIV incidence in this typical rural African population. The outcome of the ANRS TasP trial constitutes a powerful null finding with important insights for overcoming implementation challenges in the population delivery of ART. This finding does not imply lack of ART effectiveness in blocking onward transmission of HIV nor its inability to reduce HIV incidence. Rather, it demonstrates that large increases in ART coverage over current levels will require health systems innovations to attract people living with HIV in early stages of the disease to participate in HIV treatment. Such innovations and new approaches are required for the true potential of UTT to be realized.
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Affiliation(s)
- Frank Tanser
- Lincoln Institute for Health, University of Lincoln, Lincoln, LN6 7TS, UK.
- Africa Health Research Institute, 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, Durban, South Africa.
| | - Hae-Young Kim
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Population Health, New York University School of Medicine, New York, USA
- KwaZulu-Natal Innovation and Sequencing Platform, Durban, KwaZulu-Natal, South Africa
| | - Alain Vandormael
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- KwaZulu-Natal Innovation and Sequencing Platform, Durban, KwaZulu-Natal, South Africa
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Collins Iwuji
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Till Bärnighausen
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Akullian A, Morrison M, Garnett GP, Mnisi Z, Lukhele N, Bridenbecker D, Bershteyn A. The effect of 90-90-90 on HIV-1 incidence and mortality in eSwatini: a mathematical modelling study. Lancet HIV 2020; 7:e348-e358. [PMID: 32061317 PMCID: PMC7221345 DOI: 10.1016/s2352-3018(19)30436-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 12/12/2019] [Accepted: 12/20/2019] [Indexed: 12/26/2022]
Abstract
Background The rapid scale-up of antiretroviral therapy (ART) towards the UNAIDS 90-90-90 goals over the last decade has sparked considerable debate as to whether universal test and treat can end the HIV-1 epidemic in sub-Saharan Africa. We aimed to develop a network transmission model, calibrated to capture age-specific and sex-specific gaps in the scale-up of ART, to estimate the historical and future effect of attaining and surpassing the UNAIDS 90-90-90 treatment targets on HIV-1 incidence and mortality, and to assess whether these interventions will be enough to achieve epidemic control (incidence of 1 infection per 1000 person-years) by 2030. Methods We used eSwatini (formerly Swaziland) as a case study to develop our model. We used data on HIV prevalence by 5-year age bins, sex, and year from the 2007 Swaziland Demographic Health Survey (SDHS), the 2011 Swaziland HIV Incidence Measurement Survey, and the 2016 Swaziland Population Health Impact Assessment (PHIA) survey. We estimated the point prevalence of ART coverage among all HIV-infected individuals by age, sex, and year. Age-specific data on the prevalence of male circumcision from the SDHS and PHIA surveys were used as model inputs for traditional male circumcision and scale-up of voluntary medical male circumcision (VMMC). We calibrated our model using publicly available data on demographics; HIV prevalence by 5-year age bins, sex, and year; and ART coverage by age, sex, and year. We modelled the effects of five scenarios (historical scale-up of ART and VMMC [status quo], no ART or VMMC, no ART, age-targeted 90-90-90, and 100% ART initiation) to quantify the contribution of ART scale-up to declines in HIV incidence and mortality in individuals aged 15–49 by 2016, 2030, and 2050. Findings Between 2010 and 2016, status-quo ART scale-up among adults (aged 15–49 years) in eSwatini (from 34·0% in 2010 to 74·1% in 2016) reduced HIV incidence by 43·57% (95% credible interval 39·71 to 46·36) and HIV mortality by 56·17% (54·06 to 58·92) among individuals aged 15–49 years, with larger reductions in incidence among men and mortality among women. Holding 2016 ART coverage levels by age and sex into the future, by 2030 adult HIV incidence would fall to 1·09 (0·87 to 1·29) per 100 person-years, 1·42 (1·13 to 1·71) per 100 person-years among women and 0·79 (0·63 to 0·94) per 100 person-years among men. Achieving the 90-90-90 targets evenly by age and sex would further reduce incidence beyond status-quo ART, primarily among individuals aged 15–24 years (an additional 17·37% [7·33 to 26·12] reduction between 2016 and 2030), with only modest additional incidence reductions in adults aged 35–49 years (1·99% [–5·09 to 7·74]). Achieving 100% ART initiation among all people living with HIV within an average of 6 months from infection—an upper bound of plausible treatment effect—would reduce adult HIV incidence to 0·73 infections (0·55 to 0·92) per 100 person-years by 2030 and 0·46 (0·33 to 0·59) per 100 person-years by 2050. Interpretation Scale-up of ART over the last decade has already contributed to substantial reductions in HIV-1 incidence and mortality in eSwatini. Focused ART targeting would further reduce incidence, especially in younger individuals, but even the most aggressive treatment campaigns would be insufficient to end the epidemic in high-burden settings without a renewed focus on expanding preventive measures. Funding Global Good Fund and the Bill & Melinda Gates Foundation.
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Affiliation(s)
- Adam Akullian
- Institute for Disease Modeling, Bellevue, WA, USA; Department of Global Health, University of Washington, Seattle, WA, USA.
| | | | | | - Zandile Mnisi
- Ministry of Health, Kingdom of eSwatini, Mbabane, eSwatini
| | | | | | - Anna Bershteyn
- Institute for Disease Modeling, Bellevue, WA, USA; Department of Population Health, New York University School of Medicine, New York, NY, USA
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11
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Camlin CS, Akullian A, Neilands TB, Getahun M, Bershteyn A, Ssali S, Geng E, Gandhi M, Cohen CR, Maeri I, Eyul P, Petersen ML, Havlir DV, Kamya MR, Bukusi EA, Charlebois ED. Gendered dimensions of population mobility associated with HIV across three epidemics in rural Eastern Africa. Health Place 2019; 57:339-351. [PMID: 31152972 DOI: 10.1016/j.healthplace.2019.05.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/25/2019] [Accepted: 05/03/2019] [Indexed: 11/18/2022]
Abstract
Mobility in sub-Saharan Africa links geographically-separate HIV epidemics, intensifies transmission by enabling higher-risk sexual behavior, and disrupts care. This population-based observational cohort study measured complex dimensions of mobility in rural Uganda and Kenya. Survey data were collected every 6 months beginning in 2016 from a random sample of 2308 adults in 12 communities across three regions, stratified by intervention arm, baseline residential stability and HIV status. Analyses were survey-weighted and stratified by sex, region, and HIV status. In this study, there were large differences in the forms and magnitude of mobility across regions, between men and women, and by HIV status. We found that adult migration varied widely by region, higher proportions of men than women migrated within the past one and five years, and men predominated across all but the most localized scales of migration: a higher proportion of women than men migrated within county of origin. Labor-related mobility was more common among men than women, while women were more likely to travel for non-labor reasons. Labor-related mobility was associated with HIV positive status for both men and women, adjusting for age and region, but the association was especially pronounced in women. The forms, drivers, and correlates of mobility in eastern Africa are complex and highly gendered. An in-depth understanding of mobility may help improve implementation and address gaps in the HIV prevention and care continua.
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Affiliation(s)
- Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, USA; Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, 3rd Floor, UCSF Mail Code 0886, San Francisco, CA 94158, USA.
| | - Adam Akullian
- Institute for Disease Modeling, 3150 139th Ave SE, Bellevue, WA 98005, USA; Department of Global Health, University of Washington, Seattle, USA.
| | - Torsten B Neilands
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, 3rd Floor, UCSF Mail Code 0886, San Francisco, CA 94158, USA.
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, USA.
| | - Anna Bershteyn
- Institute for Disease Modeling, 3150 139th Ave SE, Bellevue, WA 98005, USA; Department of Global Health, University of Washington, Seattle, USA.
| | - Sarah Ssali
- School of Medicine, Makerere University College of Health Sciences, Upper Mulago Hill Road, New Mulago Hospital Complex, P.O Box 7072, Kampala, Uganda.
| | - Elvin Geng
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, 1001 Potrero Ave., San Francisco, CA 94110, USA.
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, 1001 Potrero Ave., San Francisco, CA 94110, USA.
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, USA.
| | - Irene Maeri
- Kenya Medical Research Institute, Centre for Microbiology Research, Box 19464, Post Code 00202, Nairobi, Kenya.
| | - Patrick Eyul
- The Infectious Diseases Research Collaboration (IDRC), Plot 2C Nakasero Hill Road, P.O Box 7475, Kampala, Uganda.
| | - Maya L Petersen
- University of California, Berkeley, 101 Haviland Hall, Suite 102; School of Public Health, UC Berkeley, Berkeley, CA 94720-7358, USA.
| | - Diane V Havlir
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, 1001 Potrero Ave., San Francisco, CA 94110, USA.
| | - Moses R Kamya
- School of Medicine, Makerere University College of Health Sciences, Upper Mulago Hill Road, New Mulago Hospital Complex, P.O Box 7072, Kampala, Uganda.
| | - Elizabeth A Bukusi
- Kenya Medical Research Institute, Centre for Microbiology Research, Box 19464, Post Code 00202, Nairobi, Kenya.
| | - Edwin D Charlebois
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, 3rd Floor, UCSF Mail Code 0886, San Francisco, CA 94158, USA.
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12
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Green D, Kharono B, Tordoff DM, Akullian A, Bershteyn A, Morrison M, Garnett G, Duerr A, Drain P. Demographic and risk group heterogeneity across the UNAIDS 90-90-90 targets: a systematic review and meta-analysis protocol. Syst Rev 2019; 8:110. [PMID: 31060607 PMCID: PMC6501385 DOI: 10.1186/s13643-019-1024-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 04/12/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Despite policies for universal HIV testing and treatment (UTT) regardless of CD4 count, there are still 1.8 million new HIV infections and 1 million AIDS-related deaths annually. The UNAIDS 90-90-90 goals target suppression of HIV viral load in 73% of all HIV-infected people worldwide by 2030. However, achieving these targets may not lead to expected reductions in HIV incidence if the remaining 27% (persons with unsuppressed viral load) are the drivers of HIV transmission through high-risk behaviors. We aim to conduct a systematic review and meta-analysis to understand the demographics, mobility, geographic distribution, and risk profile of adults who are not virologically suppressed in sub-Saharan Africa in the era of UTT. METHODS We will review the published and grey literature for study sources that contain data on demographic and behavioral strata of virologically suppressed and unsuppressed populations since 2014. We will search PubMed and Embase using four sets of search terms tailored to identify characteristics associated with virological suppression (or lack thereof) and each of the individual 90-90-90 goals. Record screening and data abstraction will be done independently and in duplicate. We will use random effects meta-regression analyses to estimate the distribution of demographic and risk features among groups not virologically suppressed and for each individual 90-90-90 goal. DISCUSSION The results of our review will help elucidate factors associated with failure to achieve virological suppression in sub-Saharan Africa, as well as factors associated with failure to achieve each of the 90-90-90 goals. These data will help quantify the population-level effects of current HIV treatment interventions to improve strategies for maximizing virological suppression and ending the HIV epidemic. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018089505 .
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Affiliation(s)
- Dylan Green
- Departments of Epidemiology and Global Health, University of Washington, 1959 NE Pacific St, Seattle, 98195 Washington USA
- Strategic Analysis, Research & Training (START) Center, University of Washington, 1510 San Juan Rd NE, 3rd floor, Seattle, Washington 98195 USA
| | - Brenda Kharono
- Departments of Epidemiology and Global Health, University of Washington, 1959 NE Pacific St, Seattle, 98195 Washington USA
- Strategic Analysis, Research & Training (START) Center, University of Washington, 1510 San Juan Rd NE, 3rd floor, Seattle, Washington 98195 USA
| | - Diana M. Tordoff
- Departments of Epidemiology and Global Health, University of Washington, 1959 NE Pacific St, Seattle, 98195 Washington USA
- Strategic Analysis, Research & Training (START) Center, University of Washington, 1510 San Juan Rd NE, 3rd floor, Seattle, Washington 98195 USA
| | - Adam Akullian
- Departments of Epidemiology and Global Health, University of Washington, 1959 NE Pacific St, Seattle, 98195 Washington USA
- Institute for Disease Modeling, 3150 139th Ave SE, Building IV, Bellevue, 98005 Washington USA
| | - Anna Bershteyn
- Institute for Disease Modeling, 3150 139th Ave SE, Building IV, Bellevue, 98005 Washington USA
| | - Michelle Morrison
- Bill and Melinda Gates Foundation, 500 5th Ave N, Seattle, 98109 Washington USA
| | - Geoff Garnett
- Bill and Melinda Gates Foundation, 500 5th Ave N, Seattle, 98109 Washington USA
| | - Ann Duerr
- Departments of Epidemiology and Global Health, University of Washington, 1959 NE Pacific St, Seattle, 98195 Washington USA
- Strategic Analysis, Research & Training (START) Center, University of Washington, 1510 San Juan Rd NE, 3rd floor, Seattle, Washington 98195 USA
- HIV Vaccine Trials Network, Vaccine and Infectious Disease and Public Health Science Divisions, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, 98109 Washington USA
| | - Paul Drain
- Departments of Epidemiology and Global Health, University of Washington, 1959 NE Pacific St, Seattle, 98195 Washington USA
- Strategic Analysis, Research & Training (START) Center, University of Washington, 1510 San Juan Rd NE, 3rd floor, Seattle, Washington 98195 USA
- Division of Allergy and Infectious Diseases, Department of Medicine, School of Medicine, University of Washington, 1959 NE Pacific St, Seattle, 98195 Washington USA
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Masebo W. Accessing ART in Malawi while living in South Africa - a thematic analysis of qualitative data from undocumented Malawian migrants. Glob Public Health 2018; 14:621-635. [PMID: 30235977 DOI: 10.1080/17441692.2018.1524920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The majority of international migrants from Malawi to South Africa are undocumented, and some of them are on ART. This study explored how these migrants manage to access ART. Qualitative data were collected using open-ended questions in semi-structured interviews. 23 returned undocumented Malawian migrants from South Africa participated in the study. Also, key informant discussions were held with three health workers. Data collection took place in April and May 2015 at a rural village of Namwera in Mangochi district in southern Malawi. Interviews were audio-recorded, transcribed and translated into English for thematic analysis. The guardians collected ART from health facilities in Malawi on behalf of the migrants. The guardians sent ART through truck and bus drivers to the migrants in South Africa. The migrants shared their ART. Others bought ART from the 'street pharmacies'. Others accessed ART from South African health facilities through the help of their South African friends. There are risks to dispensing ART to the migrants who do not themselves present at health facilities. There is value to more regular contacts between clients and health service system that is compromised by alternative strategies. It is better to deliver ART services in South Africa to the undocumented migrants.
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Affiliation(s)
- Wilfred Masebo
- a Health Economics and HIV and AIDS Research Division , University of KwaZulu-Natal , Durban , South Africa
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Camlin CS, Akullian A, Neilands TB, Getahun M, Eyul P, Maeri I, Ssali S, Geng E, Gandhi M, Cohen CR, Kamya MR, Odeny T, Bukusi EA, Charlebois ED. Population mobility associated with higher risk sexual behaviour in eastern African communities participating in a Universal Testing and Treatment trial. J Int AIDS Soc 2018; 21 Suppl 4:e25115. [PMID: 30027668 PMCID: PMC6053476 DOI: 10.1002/jia2.25115] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 05/08/2018] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION There are significant knowledge gaps concerning complex forms of mobility emergent in sub-Saharan Africa, their relationship to sexual behaviours, HIV transmission, and how sex modifies these associations. This study, within an ongoing test-and-treat trial (SEARCH, NCT01864603), sought to measure effects of diverse metrics of mobility on behaviours, with attention to gender. METHODS Cross-sectional data were collected in 2016 from 1919 adults in 12 communities in Kenya and Uganda, to examine mobility (labour/non-labour-related travel), migration (changes of residence over geopolitical boundaries) and their associations with sexual behaviours (concurrent/higher risk partnerships), by region and sex. Multilevel mixed-effects logistic regression models, stratified by sex and adjusted for clustering by community, were fitted to examine associations of mobility with higher-risk behaviours, in past 2 years/past 6 months, controlling for key covariates. RESULTS The population was 45.8% male and 52.4% female, with mean age 38.7 (median 37, IQR: 17); 11.2% had migrated in the past 2 years. Migration varied by region (14.4% in Kenya, 11.5% in southwestern and 1.7% in eastern and Uganda) and sex (13.6% of men and 9.2% of women). Ten per cent reported labour-related travel and 45.9% non-labour-related travel in past 6 months-and varied by region and sex: labour-related mobility was more common in men (18.5%) than women (2.9%); non-labour-related mobility was more common in women (57.1%) than men (32.6%). In 2015 to 2016, 24.6% of men and 6.6% of women had concurrent sexual partnerships; in past 6 months, 21.6% of men and 5.4% of women had concurrent partnerships. Concurrency in 2015 to 2016 was more strongly associated with migration in women [aRR = 2.0, 95% CI(1.1 to 3.7)] than men [aRR = 1.5, 95% CI(1.0 to 2.2)]. Concurrency in past 6 months was more strongly associated with labour-related mobility in women [aRR = 2.9, 95% CI(1.0 to 8.0)] than men [aRR = 1.8, 95% CI(1.2 to 2.5)], but with non-labour-related mobility in men [aRR = 2.2, 95% CI(1.5 to 3.4)]. CONCLUSIONS In rural eastern Africa, both longer-distance/permanent, and localized/shorter-term forms of mobility are associated with higher-risk behaviours, and are highly gendered: the HIV risks associated with mobility are more pronounced for women. Gender-specific interventions among mobile populations are needed to combat HIV in the region.
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Affiliation(s)
- Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive SciencesUniversity of CaliforniaSan Francisco (UCSF)San FranciscoCAUSA
- Department of MedicineCenter for AIDS Prevention StudiesUCSFSan FranciscoCAUSA
| | - Adam Akullian
- Institute for Disease ModelingUniversity of WashingtonSeattleWashingtonUSA
| | - Torsten B Neilands
- Department of MedicineCenter for AIDS Prevention StudiesUCSFSan FranciscoCAUSA
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive SciencesUniversity of CaliforniaSan Francisco (UCSF)San FranciscoCAUSA
| | - Patrick Eyul
- Infectious Diseases Research Collaboration (IDRC)Makerere University (MU‐UCSF)KampalaUganda
| | - Irene Maeri
- Kenya Medical Research Institute (KEMRI)NairobiKenya
| | - Sarah Ssali
- Infectious Diseases Research Collaboration (IDRC)Makerere University (MU‐UCSF)KampalaUganda
| | - Elvin Geng
- Department of MedicineDivision of HIV, Infectious Diseases and Global MedicineUCSFSan FranciscoCAUSA
| | - Monica Gandhi
- Department of MedicineDivision of HIV, Infectious Diseases and Global MedicineUCSFSan FranciscoCAUSA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive SciencesUniversity of CaliforniaSan Francisco (UCSF)San FranciscoCAUSA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration (IDRC)Makerere University (MU‐UCSF)KampalaUganda
| | - Thomas Odeny
- Kenya Medical Research Institute (KEMRI)NairobiKenya
| | | | - Edwin D Charlebois
- Department of MedicineCenter for AIDS Prevention StudiesUCSFSan FranciscoCAUSA
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Camlin CS, Cassels S, Seeley J. Bringing population mobility into focus to achieve HIV prevention goals. J Int AIDS Soc 2018; 21 Suppl 4:e25136. [PMID: 30027588 PMCID: PMC6053544 DOI: 10.1002/jia2.25136] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 05/22/2018] [Indexed: 11/08/2022] Open
Affiliation(s)
- Carol S Camlin
- Department of Obstetrics, Gynecology and Reproductive SciencesDepartment of MedicineUniversity of CaliforniaSan FranciscoUSA
| | - Susan Cassels
- Department of GeographyUniversity of CaliforniaSanta BarbaraUSA
| | - Janet Seeley
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUK
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