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Pokhrel D, Lang SG, Elder H, John B, Roosevelt KA, Klevens M, Randall LM, DeMaria A. Predictors of HIV Care Outcomes among Recently Out-of-Care Individuals in The Massachusetts Cooperative Re-engagement Controlled Trial Cohort. AIDS Behav 2024:10.1007/s10461-024-04457-1. [PMID: 39172186 DOI: 10.1007/s10461-024-04457-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2024] [Indexed: 08/23/2024]
Abstract
A cohort of individuals in care for HIV infection who were identified as being recently out-of-care (OOC) was recruited for a trial using a data-to-care approach and an intervention to facilitate re-engagement and retention in care. This allowed for analysis of demographic and clinical characteristics correlated with recently being OOC, re-engagement, and successful retention in care and viral suppression. Recently OOC persons with HIV infection (PWH) were identified for enrollment in the Cooperative Re-engagement Controlled Trial (CoRECT). CoRECT employed a data-to-care strategy, using both clinical and surveillance data, and an active public health re-engagement intervention. We estimated relative risks (RRs), unadjusted and with multivariate log binomial regression models, to analyze associations between sociodemographic and clinical predictors of being OOC, re-engagement, retention in care, and viral suppression. Of the 630 OOC PWH enrolled in CoRECT, most were male (72.7%) and over 30 years old (91.3%). Almost 40.0% were Black non-Hispanic, 29.7% were non-US born, and 41.6% were men who have sex with men (MSM). Possible predictors of re-engagement, retention in care, and viral suppression included younger age, Hispanic race/ethnicity, birth in a US dependency, AIDS status, and HIV exposure mode. Viral suppression status within 1-year pre-enrollment was significantly associated with all outcomes: re-engagement (aRR 1.28), retention (aRR 1.72), viral suppression (aRR 1.81), and durable viral suppression (aRR 3.30). Findings elucidate factors associated with care engagement and continuity for recently OOC PWH which can be used to inform targeted re-engagement activities for priority populations and guide future data-to-care interventions.
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Affiliation(s)
- Dinesh Pokhrel
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, Boston, MA, USA.
| | - Simona G Lang
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, Boston, MA, USA
| | - Heather Elder
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, Boston, MA, USA
| | - Betsey John
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, Boston, MA, USA
| | - Kathleen A Roosevelt
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, Boston, MA, USA
| | - Monina Klevens
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, Boston, MA, USA
| | - Liisa M Randall
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, Boston, MA, USA
| | - Alfred DeMaria
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, Boston, MA, USA
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Awuoche HC, Joseph RH, Magut F, Khagayi S, Odongo FS, Otieno M, Appolonia A, Odoyo-June E, Kwaro DO. Prevalence and risk factors of sexually transmitted infections in the setting of a generalized HIV epidemic-a population-based study, western Kenya. Int J STD AIDS 2024; 35:418-429. [PMID: 38240604 PMCID: PMC11047016 DOI: 10.1177/09564624241226487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/09/2023] [Accepted: 12/29/2023] [Indexed: 04/28/2024]
Abstract
BACKGROUND Sexually transmitted infections (STIs) cause adverse health outcomes, including increasing HIV acquisition/transmission risk. We analyzed data from an HIV biomarker and behavioral survey to estimate STI prevalence, and explore associated factors in the setting of a generalized HIV epidemic in Siaya County, western Kenya. METHODS Data were collected in March-September 2022 through face-to-face interviews using structured questionnaires; records from 9643 sexually active participants aged 13+ years were included in the analysis. We calculated weighted self-reported STI prevalence, by sex, age, and HIV status and explored associated factors using multivariable logistic regression. RESULTS Median age was 37 years and 59.9% were female; HIV prevalence was 18.0%. Overall STI prevalence was 1.8%; 1.5-fold higher among males vs. females, and 2.6-fold higher among participants living with HIV vs. those without. HIV status and multiple sexual partners were independently associated with STI in both sexes. Mind-altering substance use and being circumcised were associated with STI among males. CONCLUSIONS This study estimates STI prevalence in the setting of high HIV prevalence. Findings underscore the importance of: effective STI screening in HIV clinics and HIV testing and counseling in STI clinics; screening and counseling on substance use, and HIV pre-exposure prophylaxis; and intensive sexual health counseling in male circumcision programmes.
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Affiliation(s)
- Hellen Carolyne Awuoche
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Kisumu, Kenya
| | - Rachael H Joseph
- United States Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - Faith Magut
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Kisumu, Kenya
| | - Sammy Khagayi
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Kisumu, Kenya
| | - Fredrick S Odongo
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Kisumu, Kenya
| | - Moses Otieno
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Kisumu, Kenya
| | - Aoko Appolonia
- United States Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - Elijah Odoyo-June
- United States Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - Daniel O Kwaro
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Kisumu, Kenya
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Ndugga P, Kwagala B, Wandera SO, Kisaakye P, Mbonye MK, Ngabirano F. "If your mother does not teach you, the world will…": a qualitative study of parent-adolescent communication on sexual and reproductive health issues in Border districts of eastern Uganda. BMC Public Health 2023; 23:678. [PMID: 37041536 PMCID: PMC10088803 DOI: 10.1186/s12889-023-15562-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 03/29/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND Adolescents experience a host of sexual and reproductive health (SRH) challenges, with detrimental SRH and socio-economic consequences. These include early sexual debut, sexually transmitted infections including HIV/AIDS, teenage pregnancy, and early childbearing. Parent-adolescent communication about SRH has significant potential to reduce adolescents' risky sexual behaviors. However, communication between parents and adolescents is limited. This study explored the facilitators and barriers to parent-adolescent communication about sexual and reproductive health. METHODS We conducted a qualitative study in the border districts of Busia and Tororo in Eastern Uganda. Data collection entailed 8 Focus Group Discussions comprising of parents, adolescents (10-17 years), and 25 key informants. Interviews were audio-recorded, transcribed, and translated into English. Thematic analysis was conducted with the aid of NVIVO 12 software. RESULTS Participants acknowledged the key role parents play in communicating SRH matters; however, only a few parents engage in such discussions. Facilitators of parent-adolescent communication were: having a good parent-child relationship which makes parents approachable and motivates children to discuss issues openly, a closer bond between mothers and children which is partly attributed to gender roles and expectations eases communication, and having parents with high education making them more knowledgeable and confident when discussing SRH issues with children. However, the discussions are limited by cultural norms that treat parent-child conversations on SRH as a taboo, parents' lack of knowledge, and parents busy work schedules made them unavailable to address pertinent SRH issues. CONCLUSION Parents' ability to communicate with their children is hindered by cultural barriers, busy work schedules, and a lack of knowledge. Engaging all stakeholders including parents to deconstruct sociocultural norms around adolescent SRH, developing the capacity of parents to confidently initiate and convey accurate SRH information, initiation of SRH discussions at early ages, and integrating parent-adolescent communication into parenting interventions, are potential strategies to improve SRH communication between parents and adolescents in high-risk settings such as borders.
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Affiliation(s)
- Patricia Ndugga
- College of Business and Management Sciences (CoBAMS), School of Statistics and Planning, Department of Population Studies, Makerere University, Kampala, Uganda.
| | - Betty Kwagala
- College of Business and Management Sciences (CoBAMS), School of Statistics and Planning, Department of Population Studies, Makerere University, Kampala, Uganda
| | - Stephen Ojiambo Wandera
- College of Business and Management Sciences (CoBAMS), School of Statistics and Planning, Department of Population Studies, Makerere University, Kampala, Uganda
| | - Peter Kisaakye
- College of Business and Management Sciences (CoBAMS), School of Statistics and Planning, Department of Population Studies, Makerere University, Kampala, Uganda
| | - Martin K Mbonye
- College of Business and Management Sciences (CoBAMS), School of Statistics and Planning, Department of Population Studies, Makerere University, Kampala, Uganda
| | - Fred Ngabirano
- Labor and Social Development (MGLSD), Ministry of Gender, Kampala, Uganda
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Is There Risk Compensation among HIV Infected Youth and Adults 15 Years and Older on Antiretroviral Treatment in South Africa? Findings from the 2017 National HIV Prevalence, Incidence, Behaviour and Communication Survey. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19106156. [PMID: 35627693 PMCID: PMC9141949 DOI: 10.3390/ijerph19106156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 11/17/2022]
Abstract
In this paper, risk compensation among individuals on antiretroviral therapy (ART), using the 2017 South African national survey on HIV, is explored. A multi-stage stratified cluster random sampling approach was used to realize 11,130 participants 15 years and older. Logistic regression analysis assessed the association between multiple sexual partners, condom use at last sexual encounter, consistency of condom usage and potential explanatory variables using HIV status and ART exposure as a mediator variable. HIV positive participants who were aware and on ART were less likely to have multiple sexual partners, and less likely not to use a condom at last sex compared to HIV positive participants who were aware but not on ART. The odds of reporting multiple sexual partners were significantly lower among older age groups, females, non-Black Africans, and rural settings, and higher among those with tertiary level education, and risky alcohol users. The odds of no condom use at last sexual encounter were more likely among older age groups, females, other race groups, and less likely among those with secondary level education. The odds of inconsistent condom use were more likely among older age groups, females, and other race groups, and less likely among those with tertiary level education, high risk and hazardous alcohol users. Risk compensation is not apparent among HIV infected adults who are on ART. Risk groups that should receive tailored interventions to reduced risky sexual behaviours were identified.
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Nyombayire J, Ingabire R, Mukamuyango J, Karita E, Mazzei A, Wall KM, Parker R, Tichacek A, Allen S, Hunter E, Price MA. Antiretroviral Therapy Use and HIV Transmission Among Discordant Couples in Nonresearch Settings in Kigali, Rwanda. Sex Transm Dis 2021; 48:424-428. [PMID: 33433171 PMCID: PMC10881059 DOI: 10.1097/olq.0000000000001350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Antiretroviral therapy (ART) efficacy for HIV prevention among discordant couples has been demonstrated in clinical trials. Effectiveness outside of research settings is less well understood. METHODS HIV-discordant couples were enrolled in couples' testing and follow-up at 20 government clinics in Kigali from 2010 to 2014. We performed viral linkage analysis on seroconverting couples to determine infection sources (intracouple vs. extracouple). Antiretroviral therapy use in index partners was collected at baseline and during follow-up by self-report with verification of government medical records. RESULTS A total of 3777 HIV-discordant couples were identified and followed up at government health clinics. Fifty-four incident HIV infections were identified, of which 36 were confirmed linked to the index partner, 4 were unlinked, and 14 were unknown. Among the 50 linked or unknown transmission pairs, 38% occurred among couples in which the index partner was on ART (HIV incidence rate of 0.63/100 person-years), whereas 62% occurred among couples in which the index partner was not on ART (HIV incidence rate of 5.51/100 person-years; adjusted rate ratio, 6.9). HIV acquisition was higher in women than in men with non-ART using index partners (P < 0.001). CONCLUSIONS Couples in a government clinic couples' HIV testing and follow-up program in Rwanda had an 89% reduction in HIV incidence when index partners were using ART, slightly lower than efficacy estimates from randomized trials. Antiretroviral therapy for prevention should be prioritized for key populations including discordant couples identified via couples' voluntary counseling and testing, with increased efforts to improve uptake, adherence, and viral load monitoring.
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Affiliation(s)
- Julien Nyombayire
- From the Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
| | - Rosine Ingabire
- From the Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
| | | | - Etienne Karita
- From the Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
| | - Amelia Mazzei
- From the Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
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Harlow AF, Bor J, Brennan AT, Maskew M, MacLeod W, Carmona S, Mlisana K, Fox MP. Impact of Viral Load Monitoring on Retention and Viral Suppression: A Regression Discontinuity Analysis of South Africa's National Laboratory Cohort. Am J Epidemiol 2020; 189:1492-1501. [PMID: 32648905 DOI: 10.1093/aje/kwaa140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 07/02/2020] [Accepted: 07/07/2020] [Indexed: 02/04/2023] Open
Abstract
South African guidelines recommend repeat viral load testing within 6 months when human immunodeficiency virus (HIV) viral loads exceed 1,000 copies/mL. We assessed whether South African facilities follow viral load monitoring guidelines and whether guidelines improve HIV-related outcomes, using a regression discontinuity design in a national HIV cohort of 174,574 patients (2013-2015). We assessed whether patients with viral loads just above versus just below 1,000 copies/mL were more likely to receive repeat testing in 6 months, and we compared differences in clinic transfers, retention, and viral suppression. The majority (67%) of patients with viral loads of >1,000 copies/mL did not receive repeat testing within 6 months, and these patients were 8.0% (95% confidence interval (CI): 6.2, 9.7) more likely to receive repeat testing compared with ≤1,000 copies/mL. Eligibility for repeat testing (>1,000 copies/mL) was associated with greater 12-month retention (risk difference = 2.9%, 95% CI: 0.6, 5.2) and combined suppression and retention (risk difference = 5.8%, 95% CI: 3.0, 8.6). Patients with viral loads of >1,000 copies/mL who actually received repeat testing were 85.2% more likely to be both retained and virally suppressed at 12 months (95% CI: 35.9, 100.0). Viral load monitoring might improve patient outcomes, but most patients with elevated viral loads do not receive monitoring within recommended timelines.
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Tiwari R, Wang J, Han H, Kalu N, Sims LB, Katz DA, Burke B, Tsegaye AT, Carter KA, Freije S, Guo B, Albirair M, Barr‐DiChiara M, Baggaley R, Jamil MS, Senya K, Johnson C, Khosropour CM. Sexual behaviour change following HIV testing services: a systematic review and meta-analysis. J Int AIDS Soc 2020; 23:e25635. [PMID: 33161636 PMCID: PMC7649006 DOI: 10.1002/jia2.25635] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 10/06/2020] [Accepted: 10/12/2020] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Learning one's HIV status through HIV testing services (HTS) is an essential step toward accessing treatment and linking to preventive services for those at high HIV risk. HTS may impact subsequent sexual behaviour, but the degree to which this varies by population or is true in the setting of contemporary HIV prevention activities is largely unknown. As part of the 2019 World Health Organization Consolidated Guidelines on HTS, we undertook a systematic review and meta-analysis to determine the effect of HTS on sexual behaviour. METHODS We searched nine electronic databases for studies published between July 2010 and December 2019. We included studies that reported on at least one outcome (condom use [defined as the frequency of condom use or condom-protected sex], number of sex partners, HIV incidence, STI incidence/prevalence). We included studies that prospectively assessed outcomes and that fit into one of three categories: (1) those evaluating more versus less-intensive HTS, (2) those of populations receiving HTS versus not and (3) those evaluating outcomes after versus before HTS. We conducted meta-analyses using random-effects models. RESULTS AND DISCUSSION Of 29 980 studies screened, 76 studies were included. Thirty-eight studies were randomized controlled trials, 36 were cohort studies, one was quasi-experimental and one was a serial cross-sectional study. There was no significant difference in condom use among individuals receiving more-intensive HTS compared to less-intensive HTS (relative risk [RR]=1.03; 95% CI: 0.99 to 1.07). Condom use was significantly higher after receiving HTS compared to before HTS for individuals newly diagnosed with HIV (RR = 1.65; 95% CI: 1.36 to 1.99) and marginally significantly higher for individuals receiving an HIV-negative diagnosis (RR = 1.63; 95% CI: 1.01 to 2.62). Individuals receiving more-intensive HTS reported fewer sex partners at follow-up than those receiving less-intensive HTS, but the finding was not statistically significant (mean difference = -0.28; 95% CI: -3.66, 3.10). CONCLUSIONS Our findings highlight the importance of using limited resources towards HTS strategies that focus on early HIV diagnosis, treatment and prevention services rather than resources dedicated to supplementing or enhancing HTS with additional counselling or other interventions.
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Affiliation(s)
- Ruchi Tiwari
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | - Jiayu Wang
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Hannah Han
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Ngozi Kalu
- Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Lee B Sims
- School of Public HealthImperial College LondonLondonUnited Kingdom
| | - David A Katz
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Barbara Burke
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Adino T Tsegaye
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | - Kayla A Carter
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | - Sophie Freije
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | - Boya Guo
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | | | | | - Rachel Baggaley
- Global HIV, Hepatitis and STIs programmeWorld Health OrganizationGenevaSwitzerland
| | - Muhammad S Jamil
- Global HIV, Hepatitis and STIs programmeWorld Health OrganizationGenevaSwitzerland
| | - Kafui Senya
- Communicable Diseases ClusterWorld Health OrganizationAccraGhana
| | - Cheryl Johnson
- Global HIV, Hepatitis and STIs programmeWorld Health OrganizationGenevaSwitzerland
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Iliyasu Z, Owen J, Aliyu MH, Simkhada P. "I prefer not to have a child than have a HIV-positive child": a Mixed Methods Study of Fertility Behaviour of Men Living with HIV in Northern Nigeria. Int J Behav Med 2020; 27:87-99. [PMID: 31836947 DOI: 10.1007/s12529-019-09837-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND In the era of HIV treatment as prevention, little research has focused on the fertility behaviour of men living with HIV. This study examines the predictors and motivators of fertility among men living with HIV and on antiretroviral treatment in Kano, Nigeria. METHOD Using mixed methods, structured questionnaires were administered to a clinic-based sample of men living with HIV (n = 270) and HIV-negative/untested controls (n = 270), followed by in-depth interviews with a sub-group of 22 HIV-positive participants. Logistic regression and the framework approach were used to analyse the data. RESULTS Compared to HIV-negative/untested controls, lower proportions of men living with HIV desired more children (79.3%, n = 214 vs. 91.1%, n = 246, p < 0.05) and intended to bear children within 3 years (57.0%, n = 154 vs. 67.0%, n = 181) (p < 0.05). Marital status (ever married vs. single) predicted fertility intention among men living with HIV (adjusted odds ratio, AOR = 4.70, 95% confidence interval CI, 1.75-13.64) and HIV-negative/untested controls (AOR = 4.23, 95% CI, 1.37-16.45). Men considered self and partner health status, HIV transmission risks, poverty, the effectiveness of interventions, child survival and religion when making fertility decisions. CONCLUSION Fertility desires remain high post-HIV diagnosis. HIV services should include integrated reproductive health programs that address the fertility desires of clients and include considerations for fertility services.
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Affiliation(s)
- Zubairu Iliyasu
- Section of Public Health, School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK.
- Department of Community Medicine, Bayero University Kano, Kano, Nigeria.
| | - Jenny Owen
- Section of Public Health, School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Muktar H Aliyu
- Department of Health Policy & Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Padam Simkhada
- Section of Public Health, School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
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Determinants and Outcomes of Late Presentation of HIV Infection in Migrants in Catalonia, Spain: PISCIS Cohort 2004-2016. J Immigr Minor Health 2020; 21:920-930. [PMID: 30377891 DOI: 10.1007/s10903-018-0834-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
This study using the Catalan PISCIS cohort explores risk factors of migrants' late presentation and the impact of late presentation on their health outcomes. We analyse 9590 new HIV diagnoses enrolled in the cohort between 2004 and 2016. Univariate and multivariate logistic regression models are used to identify risk factors associated with late presentation among migrants, giving crude and adjusted odds ratios and their 95% confidence intervals. Cox regression models are estimated to identify risk factors associated with AIDS/death, and crude and adjusted hazard ratios and 95% confidence intervals are reported. Late presentation is higher in migrants than non-migrants. Among migrants, region of origin is associated with late presentation and AIDS/death during follow-up. The results highlight persisting inequalities in HIV diagnosis and care among migrants in Catalonia. Targeted interventions addressed to specific subgroups in the migrant population are needed.
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LeMessurier J, Traversy G, Varsaneux O, Weekes M, Avey MT, Niragira O, Gervais R, Guyatt G, Rodin R. Risk of sexual transmission of human immunodeficiency virus with antiretroviral therapy, suppressed viral load and condom use: a systematic review. CMAJ 2019; 190:E1350-E1360. [PMID: 30455270 DOI: 10.1503/cmaj.180311] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The Public Health Agency of Canada reviewed sexual transmission of HIV between serodiscordant partners to support examination of the criminal justice system response to HIV nondisclosure by the Department of Justice of Canada. We sought to determine HIV transmission risk when an HIV-positive partner takes antiretroviral therapy, has a suppressed viral load or uses condoms. METHODS We conducted an overview and systematic review update by searching MEDLINE and other databases (Jan. 1, 2007, to Mar. 13, 2017; and Nov. 1, 2012, to Apr. 27, 2017, respectively). We considered reviews and studies about absolute risk of sexual transmission of HIV between serodiscordant partners to be eligible for inclusion. We used A Measurement Tool to Assess Systematic Reviews (AMSTAR) for review quality, Quality in Prognosis Studies (QUIPS) instrument for study risk of bias and then the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to assess the quality of evidence across studies. We calculated HIV incidence per 100 person-years with 95% confidence intervals (CIs). We assigned risk categories according to potential for and evidence of HIV transmission. RESULTS We identified 12 reviews. We selected 1 review to estimate risk of HIV transmission for condom use without antiretroviral therapy (1.14 transmissions/100 person-years, 95% CI 0.56-2.04; low risk). We identified 11 studies with 23 transmissions over 10 511 person-years with antiretroviral therapy (0.22 transmissions/ 100 person-years, 95% CI 0.14-0.33; low risk). We found no transmissions with antiretroviral therapy and a viral load of less than 200 copies/mL across consecutive measurements 4 to 6 months apart (0.00 transmissions/100 person-years, 95% CI 0.00-0.28; negligible risk regardless of condom use). INTERPRETATION Based on high-quality evidence, there is a negligible risk of sexual transmission of HIV when an HIV-positive sex partner adheres to antiretroviral therapy and maintains a suppressed viral load of less than 200 copies/mL measured every 4 to 6 months. Sexual transmissions of HIV have occurred when viral load was more than 200 copies/mL with antiretroviral therapy or condoms alone were used, although the risk remains low. These findings will help to support patient and clinician decision-making, affect public health case management and contact tracing, and inform justice system responses to HIV nondisclosure.
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Affiliation(s)
- Jennifer LeMessurier
- Centre for Communicable Diseases and Infection Control (Traversy, Varsaneux, Weekes, Avey, Niragira, Gervais, Rodin), Public Health Agency of Canada; Department of Family Medicine (LeMessurier) and School of Epidemiology and Public Health (LeMessurier), University of Ottawa, Ottawa, Ont.; Department of Health Research Methods, Evidence, and Impact (Guyatt), McMaster University, Hamilton, Ont
| | - Gregory Traversy
- Centre for Communicable Diseases and Infection Control (Traversy, Varsaneux, Weekes, Avey, Niragira, Gervais, Rodin), Public Health Agency of Canada; Department of Family Medicine (LeMessurier) and School of Epidemiology and Public Health (LeMessurier), University of Ottawa, Ottawa, Ont.; Department of Health Research Methods, Evidence, and Impact (Guyatt), McMaster University, Hamilton, Ont
| | - Olivia Varsaneux
- Centre for Communicable Diseases and Infection Control (Traversy, Varsaneux, Weekes, Avey, Niragira, Gervais, Rodin), Public Health Agency of Canada; Department of Family Medicine (LeMessurier) and School of Epidemiology and Public Health (LeMessurier), University of Ottawa, Ottawa, Ont.; Department of Health Research Methods, Evidence, and Impact (Guyatt), McMaster University, Hamilton, Ont
| | - Makenzie Weekes
- Centre for Communicable Diseases and Infection Control (Traversy, Varsaneux, Weekes, Avey, Niragira, Gervais, Rodin), Public Health Agency of Canada; Department of Family Medicine (LeMessurier) and School of Epidemiology and Public Health (LeMessurier), University of Ottawa, Ottawa, Ont.; Department of Health Research Methods, Evidence, and Impact (Guyatt), McMaster University, Hamilton, Ont
| | - Marc T Avey
- Centre for Communicable Diseases and Infection Control (Traversy, Varsaneux, Weekes, Avey, Niragira, Gervais, Rodin), Public Health Agency of Canada; Department of Family Medicine (LeMessurier) and School of Epidemiology and Public Health (LeMessurier), University of Ottawa, Ottawa, Ont.; Department of Health Research Methods, Evidence, and Impact (Guyatt), McMaster University, Hamilton, Ont
| | - Oscar Niragira
- Centre for Communicable Diseases and Infection Control (Traversy, Varsaneux, Weekes, Avey, Niragira, Gervais, Rodin), Public Health Agency of Canada; Department of Family Medicine (LeMessurier) and School of Epidemiology and Public Health (LeMessurier), University of Ottawa, Ottawa, Ont.; Department of Health Research Methods, Evidence, and Impact (Guyatt), McMaster University, Hamilton, Ont
| | - Robert Gervais
- Centre for Communicable Diseases and Infection Control (Traversy, Varsaneux, Weekes, Avey, Niragira, Gervais, Rodin), Public Health Agency of Canada; Department of Family Medicine (LeMessurier) and School of Epidemiology and Public Health (LeMessurier), University of Ottawa, Ottawa, Ont.; Department of Health Research Methods, Evidence, and Impact (Guyatt), McMaster University, Hamilton, Ont
| | - Gordon Guyatt
- Centre for Communicable Diseases and Infection Control (Traversy, Varsaneux, Weekes, Avey, Niragira, Gervais, Rodin), Public Health Agency of Canada; Department of Family Medicine (LeMessurier) and School of Epidemiology and Public Health (LeMessurier), University of Ottawa, Ottawa, Ont.; Department of Health Research Methods, Evidence, and Impact (Guyatt), McMaster University, Hamilton, Ont
| | - Rachel Rodin
- Centre for Communicable Diseases and Infection Control (Traversy, Varsaneux, Weekes, Avey, Niragira, Gervais, Rodin), Public Health Agency of Canada; Department of Family Medicine (LeMessurier) and School of Epidemiology and Public Health (LeMessurier), University of Ottawa, Ottawa, Ont.; Department of Health Research Methods, Evidence, and Impact (Guyatt), McMaster University, Hamilton, Ont.
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11
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Brief Report: Per Sex-Act Risk of HIV Transmission Under Antiretroviral Treatment: A Data-Driven Approach. J Acquir Immune Defic Syndr 2019; 79:440-444. [PMID: 30179982 DOI: 10.1097/qai.0000000000001845] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Before the completion of HPTN 052, PARTNER, and Opposites Attract studies, data were lacking to directly estimate HIV transmission risk under effective combined antiretroviral treatment (cART). Rather, estimates were obtained by extrapolating a dose-response relationship between viral load and risk of HIV transmission, observed among untreated individuals, to treated individuals. Presently, data have accumulated from 9 clinical studies for a direct validation of this extrapolation. METHODS Using estimates of per sex-act risk of HIV transmission on effective cART obtained by extrapolation, sexual behavior data, and a simple mathematical model, we estimated the number of seroconversions that should have been observed in HIV-serodiscordant couples where the HIV-positive partner was on cART across the 9 studies. We compared this with the number of seroconversions actually observed. Next, we directly estimated the risk of HIV transmission on effective cART, using Bayesian statistics to combine all available data. RESULTS We found that at least 4.7 (uncertainty bounds: 1.7-12.6) and 35.1 (uncertainty bounds: 13.2-92.0) seroconversions should have been observed among, respectively, heterosexual and men who have sex with men (MSM) serodiscordant couples. This is not validated by observations across the studies, which reported at most 1 seroconversion among heterosexual couples and 0 for MSM. Combining all available data, we found that the maximum per sex-act risk of HIV transmission under effective cART is 3.9:100,000 for heterosexuals and 4.4:100,000 for MSM. CONCLUSIONS Data have accumulated to render obsolete estimates of the risk of HIV transmission on cART obtained by extrapolation. Direct estimates are substantially lower and should be used in practice.
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Wei X, Zhang Y, Santella AJ, Wang L, Zhuang G, Li S, Zhang H. Effect of early highly active antiretroviral therapy on viral suppression among newly diagnosed men who have sex with men living with human immunodeficiency virus in Xi'an, China. J Med Virol 2019; 91:1263-1271. [PMID: 30840771 DOI: 10.1002/jmv.25449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/27/2019] [Accepted: 03/01/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND The number of men who have sex with men (MSM) living with human immunodeficiency virus (HIV) in China has increased rapidly and thus immediate highly active antiretroviral therapy (HAART) after diagnosis was implemented as a strategy to reduce the HIV transmission. METHODS MSM who were diagnosed with HIV and received HAART between 2013 to 2015 in Xi'an were divided into three groups (>350, 200-350, and <200 cell/μL) according to their baseline CD4+ T cell count. The time of follow-up was calculated from the first date of receiving HAART to December 31, 2016. The CD4+ T cell count was detected with 1 week before or after HAART. The plasma viral loads were tested after 1, 2, and 3 years of treatment. RESULTS Of 1442 subjects who received HAART, 690 (47.9%) cases were in >350 cell/μL group, whereas 400 (27.7%) cases and 352 (24.4%) cases were in the 200-350 cell/μL group and <200 cell/μL group, respectively. After 1 year of treatment, the viral suppression rate in the <200 cell/μL group was 91.1%, which was significantly lower than the other two groups. The logistic regression results show that the >350 cell/μL group and 200-350 cell/μL group predicted higher viral suppression rates. CONCLUSIONS Baseline CD4+ T cell count more than 350 cell/μL can improve viral suppression among MSM living with HIV. Furthermore, to reduce the transmission risk, the treatment compliance of people living with HIV with high CD4+ T cell levels should be improved, and their diagnosis to the treatment time should be decreased.
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Affiliation(s)
- Xiaoli Wei
- Department of Sexually Transmitted Diseases Prevention and Control, Xi'an Centers for Disease Control and Prevention, Xi'an, China
| | - Yajuan Zhang
- Department of Sexually Transmitted Diseases Prevention and Control, Xi'an Centers for Disease Control and Prevention, Xi'an, China
| | - Anthony J Santella
- Department of Health Professions, School of Health Professions and Human Services, Hofstra University, Hempstead, New York
| | - Lirong Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Guihua Zhuang
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Siwen Li
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Hailan Zhang
- Department of Sexually Transmitted Diseases Prevention and Control, Xi'an Centers for Disease Control and Prevention, Xi'an, China
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13
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Okoboi S, Castelnuovo B, Moore DM, Musaazi J, Kambugu A, Birungi J, Kaleebu P, Nanfuka M, Kamya MR, Van Rie A. Risky sexual behavior among patients on long-term antiretroviral therapy: a prospective cohort study in urban and rural Uganda. AIDS Res Ther 2018; 15:15. [PMID: 30340608 PMCID: PMC6195707 DOI: 10.1186/s12981-018-0203-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 10/10/2018] [Indexed: 11/10/2022] Open
Abstract
Background While the effects of initiation of antiretroviral treatment (ART) on risky sexual behavior have been extensively studied, less is known about the long-term changes in risky sexual behavior over time in resource-poor settings. Methods We conducted a secondary longitudinal analysis of one rural and one urban cohort of patients who initiated ART in Uganda between April 2004 and July 2007 followed up-to 2016. Data on sexual behavior were collected every 6 months for 3.5 years in individuals on ART ≥ 4 years (baseline) when a behavioral questionnaire was introduced. Risky sexual behavior was defined as sexual intercourse with ≥ 2 partners or inconsistent or no condom use in previous 6 months. We report characteristics overall, and by cohort. We used multivariable generalized estimating equations logistic regression to assess the effects of time on ART on risky sexual behavior. Results Of 1012 participants, 402 (39.8%) were urban and 610 (60.2%) were rural residents. Mean age was 42.8 years (SD 8.5). Mean duration of follow-up was 51.3 months (SD 15.3), but longer for urban than rural participants (64.5 vs 36.4 months). Risky sexual behavior declined from 33.1% at baseline to 9.6% after 3.5 years of follow-up in the rural cohort (p ≤ 0.01 for the test of trend) and was unchanged from 9.7% at baseline to 9.9% after 3.5 years in the urban cohort (p = 0.51). Receiving care at a rural clinic (aOR 4.99, 95% CI 3.64–6.84); male gender (aOR 1.66, 95% CI 1.26–2.19) and being younger (aOR 5.60, 95% CI 3.80–8.25 for 18–34 years and aOR 2.34, 95% CI 1.74–3.14 for 35–44 years) were associated with increased odds of risky sexual behavior. Not being married (aOR 0.25; 95% CI 0.19–0.34), and longer time on ART (aOR 0.71 95% CI 0.67–0.76) were associated with reduced odds of risky sex. Conclusions We observed a decline in risky sexual behavior in rural people on long-term (≥ 4 years) ART. Rural, male and young individuals had higher odds of self-reported risky sexual behavior. ART programs should continue to emphasize risk reduction practices, especially among people receiving care in rural health facilities, males, younger individuals and those who are married.
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Hosseinipour MC, Kang M, Krown SE, Bukuru A, Umbleja T, Martin JN, Orem J, Godfrey C, Hoagland B, Mwelase N, Langat D, Nyirenda M, MacRae J, Borok M, Samaneka W, Moses A, Mngqbisa R, Busakhala N, Martínez-Maza O, Ambinder R, Dittmer DP, Nokta M, Campbell TB. As-Needed Vs Immediate Etoposide Chemotherapy in Combination With Antiretroviral Therapy for Mild-to-Moderate AIDS-Associated Kaposi Sarcoma in Resource-Limited Settings: A5264/AMC-067 Randomized Clinical Trial. Clin Infect Dis 2018; 67:251-260. [PMID: 29365083 PMCID: PMC6030807 DOI: 10.1093/cid/ciy044] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 01/18/2018] [Indexed: 12/13/2022] Open
Abstract
Background Mild-to-moderate AIDS-associated Kaposi sarcoma (KS) often responds to antiretroviral therapy (ART) alone; the role of chemotherapy is unclear. We assessed the impact of immediate vs as-needed oral etoposide (ET) among human immunodeficiency virus (HIV)-infected individuals with mild-to-moderate KS initiating ART. Methods Chemotherapy-naive, HIV type 1-infected adults with mild-to-moderate KS initiating ART in Africa and South America were randomized to ART (tenofovir/emtricitabine/efavirenz) alone (chemotherapy "as-needed" arm) vs ART plus up to 8 cycles of oral ET (immediate arm). Participants with KS progression on ART alone received ET as part of the as-needed strategy. Primary outcome was ordinal as follows: failure, stable, and response at 48 weeks. Secondary outcomes included time to initial KS progression, KS-associated immune reconstitution inflammatory syndrome (KS-IRIS), and KS response. Results Of 190 randomized participants (as-needed = 94, immediate = 96), the majority were men (71%) and African (93%). Failure (53.8% vs 56.6%), stable (16.3% vs 10.8%), and response (30% vs 32.5%) did not differ between arms (as-needed vs immediate) among those with week 48 data potential (N = 163, P = .91). Time to KS progression (P = .021), KS-IRIS (P = .003), and KS response (P = .003) favored the immediate arm. Twenty-five participants died (13%). Mortality, adverse events, CD4+ T-cell changes, and HIV RNA suppression were similar at 48 weeks. Conclusions Among HIV-infected adults with mild-to-moderate KS, immediate ET provided early, nondurable clinical benefits. By 48 weeks, no clinical benefit was observed compared to use of ET as needed. Mortality was high and tumor response was low. Clinical Trials Registration NCT01352117.
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Affiliation(s)
- Mina C Hosseinipour
- UNC Project, Lilongwe, Malawi
- University of North Carolina School of Medicine, Chapel Hill
| | - Minhee Kang
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | | | - Triin Umbleja
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | | | - Catherine Godfrey
- HIV Research Branch, TRP, DAIDS, NIAID, National Institutes of Health, Rockville, Maryland
| | | | | | - Deborah Langat
- Kenya Medical Research Institute/Walter Reed Project, Kericho
| | - Mulinda Nyirenda
- Johns Hopkins Project, University of Malawi College of Medicine, Blantyre, Malawi
| | | | - Margaret Borok
- AIDS Malignancy Consortium, New York, New York
- University of Zimbabwe, Harare
| | | | - Agnes Moses
- UNC Project, Lilongwe, Malawi
- University of North Carolina School of Medicine, Chapel Hill
- AIDS Malignancy Consortium, New York, New York
| | | | | | | | - Richard Ambinder
- AIDS Malignancy Consortium, New York, New York
- Johns Hopkins University, Baltimore
| | - Dirk P Dittmer
- University of North Carolina School of Medicine, Chapel Hill
- AIDS Malignancy Consortium, New York, New York
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How Do We Get Partners to Test for HIV?: Predictors of Uptake of Partner HIV Testing Following Individual Outpatient Provider Initiated HIV Testing in Rural Uganda. AIDS Behav 2017; 21:2497-2508. [PMID: 28585100 DOI: 10.1007/s10461-017-1817-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
In a sample of outpatients (152 females, 152 males) receiving individual provider-initiated HIV testing and counselling (PITC) we aimed to identify factors associated with subsequent uptake of partner HIV testing. Purposively sampled outpatients receiving PITC at a Ugandan hospital completed a questionnaire immediately prior to testing for HIV, and then at 3 and 6 months post-test. By 6-month follow-up 96% of participants reported disclosing their HIV test results to their partner and 96.4% reported asking their partner to test. 38.8% of women and 78.9% of men reported that their partner tested and they knew their results. Recent (men AOR 5.84, 95.0% CI 1.90-17.99; women AOR 6.19, 95.0% CI 2.74-13.59) or any previous testing by the partner (women AOR 4.01, 95% CI 1.06-15.10) predicted uptake of partner testing by the 6-month follow-up. Among women, perceiving greater social support from their partner, which perhaps reflects better relationship quality, was predictive of their male partner testing for HIV (AOR 2.37, 95% CI 1.22-4.58). Notably intimate partner violence showed no negative association with partner testing. Our findings demonstrate that women are at a disadvantage compared to men in their ability to influence their partner to test for HIV, and that improving social support in intimate relationships should be a focus of HIV partner testing interventions. However, more research on interventions to improve partner testing is needed, particularly in identifying effective ways to support women in engaging their partners to test.
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HIV Transmission Risk Persists During the First 6 Months of Antiretroviral Therapy. J Acquir Immune Defic Syndr 2017; 72:579-84. [PMID: 27070123 DOI: 10.1097/qai.0000000000001019] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Combination antiretroviral therapy (ART) decreases the risk of sexual HIV transmission by suppressing blood and genital HIV RNA concentrations. We sought to determine HIV transmission risk prior to achieving complete viral suppression. DESIGN Prospective cohort study. METHODS Using data from the Partners PrEP Study, a prospective study of 4747 heterosexual HIV-serodiscordant couples in Kenya and Uganda, we examined multiple markers of HIV transmission risk during the first months after ART initiation: time to viral suppression in blood, persistence of HIV RNA in genital specimens, sexual risk behavior, pregnancy incidence, and HIV transmission using survival analysis and generalized estimating equations logistic regression. RESULTS The cumulative probabilities of achieving blood viral suppression (<80 copies per milliliter) 3, 6, and 9 months after ART initiation were 65.3%, 84.8%, and 89.1%, respectively. Endocervical and seminal HIV RNA were detectable in 12% and 21% of samples obtained within 6 months of ART. Pregnancy incidence was 8.8 per 100 person-years during the first 6 months of ART, and sex unprotected by condoms was reported at 10.5% of visits. Among initially uninfected partners, HIV incidence before ART was 2.08 per 100 person-years (55 infections; 2644 person-years), 1.79 for 0-6 months after ART initiation (3 infections; 168 person-years), and 0.00 with >6 months of ART (0 infections; 167 person-years). CONCLUSIONS Residual HIV transmission risk persists during the first 6 months of ART, with incomplete viral suppression in blood and genital compartments. For HIV-serodiscordant couples in which the infected partner starts ART, other prevention options are needed, such as pre-exposure prophylaxis, until viral suppression is achieved.
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Mujugira A, Celum C, Ngure K, Thomas KK, Katabira E, Baeten JM. Antiretroviral Therapy Initiation Is Not Associated With Risky Sexual Behavior Among Heterosexual Human Immunodeficiency Virus-Infected Persons in Serodiscordant Partnerships. Sex Transm Dis 2017; 44:57-61. [PMID: 27898566 PMCID: PMC5145755 DOI: 10.1097/olq.0000000000000534] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Few prospective studies have assessed whether antiretroviral therapy (ART) use is associated with changes in sexual risk behavior of human immunodeficiency virus (HIV)-infected persons in known HIV-serodiscordant partnerships. METHODS We conducted a longitudinal analysis of HIV-infected persons with known uninfected partners enrolled in the Partners Pre-Exposure Prophylaxis Study in Kenya and Uganda. Antiretroviral therapy use and self-reported sexual behavior were ascertained every 3 months. We assessed the effect of ART on sexual risk behaviors using zero-inflated negative binomial regression. Primary outcomes were condomless vaginal sex acts, pregnancy incidence and new sexually transmitted infection diagnoses. RESULTS We followed 1817 HIV-infected persons (58% women) for 864 person-years before ART initiation and 771 person-years after ART. Median CD4 and plasma viral load at ART initiation were 277 cells/μL and 4.18 log10 copies/mL. Antiretroviral therapy use was associated with a significant decrease in condomless vaginal sex acts with HIV-uninfected partners (0.65 vs 0.39 per month; rate ratio, 0.64; 95% confidence interval [CI], 0.55-0.75; P < 0.001), but not condomless vaginal sex acts with nonprimary partners (1.30 vs 1.04 per month; rate ratio, 0.94; 95% CI, 0.94-1.20; P = 0.62). Pregnancy incidence was lower after ART (13.2 vs 8.4 per 100 person-years; HR, 0.71; 95% CI, 0.60-0.84; P < 0.001). Incident sexually transmitted infection diagnoses were similar (odds ratio, 1.05; 95% CI, 0.86-1.29; P = 0.63). CONCLUSIONS Substantial risk compensation did not occur after ART initiation among East African HIV-infected persons with known HIV-uninfected partners. These data inform modelling studies of ART for HIV prevention by suggesting that risky sexual behavior did not appear to offset decreased HIV infectiousness in this key population.
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Affiliation(s)
- Andrew Mujugira
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Kenya
| | | | - Elly Katabira
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
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Landovitz RJ, Tran TTT, Cohn SE, Ofotokun I, Godfrey C, Kuritzkes DR, Lennox JL, Currier JS, Ribaudo HJ. HIV Transmission Risk Behavior in a Cohort of HIV-Infected Treatment-Naïve Men and Women in the United States. AIDS Behav 2016; 20:2983-2995. [PMID: 26979419 PMCID: PMC5026544 DOI: 10.1007/s10461-016-1365-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Antiretroviral therapy (ART) can minimize HIV transmission. Prevention benefits may be compromised by barriers to virologic suppression, and by increased condomless sex among those initiating ART. We evaluated condomless sex in a cohort of HIVinfected US individuals poised to initiate ART in a clinical trial. We assessed partner and sex act type, condom use, and perception of infectiousness. Six percent of participants reported as not infectious; men who have sex with men were more likely to perceive high infectivity. Prevalence of condomless sex was 44 %; 74 % of those also reported homosexual acquisition of HIV. Predictors of increased risk of condomless sex included greater numbers of lifetime partners, recent stimulant drug use and an HIV-positive or unknown serostatus partner. In the context of serodifferent partners, lower perception of infectiousness was also associated with a higher risk of condomless sex. Results highlight opportunities for prevention education for HIV infected individuals at ART initiation.
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Affiliation(s)
- Raphael J Landovitz
- Division of Infectious Diseases, UCLA Center for Clinical AIDS Research and Education, University of California, Los Angeles, 11075 Santa Monica Blvd, Suite 100, Los Angeles, CA, 90025, USA.
| | - Thuy Tien T Tran
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Susan E Cohn
- Division of Infectious Diseases, Northwestern University School of Medicine, Chicago, IL, USA
| | - Ighovwhera Ofotokun
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Catherine Godfrey
- Therapeutics Research Branch, Division of AIDS, National Institutes of Health, Bethesda, MD, USA
| | - Daniel R Kuritzkes
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
| | - Jeffrey L Lennox
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Judith S Currier
- Division of Infectious Diseases, UCLA Center for Clinical AIDS Research and Education, University of California, Los Angeles, 11075 Santa Monica Blvd, Suite 100, Los Angeles, CA, 90025, USA
| | - Heather J Ribaudo
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, MA, USA
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Carlos S, Lopez-Del Burgo C, Burgueño E, Martinez-Gonzalez MA, Osorio A, Ndarabu A, Passabosc C, de Irala J. Male condom use, multiple sexual partners and HIV: a prospective case-control study in Kinshasa (DRC). AIDS Care 2016; 29:772-781. [PMID: 27852108 DOI: 10.1080/09540121.2016.1258450] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In the Democratic Republic of Congo no previous studies have assessed the factors associated with different patterns of condom use and with multiple sexual partners, and the association between condom use simultaneously taking into account multiple sexual partnerships, and HIV infection. We carried out a prospective case-control study. From December 2010 until June 2012, 1630 participants aged 15-49 getting HIV Voluntary Counseling and Testing in a hospital in Kinshasa were selected. Cases were new HIV diagnosis and controls were HIV-negative participants detected along the study period. We recruited 274 cases and 1340 controls that were interviewed about HIV-related knowledge, attitudes and behaviours. Among cases there was a high prevalence of multiple lifetime and concurrent sexual partnerships (89.8% and 20.4%, respectively) and most cases never used condoms with only 1.5% using them consistently. Condom use and multiple partnerships were associated with male, single and high-educated participants. An association was found between multiple lifetime partners and 'any condom use' (OR = 2.99; 95%CI: 2.14-4.19) but not with consistent use. Both having two or more multiple concurrent sexual partners or not using condoms were variables similarly and highly associated to HIV risk. The association found between having two or more concurrent sexual partners and HIV was slightly higher (OR = 3.58, 95%CI:2.31-5.56) than the association found between never condom use and HIV (OR = 3.38, 95%CI:1.15-9.93). We found a high prevalence of multiple lifetime sexual partners and an extremely high prevalence of inconsistent condom use, both strongly associated with HIV seropositivity. Local programmes would benefit from comprehensive interventions targeting all behavioural and sociocultural determinants.
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Affiliation(s)
- Silvia Carlos
- a Preventive Medicine and Public Health Department , University of Navarra , Pamplona , Spain.,b IdiSNA, Navarra Institute for Health Research , Pamplona , Spain.,c Institute for Culture and Society (ICS), Education of Affectivity and Human Sexuality , University of Navarra , Pamplona Spain
| | - Cristina Lopez-Del Burgo
- a Preventive Medicine and Public Health Department , University of Navarra , Pamplona , Spain.,b IdiSNA, Navarra Institute for Health Research , Pamplona , Spain.,c Institute for Culture and Society (ICS), Education of Affectivity and Human Sexuality , University of Navarra , Pamplona Spain
| | - Eduardo Burgueño
- d CEFA-Monkole , Kinshasa , Democratic Republic of the Congo.,e Department of Family Medicine and Primary Health Care , UPC - Protestant University in Congo, Kinshasa , Democratic Republic of the Congo
| | - Miguel Angel Martinez-Gonzalez
- a Preventive Medicine and Public Health Department , University of Navarra , Pamplona , Spain.,b IdiSNA, Navarra Institute for Health Research , Pamplona , Spain.,f CIBER Fisiopatología de la Obesidad y Nutrición (CIBER obn), Spanish Government (ISCIII) , Madrid , Spain
| | - Alfonso Osorio
- b IdiSNA, Navarra Institute for Health Research , Pamplona , Spain.,c Institute for Culture and Society (ICS), Education of Affectivity and Human Sexuality , University of Navarra , Pamplona Spain.,g School of Education and Psychology , University of Navarra , Pamplona , Spain
| | - Adolphe Ndarabu
- h Monkole Hospital , Kinshasa, Democratic Republic of the Congo
| | - Clément Passabosc
- i Department of Ophthalmology , Hospital de la Santa Creu i Sant Pau , Barcelona , Spain
| | - Jokin de Irala
- a Preventive Medicine and Public Health Department , University of Navarra , Pamplona , Spain.,b IdiSNA, Navarra Institute for Health Research , Pamplona , Spain.,c Institute for Culture and Society (ICS), Education of Affectivity and Human Sexuality , University of Navarra , Pamplona Spain
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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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Shukla M, Agarwal M, Singh JV, Tripathi AK, Srivastava AK, Singh VK. High-risk sexual behavior among people living with HIV/AIDS attending tertiary care hospitals in district of Northern India. Indian J Sex Transm Dis AIDS 2016; 37:46-51. [PMID: 27190412 DOI: 10.4103/0253-7184.176212] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
CONTEXT Prevention with a positive approach has been advocated as one of the main strategies to diminish the new instances of HIV and the target are those who are engaged in high-risk sexual behavior. Therefore, understanding the risky behaviors of the HIV-infected individual is important. AIMS This study aimed to assess the prevalence and the predictors of high-risk sexual behavior among people living with HIV/AIDS (PLHA). SETTINGS AND DESIGN A hospital-based cross-sectional study was conducted at antiretroviral therapy centers of two tertiary care hospitals in Lucknow. MATERIALS AND METHODS A total of 322 HIV-positive patients were interviewed about their sexual behaviors during last 3 months using a pretested questionnaire. STATISTICAL ANALYSIS USED Probability (p) was calculated to test for statistical significance at 5% level of significance. Association between risk factors and high-risk sexual behavior was determined using bivariate analysis followed by multivariate logistic regression. RESULTS Prevalence of high-risk sexual behavior was 24.5%. Of these patients, multiple sexual partners were reported by 67.3% whereas about 46.9% were engaged in unprotected sex. Multivariate logistic regression analysis revealed that high-risk sexual behavior was significantly associated with nonsupporting attitude of spouse (odds ratio [OR]: 18; 95% confidence interval [CI]: 1.4-225.5; P = 0.02) and alcohol consumption (OR: 9.3; 95% CI: 2.4-35.4; P = 0.001). CONCLUSIONS Specific intervention addressing alcohol consumption and encouragement of spouse and family support should be integrated in the routine HIV/AIDS care and treatment apart from HIV transmission and prevention knowledge.
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Affiliation(s)
- Mukesh Shukla
- Department of Community Medicine and Public Health, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Monica Agarwal
- Department of Community Medicine and Public Health, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Jai Vir Singh
- Department of Community Medicine and Public Health, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Anil Kumar Tripathi
- Department of Clinical Hematology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Anand Kumar Srivastava
- Department of Community Medicine and Public Health, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Vijay Kumar Singh
- Department of Community Medicine and Public Health, King George's Medical University, Lucknow, Uttar Pradesh, India
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Risher K, Rehle T, Simbayi L, Shisana O, Celentano DD. Antiretroviral Treatment and Sexual Risk Behavior in South Africa. AIDS Behav 2016; 20:710-6. [PMID: 26194426 DOI: 10.1007/s10461-015-1125-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The sexual behavior of individuals living with HIV determines the onward transmission of HIV. With the understanding that antiretroviral therapy (ART) prevents transmission of HIV, the sexual behaviors of the individuals not on ART with unsuppressed viral loads becomes of the greatest importance in elucidating transmission. We assessed the association between being on ART and sexual risk behavior among those living with HIV in a nationally representative population-based cross-sectional survey of households in South Africa that was conducted in 2012. Of 2237 adults (aged 15-49) who tested HIV-seropositive, 667 (29.8 %) had detectable antiretroviral drugs in their blood specimens. Among males, 77.7 % of those on ART reported having had sex in the past year contrasted with 88.4 % of those not on ART (p = 0.001); among females, 72.2 % of those on ART reported having had sex in the past year while 80.3 % of those not on ART did (p < 0.001). For males and females, the odds of reporting consistent condom use and condom use at last sex were statistically significantly higher for individuals on ART compared to those not on ART (males: consistent condom use aOR 2.8, 95 % CI 1.6-4.9, condom use at last sex aOR 2.6, 95 % CI 1.5-4.6; females: consistent condom use aOR 2.3, 95 % CI 1.7-3.1, condom use at last sex aOR 2.3, 95 % CI 1.7-3.1), while there were no statistically significant differences in odds of reporting multiple sexual partners in the past year. In this nationally representative population-based survey of South African adults, we found evidence of less risky sexual risk behavior among people living with HIV on ART compared to those not on ART.
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Affiliation(s)
- Kathryn Risher
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, W6604, Baltimore, MD, 20205, USA.
| | - Thomas Rehle
- Human Sciences Research Council, Cape Town, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Leickness Simbayi
- Human Sciences Research Council, Cape Town, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Olive Shisana
- Human Sciences Research Council, Cape Town, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - David D Celentano
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, W6604, Baltimore, MD, 20205, USA
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King R, Min J, Birungi J, Nyonyintono M, Muldoon KA, Khanakwa S, Kaleebu P, Moore DM. Effect of Couples Counselling on Reported HIV Risk Behaviour among HIV Serodiscordant Couples by ART Use, HIV Status and Gender in Rural Uganda. PLoS One 2015; 10:e0136531. [PMID: 26384103 PMCID: PMC4575207 DOI: 10.1371/journal.pone.0136531] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 08/04/2015] [Indexed: 12/31/2022] Open
Abstract
Background We examined several measures of self-reported HIV risk behaviour in mutually disclosed sero-discordant couples over time to see if a couples counselling intervention was associated with changes in these behaviors. Methods We analysed data from a prospective cohort study of HIV sero-discordant couples in Jinja, Uganda collected between June 2009 and December 2011. Participants received couples counselling, at 3-monthly intervals. We examined trends in reported condom-use, number of concurrent sexual partners, knowledge of HIV serostatus of concurrent partners and condom use of concurrent partners using Generalized Estimating Equation models, comparing responses at study enrollment with responses at six, 12 18 and 24 months of follow-up. Results A total of 586 couples were enrolled and the female member was HIV positive in 255 (44%) of them. The median age for female participants was 35 years and 42 years for men. Reported condom use at last sex with spouse increased over time (p<0.001) with the largest increases found among couples where the positive participant never received ART during the study(an increase from 68.8% at enrollment to 97.1% at 24 months). Male participants reported reductions in the number of concurrent sexual partners (p<0.001), increase in the knowledge of the HIV serostatus of these partners (p = 0.001) and a trend towards improved condom-use among non-primary partners (p = 0.070). Reported reduced risky behaviors did not wane over the study period. Conclusion Couples counselling resulted in increased condom use among all participants and among men the intervention resulted in reductions in risk behaviour with concurrent sexual partners. Routine counselling for serodiscordant couples should be integrated in routine ART care programs.
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Affiliation(s)
- Rachel King
- University of California San Francisco, Kampala, Uganda
- * E-mail:
| | - Jeong Min
- British Colombia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | | | | | - Katherine A. Muldoon
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | | | - Pontiano Kaleebu
- Uganda Virus Research Institute/ Medical Research Council Research Unit on AIDS, Entebbe, Uganda
| | - David M. Moore
- British Colombia Centre for Excellence in HIV/AIDS, Vancouver, Canada
- Faculty of Medicine, University of British Colombia, Vancouver, Canada
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Medley A, Bachanas P, Grillo M, Hasen N, Amanyeiwe U. Integrating prevention interventions for people living with HIV into care and treatment programs: a systematic review of the evidence. J Acquir Immune Defic Syndr 2015; 68 Suppl 3:S286-96. [PMID: 25768868 PMCID: PMC4666299 DOI: 10.1097/qai.0000000000000520] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION This review assesses the impact of prevention interventions for people living with HIV on HIV-related mortality, morbidity, retention in care, quality of life, and prevention of ongoing HIV transmission in resource-limited settings (RLSs). METHODS We conducted a systematic review of studies reporting the results of prevention interventions for people living with HIV in RLS published between January 2000 and August 2014. Standardized methods of searching and data abstraction were used. RESULTS Ninety-two studies met the eligibility criteria: 24 articles related to adherence counseling and support, 13 on risk reduction education and condom provision, 19 on partner HIV testing and counseling, 14 on provision of family planning services, and 22 on assessment and treatment of other sexually transmitted infections. Findings indicate good evidence that adherence counseling and sexually transmitted infection treatment can have a high impact on morbidity, whereas risk reduction education, partner HIV testing and counseling, and family planning counseling can prevent transmission of HIV. More limited evidence was found to support the impact of these interventions on retention in care and quality of life. Most studies did not report cost information, making it difficult to draw conclusions about the cost-effectiveness of these interventions. CONCLUSIONS This evidence suggests that these prevention interventions, if brought to sufficient scale and coverage, can help support and optimize the impact of core treatment and prevention interventions in RLS. Further operational research with more rigorous study designs, and ideally with biomarkers and costing information, is needed to determine the best model for providing these interventions in RLS.
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Affiliation(s)
- Amy Medley
- US Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Atlanta, GA
| | - Pamela Bachanas
- US Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Atlanta, GA
| | - Michael Grillo
- Naval Health Research Center, Department of Defense, HIV/AIDS Prevention Program, San Diego, CA
| | - Nina Hasen
- U.S. Department of State, Office of the US Global AIDS Coordinator and Health Diplomacy, Washington, DC
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Mullins TLK, Lally M, Zimet G, Kahn JA. Clinician attitudes toward CDC interim pre-exposure prophylaxis (PrEP) guidance and operationalizing PrEP for adolescents. AIDS Patient Care STDS 2015; 29:193-203. [PMID: 25692683 DOI: 10.1089/apc.2014.0273] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Prior to issuing formal HIV pre-exposure prophylaxis (PrEP) clinical practice guidelines in 2014, the US Centers for Disease Control and Prevention (CDC) had released interim guidance for oral PrEP use among adults. Because oral PrEP may be used off-label for youth and may soon be indicated for minor adolescents, we examined the potential adoption of the interim guidance among clinicians who care for HIV-infected and at-risk youth. Individual, semi-structured interviews were conducted with 15 US clinicians who were recruited through an adolescent HIV research network. The theory-driven interview guide, consisting primarily of open-ended questions, assessed demographics, familiarity with the guidance, attitudes toward the guidance, and attitudes toward the use of the guidance for adult and adolescent patients. Transcripts were analyzed using framework analysis. Most clinicians (11/15) reported that the guidance was compatible with their practice, although several reported that some aspects, particularly frequency of follow-up visits, needed to be tailored to meet their patients' needs. We found variability in clinician reported characteristics of appropriate PrEP candidates (e.g., youth with substance use and mental health issues were noted to be both suitable and unsuitable PrEP candidates) and PrEP use in serodiscordant couples (e.g., whether PrEP would be recommended to a patient whose HIV-infected partner is virally suppressed). Clinician reported steps for initiation, monitoring, and discontinuing PrEP were largely consistent with the guidance. The observed variability in clinician practice with regard to oral PrEP may be reduced through interventions to educate clinicians about the content and rationale for guideline recommendations.
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Affiliation(s)
- Tanya L. Kowalczyk Mullins
- Division of Adolescent and Transition Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Michelle Lally
- Division of Infectious Diseases, Department of Medicine, Lifespan Hospital System/Alpert Medical School of Brown University, Providence, Rhode Island
- Providence Veterans Affairs Medical Center, Providence, Rhode Island
| | - Gregory Zimet
- Division of Adolescent Medicine, Indiana University, Indianapolis, Indiana
| | - Jessica A. Kahn
- Division of Adolescent and Transition Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
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Del Romero J, Río I, Castilla J, Baza B, Paredes V, Vera M, Rodríguez C. Absence of transmission from HIV-infected individuals with HAART to their heterosexual serodiscordant partners. Enferm Infecc Microbiol Clin 2014; 33:666-72. [PMID: 25555636 DOI: 10.1016/j.eimc.2014.10.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 09/10/2014] [Accepted: 10/30/2014] [Indexed: 01/27/2023]
Abstract
BACKGROUND Further studies are needed to evaluate the level of effectiveness and durability of HAART to reduce the risk of HIV sexual transmission in serodiscordant couples having unprotected sexual practices. METHODS A cross-sectional study was conducted with prospective cohort of heterosexual HIV serodiscordant couples where the only risk factor for HIV transmission to the uninfected partner (sexual partner) was the sexual relationship with the infected partner (index case). HIV prevalence in sexual partners at enrolment and seroconversions in follow-up were compared by antiretroviral treatment in the index partner, HIV plasma viral load in index cases and sexual risk exposures in sexual partners. In each visit, an evaluation of the risks for HIV transmission, preventive counselling and screening for genitourinary infections in the sexual partner was performed, as well as the determination of the immunological and virological situation and antiretroviral treatment in the index case. RESULTS At enrolment no HIV infection was detected in 202 couples where the index case was taking HAART. HIV prevalence in sexual partners was 9.6% in 491 couples where the index case was not taking antiretroviral treatment (p<0.001). During follow-up there was no HIV seroconversion among 199 partners whose index case was taking HAART, accruing 7600 risky sexual exposures and 85 natural pregnancies. Among 359 couples whose index case was not under antiretroviral treatment, over 13,000 risky sexual exposures and 5 HIV seroconversions of sexual partners were recorded. The percentage of seroconversion among couples having risky sexual intercourse was 2.5 (95% confidence interval [CI]: 1.1-5.6) when the index case did not undergo antiretroviral treatment and zero (95% CI: 0-3.2) when the index case received HAART. CONCLUSIONS The risk of sexual transmission of HIV from individuals with HAART to their heterosexual partners can become extremely low.
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Affiliation(s)
- Jorge Del Romero
- Centro Sanitario Sandoval, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain.
| | - Isabel Río
- CIBER de Epidemiología y Salud Pública (CIBERESP), Spain; Centro Nacional de Epidemiología, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Jesús Castilla
- Instituto de Salud Pública de Navarra, Pamplona, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Spain
| | - Begoña Baza
- Centro Sanitario Sandoval, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
| | - Vanessa Paredes
- Centro Nacional de Epidemiología, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Mar Vera
- Centro Sanitario Sandoval, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
| | - Carmen Rodríguez
- Centro Sanitario Sandoval, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
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Kenyon CR, Osbak K, Buyze J, Johnson S, van Lankveld J. Variations of Sexual Scripts Relating to Concurrency by Race, Class, and Gender in South Africa. JOURNAL OF SEX RESEARCH 2014; 52:878-886. [PMID: 25349886 DOI: 10.1080/00224499.2014.963832] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
It is unclear whether higher rates of sexual partner concurrency in Black South Africans are due to socioeconomic or cultural factors. We used a nationally representative sample of 9,728 individuals aged 16 to 55 from a study conducted in 2009 to examine how the norms pertaining to concurrency and the practice of concurrency vary by race, class, and gender. The percentage of men reporting point concurrency was 14%, 6.5%, and 2.5% in Blacks, coloreds, and Whites, respectively (p < 0.001). These percentages increased to 45.7%, 24.7%, and 11.7%, respectively, for those reporting lifetime concurrency (p < 0.001). In all the racial groups, men exhibited more favorable attitudes toward concurrency than women did. For a range of indicators, White men and women had less favorable attitudes toward concurrency than Black men and women. These differences remained after controlling for a range of confounding variables. In the adjusted logistic regression model, reported concurrency in men was associated with a younger age, Black race, being in the lowest income tertile, not being in a stable relationship, and expressing various positive attitudes toward concurrency.
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Affiliation(s)
| | - Kara Osbak
- a HIV/STI Unit, Institute of Tropical Medicine
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Doyle JS, Degenhardt L, Pedrana AE, McBryde ES, Guy RJ, Stoové MA, Weaver ER, Grulich AE, Lo YR, Hellard ME. Effects of HIV antiretroviral therapy on sexual and injecting risk-taking behavior: a systematic review and meta-analysis. Clin Infect Dis 2014; 59:1483-94. [PMID: 25091305 DOI: 10.1093/cid/ciu602] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Increased global access and use of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) has been postulated to undermine HIV prevention efforts by changing individual risk-taking behavior. This review aims to determine whether ART use is associated with changes in sexual or injecting risk-taking behavior or diagnosis of sexually transmitted infections (STIs). METHODS A systematic review and meta-analysis was conducted of HIV-seropositive participants receiving ART compared with no ART use in experimental or observational studies. Primary outcomes included (1) any unprotected sexual intercourse, (2) STI diagnoses, and (3) any unsafe injecting behavior. RESULTS Fifty-eight studies met the selection criteria. Fifty-six studies containing 32 857 participants reported unprotected sex; 11 studies containing 16 138 participants reported STI diagnoses; and 4 studies containing 1600 participants reported unsafe injecting behavior. All included studies were observational. Unprotected sex was lower in participants receiving ART than in those not receiving ART (odds ratio [OR], 0.73; 95% confidence interval [CI], .64-.83; P < .001; heterogeneity I(2) = 79%) in both high-income (n = 38) and low-/middle-income country (n = 18) settings, without any evidence of publication bias. STI diagnoses were also lower among individuals on ART (OR, 0.58; 95% CI, .33-1.01; P = .053; I(2) = 92%); however, there was no difference in injecting risk-taking behavior with antiretroviral use (OR, 0.90; 95% CI, .60-1.35; P = .6; I(2) = 0%). CONCLUSIONS Despite concerns that use of ART might increase sexual or injecting risk-taking, available research suggests that unprotected sex is reduced among HIV-infected individuals on treatment. The reasons for this are not yet clear, although self-selection and mutually reinforcing effects of HIV treatment and prevention messages among people on ART are likely.
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Affiliation(s)
- Joseph S Doyle
- Centre for Population Health, Burnet Institute Department of Infectious Diseases, The Alfred Hospital Department of Epidemiology and Preventative Medicine, Monash University
| | - Louisa Degenhardt
- Centre for Health Policy, Programs and Economics, School of Population Health, University of Melbourne, Victoria National Drug and Alcohol Research Centre, University of New South Wales, Sydney
| | - Alisa E Pedrana
- Centre for Population Health, Burnet Institute Department of Epidemiology and Preventative Medicine, Monash University
| | - Emma S McBryde
- Centre for Population Health, Burnet Institute Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Victoria
| | - Rebecca J Guy
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Mark A Stoové
- Centre for Population Health, Burnet Institute Department of Epidemiology and Preventative Medicine, Monash University
| | | | - Andrew E Grulich
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Ying-Ru Lo
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Margaret E Hellard
- Centre for Population Health, Burnet Institute Department of Infectious Diseases, The Alfred Hospital Department of Epidemiology and Preventative Medicine, Monash University
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Yaya I, Saka B, Landoh DE, Patchali PM, Makawa MS, Senanou S, Idrissou D, Lamboni B, Pitche P. Sexual risk behavior among people living with HIV and AIDS on antiretroviral therapy at the regional hospital of Sokodé, Togo. BMC Public Health 2014; 14:636. [PMID: 24952380 PMCID: PMC4078095 DOI: 10.1186/1471-2458-14-636] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 06/19/2014] [Indexed: 11/12/2022] Open
Abstract
Background Several studies on the sexual risk behaviors in sub-Saharan Africa have reported that the initiation of antiretroviral therapy leads to safer sexual behaviors. There is however a persistence of risky sexual behavior which is evidenced by a high prevalence of sexually transmitted infections among people living with HIV and AIDS (PLWHA). We sought to determine the factors associated with risky sex among PLWHA on antiretroviral therapy in Togo. Methods An analytical cross-sectional survey was conducted from May to July 2013 at regional hospital of Sokodé, Togo, and targeted 291 PLWHA on antiretroviral therapy for at least three months. Results From May to July 2013, 291 PLWHA on antiretroviral treatment were surveyed. The mean age of PLWHA was 37.3 years and the sex ratio (male/female) was 0.4. Overall, 217 (74.6%) PLWHA were sexually active since initiation of antiretroviral treatment, of which, 74 (34.6%) had risky sexual relations. In multivariate analysis, the factors associated with risky sex were: the duration of antiretroviral treatment (1 to 3 years: aOR = 27.08; p = 0.003; more than 3 years: aOR = 10.87; p = 0.028), adherence of antiretroviral therapy (aOR = 2.56; p = 0.014), alcohol consumption before sex (aOR = 3.59; p = 0.013) and level of education (primary school: aOR = 0.34 p = 0.011; secondary school: aOR = 0.23 p = 0.003; high school: aOR = 0.10; p = 0.006). Conclusion There was a high prevalence of unsafe sex among PLWHA receiving ART at the hospital of Sokodé. Factors associated with sexual risk behaviors were: low education level, non-adherence to ART, alcohol consumption before sex and the duration of ART. It is important to strengthen the implementation of secondary prevention strategies among this population group.
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Supervie V, Viard JP, Costagliola D, Breban R. Heterosexual risk of HIV transmission per sexual act under combined antiretroviral therapy: systematic review and bayesian modeling. Clin Infect Dis 2014; 59:115-22. [PMID: 24723286 DOI: 10.1093/cid/ciu223] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Although essential for patient counseling and quality of life of human immunodeficiency virus (HIV)-infected individuals, the risk of HIV transmission during 1 unprotected sex act with an HIV-infected person under combination antiretroviral therapy (cART) remains unknown. METHODS We reviewed systematically the literature for studies on HIV transmission among heterosexual HIV-serodiscordant couples, where the infected partner was on cART, with regular virological monitoring, reporting on condom use and sexual activity. We used Bayesian statistics to combine data from selected studies, to investigate the per-act risk of HIV transmission through unprotected sex with an HIV-infected person on cART for >6 months. RESULTS At most, 1 HIV transmission, over an estimated 113 480 sex acts, of which 17% were not condom protected, was reported within 1672 HIV-serodiscordant couples where the index partner had been treated for >6 months. Data were insufficient to determine whether the reported transmission occurred before or after 6 months of cART. We estimated the upper-bound per-act risk of HIV transmission at either 8.7 or 13:100 000, depending on whether the transmission occurred before or after 6 months of cART. These estimates applied whether or not index partners were virally suppressed. Estimating an upper-bound risk <1:100 000 would require observing no HIV transmission while collecting >12 times the available amount of data. CONCLUSIONS Available data do not support zero risk of HIV transmission under cART. The per-act risk of HIV transmission through unprotected sex with HIV-infected individuals on cART in comprehensive care for >6 months (whether or not virally suppressed) is <13:100 000. Estimating a 10-fold lower upper-bound risk may be unfeasible due to high condom use among HIV-serodiscordant couples in most research studies.
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Affiliation(s)
- Virginie Supervie
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136 Pierre Louis Institute of Epidemiology and Public Health INSERM, UMR_S 1136 Pierre Louis Institute of Epidemiology and Public Health
| | - Jean-Paul Viard
- Sorbonne Paris Cité, Faculté de Médecine, Université Paris Descartes, EA7327 APHP, Centre de Diagnostic et de Thérapeutique, Hôpital de l'Hôtel-Dieu
| | - Dominique Costagliola
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136 Pierre Louis Institute of Epidemiology and Public Health INSERM, UMR_S 1136 Pierre Louis Institute of Epidemiology and Public Health
| | - Romulus Breban
- Unité d'Epidémiologie des Maladies Emergentes, Institut Pasteur, Paris, France
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Meriki HD, Tufon KA, Afegenwi MH, Nyindem BA, Atanga PN, Anong DN, Cho-Ngwa F, Nkuo-Akenji T. Immuno-haematologic and virologic responses and predictors of virologic failure in HIV-1 infected adults on first-line antiretroviral therapy in Cameroon. Infect Dis Poverty 2014; 3:5. [PMID: 24479873 PMCID: PMC3922096 DOI: 10.1186/2049-9957-3-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 01/27/2014] [Indexed: 11/10/2022] Open
Abstract
Background Contemporary data on the immunologic, haematologic and virologic responses and predictors of virologic failure after initiation of free antiretroviral treatment in Cameroon are needed to evaluate the current treatment-monitoring algorithm and to complement efforts to scale-up and improve on the management of HIV infections. Methods This was a cross-sectional study conducted between October 2010 and June 2012. A total of 951 participants aged 18–74 years were recruited from selected approved HIV treatment centres of the Northwest and Southwest regions. This comprised 247 males and 704 females. Demographic, self-reported risk behaviours and socioeconomic data were obtained using a structured questionnaire. Full blood and CD4 + T-cell counts were done using standard automated techniques. Determination of viral load (VL) was done using Abbott RealTime HIV-1 m2000™ system. Data was analysed using SPSS version 17. The statistical significance level was P < 0.05. Results The median duration of antiretroviral therapy (ART) was 24 months. The population mean CD4 + T-cell count was 255.3 cells/μL [95% CI, 236.8 – 273.9]. Overall, 45.9%, 43.8% and 10.2% of the participants had CD4 + T-cell counts of < 200 cells/μL, 200–499 cells/μL and > 500 cells/μL respectively. Anaemia was present in 26.2% of the participants with 62.3%, 25.7% and 12% described as mild, moderate and severe anaemia respectively. Virologic failure occurred in 23.2% of the participants with 12.3% having VL > 10,000 RNA copies/mL. Meanwhile 76.8% of patients attained adequate viral suppression with 40.8% having undetectable viral load. The age group 18–29 years (p = 0.024), co-infection with tuberculosis (p = 0.014), anaemia (p = 0.028) and distance from the treatment centre (p = 0.011) independently predicted virologic failure. Conclusion The majority of the participants achieved adequate viral suppression after ≥ 6 months of ART. Despite these favourable immuno-haematologic and virologic outcomes, the National AIDS Control Program should step-up efforts to improve on antiretroviral drug distribution, as well as proper assessment and management of anaemia, foster early diagnosis and treatment of tuberculosis and enhance treatment adherence counselling especially in younger patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Theresa Nkuo-Akenji
- Department of Microbiology and Parasitology, University of Buea, P,O, Box 63, Buea, Cameroon.
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Martin F, Kiwanuka T, Kawuma R, Zalwango F, Seeley J. Tasks and strategies of self-management of living with antiretroviral therapy in Uganda. AIDS Patient Care STDS 2013; 27:697-706. [PMID: 24219780 DOI: 10.1089/apc.2013.0254] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
There is increasing interest in promoting and supporting self-management of HIV and antiretroviral treatment (ART), including in resource-limited settings. Although the impact of HIV and ART on people in Uganda has been explored, little attention has been paid to how people self-manage. This qualitative study collected data from 20 participants on ART in Wakiso district, Uganda, using in-depth interviews, life histories, and observations to explore the tasks and strategies of living with ART. The identified strategies were compared to two existing self-management frameworks. Results highlighted a range of tasks including obtaining, taking, and adhering to ART medication, monitoring their condition, living with stigma and managing disclosure, maintaining general health, and adjusting to new roles. Participants described a range of strategies or behaviors to manage, which they actively created and used, tailored to their needs and environment. Comparison with existing frameworks revealed many similarities, with some local differences in enactment, and greater emphasis in our sample on obtaining the medication. Interventions to support people with self-management in Uganda, and possibly other resource-limited settings, require careful adaptation to local settings. The degree to which each of these strategies may improve health and quality of life requires further investigation.
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Affiliation(s)
- Faith Martin
- School of International Development, University of East Anglia, Norwich Research Park, Norwich, United Kingdom
| | - Thadeus Kiwanuka
- Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda
| | - Rachel Kawuma
- Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda
| | - Flavia Zalwango
- Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda
| | - Janet Seeley
- School of International Development, University of East Anglia, Norwich Research Park, Norwich, United Kingdom
- Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda
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Cambiano V, O'Connor J, Phillips AN, Rodger A, Lodwick R, Pharris A, Lampe F, Nakagawa F, Smith C, van de Laar MJ. Antiretroviral therapy for prevention of HIV transmission: implications for Europe. ACTA ACUST UNITED AC 2013; 18:20647. [PMID: 24308982 DOI: 10.2807/1560-7917.es2013.18.48.20647] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The aim of this review is to summarise the evidence on the population-level effect of antiretroviral therapy (ART) in preventing HIV infections, and to discuss potential implications in the European context of recommending starting ART when the CD4 count is above 350 cells/mm3. The ability of ART to reduce the risk of HIV transmission has been reported in observational studies and in a randomised controlled trial (HPTN 052), in which ART initiation reduced HIV transmission by 96% within serodiscordant couples. As yet, there is no direct evidence for such an effect among men having sex with men or people who inject drugs. HPTN 052 led international organisations to develop recommendations with a higher CD4 threshold for ART initiation. However, there remains a lack of strong evidence of clinical benefit for HIV-positive individuals starting ART with CD4 count above 350 cells/mm3. The main goal of ART provision should be to increase ART coverage for all those in need, based on the current guidelines, and the offer of ART to those who wish to reduce infectivity; increased HIV testing is therefore a key requirement. Other proven prevention means such as condom use and harm reduction for people who inject drugs remain critical.
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Affiliation(s)
- V Cambiano
- Research Department of Infection and Population Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
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Jean K, Gabillard D, Moh R, Danel C, Fassassi R, Desgrées-du-Loû A, Eholié S, Lert F, Anglaret X, Dray-Spira R. Effect of early antiretroviral therapy on sexual behaviors and HIV-1 transmission risk among adults with diverse heterosexual partnership statuses in Côte d'Ivoire. J Infect Dis 2013; 209:431-40. [PMID: 23990567 PMCID: PMC3883172 DOI: 10.1093/infdis/jit470] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background. The effect of early initiation of antiretroviral therapy (ART; ie, at CD4+ T-cell counts >350 cells/mm3) on sexual behaviors and human immunodeficiency virus type 1 (HIV) transmission risk has not been documented in populations other than HIV-serodiscordant couples in stable relationships. Methods. On the basis of data from a behavioral study nested in a randomized, controlled trial (Temprano-ANRS12136) of early ART, we compared proportions of risky sex (ie, unprotected sex with a partner of negative/unknown HIV status) reported 12 months after inclusion between participants randomly assigned to initiate ART immediately (hereafter, “early ART”) or according to ongoing World Health Organization criteria. Group-specific HIV transmission rates were estimated on the basis of sexual behaviors and viral load–specific per-act HIV transmission probabilities. The ratio of transmission rates was computed to estimate the protective effect of early ART. Results. Among 957 participants (baseline median CD4+ T-cell count, 478 cells/mm3), 46.0% reported sexual activity in the past month; of these 46.0%, sexual activity for 41.5% involved noncohabiting partners. The proportion of subjects who engaged in risky sex was 10.0% in the early ART group, compared with 12.8% in the standard ART group (P = .17). After accounting for sexual behaviors and viral load, we estimated that the protective effect of early ART was 90% (95% confidence interval, 81%–95%). Conclusion. Twelve months after inclusion, patients in the early and standard ART groups reported similar sexual behaviors. Early ART decreased the estimated risk of HIV transmission by 90%, suggesting a major prevention benefit among seronegative sex partners in stable or casual relationships with seropositive individuals.
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Affiliation(s)
- Kévin Jean
- Epidemiology of Occupational and Social Determinants of Health, Center for Research in Epidemiology and Population Health, INSERM U1018
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Man WYN, Kelly A, Worth H, Frankland A, Shih P, Kupul M, Lwin T, Mek A, Kepa B, Emori R, Akuani F, Cangah B, Walizopa L, Pirpir L, Nosi S, Siba PM. Sexual risk behaviour, marriage and ART: a study of HIV-positive people in Papua New Guinea. AIDS Res Ther 2013; 10:17. [PMID: 23805823 PMCID: PMC3699368 DOI: 10.1186/1742-6405-10-17] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 06/19/2013] [Indexed: 11/19/2022] Open
Abstract
Background The prevention of intimate partner transmission of HIV remains an important component of comprehensive HIV prevention strategies. In this paper we examine the sexual practices of people living with HIV on antiretroviral therapy (ART) in Papua New Guinea (PNG). Method In 2008, a total of 374 HIV-positive people over the age of 16 and on ART for more than two weeks were recruited using a non-probability, convenience sampling methodology. This accounted for around 18% of adults on ART at the time. A further 36 people participated in semi-structured interviews. All interviews were thematically analysed using NVivo qualitative data analysis software. Results Less than forty per cent (38%) of participants reported having had sexual intercourse in the six months prior to the survey. Marital status was by far the most important factor in determining sexual activity, but consistent condom use during vaginal intercourse with a regular partner was low. Only 46% reported consistent condom use during vaginal intercourse with a regular partner in the last six months, despite 77% of all participants reporting that consistent condom use can prevent HIV transmission. Consistent condom use was lowest amongst married couples and those in seroconcordant relationships. The vast majority (91.8%) of all participants with a regular heterosexual partner had disclosed their status to their partner. Qualitative data reinforced low rates of sexual activity and provided important insights into sexual abstinence and condom use. Conclusions Considering the importance of intimate partner transmission of HIV, these results on the sexual practices of people with HIV on ART in PNG suggest that one-dimensional HIV prevention messages focussing solely on condom use fail to account for the current practices and needs of HIV-positive people, especially those who are married and know their partners’ HIV status.
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Bajunirwe F, Bangsberg DR, Sethi AK. Alcohol use and HIV serostatus of partner predict high-risk sexual behavior among patients receiving antiretroviral therapy in South Western Uganda. BMC Public Health 2013; 13:430. [PMID: 23641795 PMCID: PMC3645971 DOI: 10.1186/1471-2458-13-430] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 04/08/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antiretroviral treatment restores the physical and immunological function for patients with HIV/AIDS and the return of sexual desire. The frequency and correlates of sexual activity among patients receiving ART have not been widely studied. There is concern that widespread availability of ART may result in sexual disinhibition including practice of high-risk sexual behavior. We determined the correlates of sexual activity and high-risk sexual behavior in an ART-treated population in rural and urban Uganda. METHODS We conducted a cross-sectional study among 329 ART-treated adult patients at two hospitals, one located in rural and another in urban western Uganda. We collected data on sexual activity, frequency of condom use, pregnancy, viral load (VL) and CD4. Patients were considered sexually active if they had had sexual intercourse in the last 6 months. Any unprotected sex was considered high-risk sex. A two-stage logistic regression was performed to determine factors associated with sexual activity and high-risk sex among those sexually active. RESULTS Overall, 222 (67%) patients were women, 138 (41.2%) had been on ART for at least one year, and 168 (51.4%) were sexually active of whom 127 (75.6%) used condoms at the last intercourse. Younger age (<=30 years) (Odds ratio; OR=2.3, 95% CI 1.2, 4.2), higher monthly income (OR=4.1, 95% CI 2.4, 7.4), and being married (OR=22.7, 95% CI 8.2, 62.9) were associated with being sexually active. Undetectable VL, CD4 count and treatment duration were not significantly associated with sexual activity. Among the sexually active, alcohol consumption (OR=3.3, 95% CI 1.2, 9.1) and unknown serostatus of partner (OR=5.8, 95% CI 1.5, 21.4) were significant predictors of high-risk sexual behavior. The frequency of unprotected sex at the last intercourse was 25.9% and 22.1% among the men and women respectively and was not significantly different (p value for chi square test =0.59). CONCLUSION Younger persons receiving ART are more likely to be sexually active. ART clients are more likely to engage in unprotected sex when sero-status of partner is unknown or report use of alcohol. Counseling on alcohol use and disclosure of sero-status may be useful in reducing high risk sexual behavior.
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Affiliation(s)
- Francis Bajunirwe
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda.
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Ndziessi G, Cohen J, Kouanfack C, Marcellin F, Carierri MP, Laborde-Balen G, Protopopescu C, Aghokeng AF, Moatti JP, Spire B, Delaporte E, Laurent C, Boyer S. Susceptibility to transmitting HIV in patients initiating antiretroviral therapy in rural district hospitals in Cameroon (Stratall ANRS 12110/ESTHER Trial). PLoS One 2013; 8:e62611. [PMID: 23638126 PMCID: PMC3640048 DOI: 10.1371/journal.pone.0062611] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 03/26/2013] [Indexed: 11/18/2022] Open
Abstract
Objectives Using cohort data nested in a randomized trial conducted in Cameroon, this study aimed to investigate time trends and predictors of the susceptibility to transmitting HIV during the first 24 months of treatment. Methods The outcome, susceptibility to transmitting HIV, was defined as reporting inconsistent condom use and experiencing incomplete virological suppression. Mixed logistic regressions were performed to identify predictors of this outcome among 250 patients reporting to have had sexual relationships either with HIV-negative or unknown HIV status partner(s). Results Despite an initial decrease from 76% at M0 to 50% at M6, the rate of inconsistent condom use significantly increased from M12 (59%) to M24 (66%) (p = 0.017). However, the proportion of patients susceptible to transmitting HIV significantly decreased over follow-up from 76% at M0, to 50% at M6, 31% at M12 and 27% at M24 (p<0.001). After controlling for age, gender and intervention group, we found that perceiving healthcare staff’s readiness to listen as poor (adjusted odds ratios (AOR) [95% Confidence Interval (CI)] = 1.87 [1.01–3.46]), reporting to have sexual relationships more than once per week (AOR [95%CI] = 2.52 [1.29–4.93]), having more than one sexual partner (AOR [95%CI] = 2.53 [1.21–5.30]) and desiring a/another child (AOR [95%CI] = 2.07 [1.10–3.87]) were all associated with a higher risk of being susceptible to transmitting HIV. Conversely, time since ART initiation (AOR [95%CI] = 0.66 [0.53–0.83] for an extra 6 months and ART adherence (AOR [95%CI] = 0.33 [0.15–0.72]) were significantly associated with a lower risk of being susceptible to transmitting HIV. Conclusions The decrease observed in the susceptibility to transmitting HIV suggests that fear of behavioural disinhibition should not be a barrier to universal access to ART. However, developing adequate preventive interventions matching patients’ expectations -like the desire to have children- and strengthening healthcare staff’s counselling skills are urgently needed to maximize the impact of ART in slowing the HIV epidemic.
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Affiliation(s)
- Gilbert Ndziessi
- INSERM, UMR912 (SESSTIM), Marseille, France
- Aix Marseille Université, UMR_S912, IRD, Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - Julien Cohen
- INSERM, UMR912 (SESSTIM), Marseille, France
- Aix Marseille Université, UMR_S912, IRD, Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
| | | | - Fabienne Marcellin
- INSERM, UMR912 (SESSTIM), Marseille, France
- Aix Marseille Université, UMR_S912, IRD, Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - Maria Patrizia Carierri
- INSERM, UMR912 (SESSTIM), Marseille, France
- Aix Marseille Université, UMR_S912, IRD, Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
| | | | - Camélia Protopopescu
- INSERM, UMR912 (SESSTIM), Marseille, France
- Aix Marseille Université, UMR_S912, IRD, Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - Avelin Fobang Aghokeng
- Institut de Recherche pour le Développement (IRD), University Montpellier 1, UMI 233, Montpellier, France
- Virology laboratory IRD/IMPM/CREMER, Yaoundé, Cameroon
| | - Jean-Paul Moatti
- INSERM, UMR912 (SESSTIM), Marseille, France
- Aix Marseille Université, UMR_S912, IRD, Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - Bruno Spire
- INSERM, UMR912 (SESSTIM), Marseille, France
- Aix Marseille Université, UMR_S912, IRD, Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - Eric Delaporte
- Institut de Recherche pour le Développement (IRD), University Montpellier 1, UMI 233, Montpellier, France
- Department of Infectious and Tropical Diseases, University Hospital, Montpellier, France
| | - Christian Laurent
- Institut de Recherche pour le Développement (IRD), University Montpellier 1, UMI 233, Montpellier, France
| | - Sylvie Boyer
- INSERM, UMR912 (SESSTIM), Marseille, France
- Aix Marseille Université, UMR_S912, IRD, Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
- * E-mail:
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Ndziessi G, Cohen J, Kouanfack C, Boyer S, Moatti JP, Marcellin F, Laurent C, Spire B, Delaporte E, Carrieri MP, for ANRS 12110/ESTHER Study Group. Changes in sexual activity and risk behaviors among PLWHA initiating ART in rural district hospitals in Cameroon – Data from the STRATALL ANRS 12110/ESTHER trial. AIDS Care 2013. [DOI: 10.1080/09540121.2012.701717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Gilbert Ndziessi
- a INSERM, U912 (SESSTIM) , Marseille , France
- b Aix Marseille Université, IRD, UMR-S912 , Marseille , France
- c Observatoire Régional de la Santé Provence Alpes Côte d'Azur (ORS PACA) , Marseille , France
| | - Julien Cohen
- a INSERM, U912 (SESSTIM) , Marseille , France
- b Aix Marseille Université, IRD, UMR-S912 , Marseille , France
- c Observatoire Régional de la Santé Provence Alpes Côte d'Azur (ORS PACA) , Marseille , France
| | | | - Sylvie Boyer
- a INSERM, U912 (SESSTIM) , Marseille , France
- b Aix Marseille Université, IRD, UMR-S912 , Marseille , France
- c Observatoire Régional de la Santé Provence Alpes Côte d'Azur (ORS PACA) , Marseille , France
| | - Jean-Paul Moatti
- a INSERM, U912 (SESSTIM) , Marseille , France
- b Aix Marseille Université, IRD, UMR-S912 , Marseille , France
- c Observatoire Régional de la Santé Provence Alpes Côte d'Azur (ORS PACA) , Marseille , France
| | - Fabienne Marcellin
- a INSERM, U912 (SESSTIM) , Marseille , France
- b Aix Marseille Université, IRD, UMR-S912 , Marseille , France
- c Observatoire Régional de la Santé Provence Alpes Côte d'Azur (ORS PACA) , Marseille , France
| | - Christian Laurent
- e Institut de Recherche pour le Développement (IRD), University Montpellier 1 , Montpellier , France
| | - Bruno Spire
- a INSERM, U912 (SESSTIM) , Marseille , France
- b Aix Marseille Université, IRD, UMR-S912 , Marseille , France
- c Observatoire Régional de la Santé Provence Alpes Côte d'Azur (ORS PACA) , Marseille , France
| | - Eric Delaporte
- e Institut de Recherche pour le Développement (IRD), University Montpellier 1 , Montpellier , France
- f Department of Infectious and Tropical Diseases , University Hospital , Montpellier , France
| | - Maria Patrizia Carrieri
- a INSERM, U912 (SESSTIM) , Marseille , France
- b Aix Marseille Université, IRD, UMR-S912 , Marseille , France
- c Observatoire Régional de la Santé Provence Alpes Côte d'Azur (ORS PACA) , Marseille , France
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Loutfy MR, Wu W, Letchumanan M, Bondy L, Antoniou T, Margolese S, Zhang Y, Rueda S, McGee F, Peck R, Binder L, Allard P, Rourke SB, Rochon PA. Systematic review of HIV transmission between heterosexual serodiscordant couples where the HIV-positive partner is fully suppressed on antiretroviral therapy. PLoS One 2013; 8:e55747. [PMID: 23418455 PMCID: PMC3572113 DOI: 10.1371/journal.pone.0055747] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 12/31/2012] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The risk of sexual HIV transmission in serodiscordant couples when the HIV-positive partner has full virologic suppression on combination antiretroviral therapy (cART) is debated. This study aims to systematically review observational studies and randomized controlled trials (RCTs), evaluating rates of sexual HIV transmission between heterosexual serodiscordant couples when the HIV-positive partner has full suppression on cART. METHODS AND FINDINGS We searched major bibliographic databases to November 2012 for relevant observational studies and RCTs without language restrictions. Conference proceedings, key journals and bibliographies were also searched. Studies reporting HIV transmission rates, cART histories and viral loads of the HIV-positive partners were included. Two reviewers extracted methodologic characteristics and outcomes. Of 20,252 citations, 3 studies met all eligibility criteria with confirmed full virologic suppression in the HIV-positive partner. We included 3 additional studies (2 cohort studies, 1 RCT) that did not confirm viral suppression in the HIV-positive partner at transmission in a secondary meta-analysis. Methodologic quality was reasonable. The rate of transmission in the 3 studies confirming virologic suppression was 0 per 100 person-years (95% CI = 0-0.05), with low heterogeneity (I(2) = 0%). When we included the 3 studies that did not confirm virologic suppression, the rate of transmission was 0.14 per 100 person-years (95%CI = 0.04-0.31) (I(2) = 0%). In a sensitivity analysis including all 6 studies, the rate of transmission was 0 per 100 person-years (95%CI = 0-0.01) after omitting all transmissions with known detectable or unconfirmed viral loads, as full suppression in these cases was unlikely. Limitations included lack of data on same-sex couples, type of sexual intercourse (vaginal vs. anal), direction of HIV transmission, exact viral load at the time of transmission, sexually transmitted infections (STI) rates, and extent of condom use. CONCLUSIONS Our findings suggest minimal risk of sexual HIV transmission for heterosexual serodiscordant couples when the HIV-positive partner has full viral suppression on cART with caveats regarding information on sexual intercourse type, STIs, and condom use. These findings have implications when counseling heterosexual serodiscordant couples on sexual and reproductive health. More research is needed to explore HIV transmission risk between same-sex couples.
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Affiliation(s)
- Mona R Loutfy
- Women's College Research Institute, Women's College Hospital, University of Toronto, Toronto, Canada.
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Home-Based HIV Testing and Counseling in Rural and Urban Kenyan Communities. J Acquir Immune Defic Syndr 2013; 62:e47-54. [DOI: 10.1097/qai.0b013e318276bea0] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Baggaley RF, White RG, Hollingsworth TD, Boily MC. Heterosexual HIV-1 infectiousness and antiretroviral use: systematic review of prospective studies of discordant couples. Epidemiology 2013; 24:110-21. [PMID: 23222513 PMCID: PMC4312663 DOI: 10.1097/ede.0b013e318276cad7] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Recent studies have estimated the reduction in HIV-1 infectiousness with antiretroviral therapy (ART), but high-quality studies such as randomized controlled trials, accompanied by rigorous adherence counseling, are likely to overestimate the effectiveness of treatment-as-prevention in real-life settings. METHODS We attempted to summarize the effect of ART on HIV transmission by undertaking a systematic review and meta-analysis of HIV-1 infectiousness per heterosexual partnership (incidence rate and cumulative incidence over study follow-up) estimated from prospective studies of discordant couples. We used random-effects Poisson regression models to obtain summary estimates. When possible, the analyses were further stratified by direction of transmission (man-to-woman or woman-to-man) and economic setting (high- or low-income countries). Potential causes of heterogeneity of estimates were explored through subgroup analyses. RESULTS Fifty publications were included. Nine allowed comparison between ART and non-ART users within studies (ART-stratified studies), in which summary incidence rates were 3.6/100 person-years (95% confidence interval = 2.0-6.5) and 0.2/100 person-years (0.07-0.7) for non-ART- and ART-using couples, respectively (P < 0.001), constituting a 91% (79-96%) reduction in per-partner HIV-1 incidence rate with ART use. The 41 studies that did not stratify by ART use provided estimates with high levels of heterogeneity (I statistic) and few reported levels of ART use, making interpretation difficult. Nevertheless, estimates tended to be lower with ART use. Infectiousness tended to be higher for low-income than high-income settings, but there was no clear pattern by direction of transmission (man-to-woman and woman-to-man). CONCLUSIONS ART substantially reduces HIV-1 infectiousness within discordant couples, based on observational studies, and could play a major part in HIV-1 prevention efforts. However, the non-zero risk from partners receiving ART demonstrates that appropriate counseling and other risk-reduction strategies for discordant couples are still required. Additional estimates of ART effectiveness by adherence level from real-life settings will be important, especially for persons starting treatment early without symptoms.
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Affiliation(s)
- Rebecca F Baggaley
- Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College London, United Kingdom.
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Yeatman S, Dovel K, Conroy A, Namadingo H. HIV treatment optimism and its predictors among young adults in southern Malawi. AIDS Care 2012; 25:1018-25. [PMID: 23227888 DOI: 10.1080/09540121.2012.748168] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This study measures HIV treatment optimism and its predictors in a representative sample of young adults in southern Malawi. In 2010, 1275 women and 470 men between the ages of 16 and 26 were asked about their exposure to people on antiretroviral therapy (ART), sexual risk behavior, HIV status, and beliefs about ART. We used confirmatory factor analysis to develop a 4-item scale of the belief that HIV is a less serious health threat due to ART (reduced-severity optimism) and used a single measure to capture belief in the reduced infectivity of HIV due to ART (reduced-susceptibility optimism). Overall, respondents reported low levels of HIV treatment optimism. Being female and using ART were the largest predictors of both types of treatment optimism. We found a nonlinear relationship between exposure to people on ART and reduced-severity optimism. People who knew someone on ART but did not discuss it with them had lower levels of reduced-severity optimism than people who did not know anyone on ART and people who regularly discussed treatment with someone on ART. In multivariate regression models, HIV treatment optimism was positively associated with all measures of sexual risk behavior among men, but negatively associated with unprotected sex with a nonprimary partner among women. Our findings suggest that the spread of ART in Malawi has not led to widespread HIV treatment optimism. This may reflect the relatively recent spread of ART, the generalized nature of the HIV epidemic, or the fact that access to ART is complicated by structural limitations that delay treatment and limited availability of second-line medicines.
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Affiliation(s)
- Sara Yeatman
- Department of Health and Behavioral Sciences, University of Colorado Denver Campus, CO, USA.
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King R, Wamai N, Khana K, Johansson E, Lindkvist P, Bunnell R. "Maybe his blood is still strong": a qualitative study among HIV-sero-discordant couples on ART in rural Uganda. BMC Public Health 2012; 12:801. [PMID: 22984868 PMCID: PMC3599002 DOI: 10.1186/1471-2458-12-801] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 09/13/2012] [Indexed: 01/17/2023] Open
Abstract
Background HIV-negative members of sero-discordant couples are at high risk for HIV acquisition but few behavioral prevention interventions have been implemented in sub-Saharan Africa and discordance is not well understood by couples themselves. Methods In this nested sub-study, we interviewed 40 HIV sero-discordant couples before and after a 6-month behavioral intervention that was comprised of four group discussions on specific HIV prevention and care topics. The content of the sessions included: 1) understanding HIV serodiscordance and reducing risk, 2) couple communication, 3) reproductive health and HIV serodiscordance, 4) coping with HIV serodiscordance and ongoing support. Couple members were interviewed individually. Data were analyzed thematically using ‘Framework Analysis’ which incorporated dyadic factors to address couple issues. Results Analysis revealed pre-identified concepts and emergent themes that were relevant to the final conceptual model. Four major categories of factors affecting couple relations, beliefs and current risk behaviors emerged: intervention factors, structural/contextual factors, physical health factors, and past risk behavior. The topics within the intervention most relevant were communication and reproductive health. The contextual factors highlighted by couples were gender norms around sexual decision-making and multiple partnerships. Individual beliefs regarding HIV serodiscordance persisted over all time points for some couples. Interestingly, some couple members had divergent views about their HIV status; some believing the HIV-negative member was negative while others described multiple beliefs around the negative member’s blood surely being positive for HIV. Couple communication emerged as an important theme mediating beliefs and behavior. Conclusions In addition to biomedical and behavioral interventions, HIV-serodiscordant couple interventions must embrace the contextual complexity and cultural understanding of HIV infection and discordance as well as the dynamic nature of couple communication to influence risk behavior.
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Affiliation(s)
- Rachel King
- Global Health Sciences, University of California, San Francisco, C/O Makerere University School of Public Health, Kampala, Uganda.
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Rose CD, Koester KA, Kang Dufour MS, Myers JJ, Shade SB, McCready K, Morin S. Messages HIV clinicians use in prevention with positives interventions. AIDS Care 2012; 24:704-11. [PMID: 22299672 DOI: 10.1080/09540121.2011.644232] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Prevention with Positives (PwP) is a component of the US HIV prevention strategy that targets HIV-infected persons who are aware of their seropositive status. This paper examines the use of prevention messages by clinical providers during the PwP intervention period of the US Health Resources and Services Administration's Special Projects of National Significance program. Quantitative approaches were used to learn which prevention topics were most discussed and qualitative interviews were also utilized to better understand the clinician perspective in providing prevention counseling. At 12-month follow-up, there was a significant increase in the percent of patients receiving all PwP counseling messages (p<0.01). Providers reported discussing safer sex with 91% of patients when sexually transmitted infection (STI) screening was conducted during a visit, an increase from baseline (83.5%). The percent of providers reporting they regularly explained the risk of superinfection to their clients also increased from 75% at baseline to 90% at 12-month follow up (p<0.001). Qualitative data suggest that providers prioritize individual care over public health approaches to PwP in counseling. Discussing superinfection offered providers a way to discuss HIV prevention from a non-judgmental clinical perspective while focusing on a patient-centered philosophy of care. However, the threat of superinfection may not be the best counseling option. Examples such as STI screening, giving messages to reduce the number of sexual partners and adherence to medication, are more evidence-based approaches to changing HIV transmission risk behavior and may be more important in PwP. Findings suggest that in order for HIV care providers to incorporate HIV prevention discussions into their practice, acceptable approaches to speaking about risk behavior and prevention of HIV transmission must be developed.
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Affiliation(s)
- Carol Dawson Rose
- Center for AIDS Prevention Studies, University of California, San Francisco, 94105, USA.
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