1
|
West BS, Darisheva M, McCrimmon T, Zholnerova N, Grigorchuk E, Starbird L, Terlikbayeva A, Primbetova S, Baiserkin B, Mussina Z, Kasymbekova S, Cordingley O, Frye VA. Scaling Up HIV Self-Testing and Linkage to Care Among Women Who Exchange Sex and/or Use Drugs in Kazakhstan. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2024; 36:216-228. [PMID: 38917303 DOI: 10.1521/aeap.2024.36.3.216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
HIV testing is the point of entry for linkage to treatment and prevention and is critically important to ending the HIV epidemic. HIV self-testing (HST) is an acceptable, user-controlled tool that can address testing barriers, which is especially important for populations who need to test frequently, like women who exchange or trade sex for money or other needed resources (WES) and women who use drugs. HST is feasible and acceptable among WES, but research among WES who also use drugs is limited, particularly in places like Kazakhstan, where HIV rates remain high and where scale-up of HST and pre-exposure prophylaxis (PrEP) is in process. To develop effective programming, there is a need to develop tailored services for WES and/or use drugs that address key barriers. We discuss opportunities to increase HST and linkage to services among WES and/or use drugs in Kazakhstan, with a focus on stigma reduction.
Collapse
Affiliation(s)
- Brooke S West
- School of Social Work, Columbia University, New York, New York
| | | | - Tara McCrimmon
- Sociomedical Sciences, Columbia University, New York, New York
| | | | | | - Laura Starbird
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Baurzhan Baiserkin
- Kazakh Scientific Center of Dermatology and Infectious Diseases, Almaty, Kazakhstan
| | - Zhannat Mussina
- Kazakh Scientific Center of Dermatology and Infectious Diseases, Almaty, Kazakhstan
| | | | | | - Victoria A Frye
- School of Social Work, Columbia University, New York, New York
| |
Collapse
|
2
|
Aytenew TM, Demis S, Birhane BM, Asferie WN, Simegn A, Nibret G, Kassaw A, Asnakew S, Tesfahun Y, Andualem H, Bantie B, Kassaw G, Kefale D, Zeleke S. Non-Adherence to Anti-Retroviral Therapy Among Adult People Living with HIV in Ethiopia: Systematic Review and Meta-Analysis. AIDS Behav 2024; 28:609-624. [PMID: 38157133 PMCID: PMC10876791 DOI: 10.1007/s10461-023-04252-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 01/03/2024]
Abstract
Human immunodeficiency virus remains a global public health problem. Despite efforts to determine the prevalence of non-adherence to ART and its predictors in Ethiopia, various primary studies presented inconsistent findings. Therefore, this review aimed to determine the pooled prevalence of non-adherence to ART and identify its predictors. We have searched PubMed, Google Scholar and Web of Science databases extensively for all available studies. A weighted inverse-variance random-effects model was used to compute the overall non-adherence to ART. The pooled prevalence of non-adherence to ART was 20.68% (95% CI: 17.74, 23.61); I2 = 98.40%; p < 0.001). Educational level of primary school and lower [AOR = 3.5, 95%CI: 1.7, 7.4], taking co-medications [AOR = 0.45, 95%CI: 0.35, 0.59], not using memory aids [AOR = 0.30, 95%CI: 0.13, 0.71], depression [AOR = 2.0, 95%CI: 1.05, 3.79], comorbidity [AOR = 2.12, 95%CI: 1.16, 3.09), under-nutrition [AOR = 2.02, 95%CI: 1.20, 3.43], not believing on ART can control HIV [AOR = 2.31, 95%CI: 1.92, 2.77], lack of access to health facilities [AOR = 3.86, 95%CI: 1.10, 13.51] and taking ART pills uncomfortably while others looking [AOR = 5.21, 95%CI: 2.56, 10.53] were significantly associated with non-adherence to anti-retroviral therapy. The overall pooled prevalence of non-adherence to ART was considerably high in Ethiopia. Educational status, taking co-medications, not using memory aids, depression, comorbidity, under nutrition, not believing on anti-retroviral therapy controls HIV, lack of access to health facilities and taking ART pills uncomfortably were independent predictors of non-adherence to ART in Ethiopia. Therefore, healthcare providers, adherence counselors and supporters should detect non-adherence behaviors and patients' difficulties with ART early, and provide intensive counseling to promote adherence.
Collapse
Affiliation(s)
- Tigabu Munye Aytenew
- Department of Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia.
| | - Solomon Demis
- Department of Maternity and Neonatal Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | | | - Worku Necho Asferie
- Department of Maternity and Neonatal Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Amare Simegn
- Department of Reproductive Health, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Gedefaye Nibret
- Department of Reproductive Health, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Amare Kassaw
- Department of Pediatrics and Child health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Sintayehu Asnakew
- Department of Psychiatry, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Yohannes Tesfahun
- Department of Emergency and Critical Care Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Henock Andualem
- Department of Medical Laboratory, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Berihun Bantie
- Department of Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Gebrie Kassaw
- Department of Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Demewoz Kefale
- Department of Pediatrics and Child health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Shegaw Zeleke
- Department of Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| |
Collapse
|
3
|
Lee P, Docrat A. Prevalence and shared risk factors of HIV in three key populations in Vietnam: A systematic review and meta-analysis. Epidemiol Infect 2023; 151:e138. [PMID: 37525376 PMCID: PMC10540180 DOI: 10.1017/s0950268823001243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 07/18/2023] [Accepted: 07/23/2023] [Indexed: 08/02/2023] Open
Abstract
This study aims to estimate the prevalence of HIV among each of the three key populations in Vietnam: people who inject drugs (PWID), female sex workers (FSW), and men who have sex with men (MSM) and quantify their shared risk factors for HIV infection through a systematic review and meta-analysis of recent literature (published in 2001-2017) in the relevant topics. A total of 17 studies consisting of 16,304 participants were selected in this review. The meta-analysis results revealed that the pooled prevalence estimates with 95% confidence intervals (CIs) among PWID, FSW, and MSM were: 0.293 (0.164, 0.421), 0.075 (0.060, 0.089), and 0.085 (0.044, 0.126), respectively. The findings also indicated that injecting drug use (OR: 9.88, 95%CI: 4.47-15.28), multiperson use of injecting equipment (OR: 2.91, 95%CI: 1.69, 4.17), and inconsistent condom use (OR: 2.11, 95%CI: 1.33, 2.90) were the shared risk factors for HIV infection among these population groups. The findings highlighted the importance of HIV prevention approaches to addressing the shared sexual and drug-related practices among the key populations in consideration of their overlapping social networks.
Collapse
Affiliation(s)
- Patricia Lee
- School of Medicine & Dentistry, Griffith University, Gold Coast, QLD, Australia
- Department of Medical Research, China Medical University Hospital, Taichung City, Taiwan
| | - Ashraf Docrat
- School of Medicine & Dentistry, Griffith University, Gold Coast, QLD, Australia
| |
Collapse
|
4
|
Coomes D, Green D, Barnabas R, Sharma M, Barr-DiChiara M, Jamil MS, Baggaley R, Owiredu MN, Macdonald V, Nguyen VTT, Vo SH, Taylor M, Wi T, Johnson C, Drake AL. Cost-effectiveness of implementing HIV and HIV/syphilis dual testing among key populations in Viet Nam: a modelling analysis. BMJ Open 2022; 12:e056887. [PMID: 35953255 PMCID: PMC9379490 DOI: 10.1136/bmjopen-2021-056887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Key populations, including sex workers, men who have sex with men, and people who inject drugs, have a high risk of HIV and sexually transmitted infections. We assessed the health and economic impacts of different HIV and syphilis testing strategies among three key populations in Viet Nam using a dual HIV/syphilis rapid diagnostic test (RDT). SETTING We used the spectrum AIDS impact model to simulate the HIV epidemic in Viet Nam and evaluated five testing scenarios among key populations. We used a 15-year time horizon and a provider perspective for costs. PARTICIPANTS We simulate the entire population of Viet Nam in the model. INTERVENTIONS We modelled five testing scenarios among key populations: (1) annual testing with an HIV RDT, (2) annual testing with a dual RDT, (3) biannual testing using dual RDT and HIV RDT, (4) biannual testing using HIV RDT and (5) biannual testing using dual RDT. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome is incremental cost-effectiveness ratios. Secondary outcomes include HIV and syphilis cases. RESULTS Annual testing using a dual HIV/syphilis RDT was cost-effective (US$10 per disability-adjusted life year (DALY)) and averted 3206 HIV cases and treated 27 727 syphilis cases compared with baseline over 15 years. Biannual testing using one dual test and one HIV RDT (US$1166 per DALY), or two dual tests (US$5672 per DALY) both averted an additional 875 HIV cases, although only the former scenario was cost-effective. Annual or biannual HIV testing using HIV RDTs and separate syphilis tests were more costly and less effective than using one or two dual RDTs. CONCLUSIONS Annual HIV and syphilis testing using dual RDT among key populations is cost-effective in Vietnam and similar settings to reach global reduction goals for HIV and syphilis.
Collapse
Affiliation(s)
- David Coomes
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Dylan Green
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Ruanne Barnabas
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Magdalena Barr-DiChiara
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Muhammad S Jamil
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - R Baggaley
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Morkor Newman Owiredu
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Virginia Macdonald
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | | | - Son Hai Vo
- Viet Nam Authority for HIV/AIDS Prevention and Control, Government of Viet Nam Ministry of Health, Hanoi, Viet Nam
| | - Melanie Taylor
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Teodora Wi
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Cheryl Johnson
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Alison L Drake
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| |
Collapse
|
5
|
Fuge TG, Tsourtos G, Miller ER. Factors affecting optimal adherence to antiretroviral therapy and viral suppression amongst HIV-infected prisoners in South Ethiopia: a comparative cross-sectional study. AIDS Res Ther 2022; 19:5. [PMID: 35093100 PMCID: PMC8800260 DOI: 10.1186/s12981-022-00429-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 01/18/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Maintaining optimal adherence and viral suppression in people living with HIV (PLWH) is essential to ensure both preventative and therapeutic benefits of antiretroviral therapy (ART). Prisoners bear a particularly high burden of HIV infection and are highly likely to transmit to others during and after incarceration. However, the level of treatment adherence and viral suppression in incarcerated populations in low-income countries is unknown. This study aimed to determine factors affecting optimal adherence to antiretroviral therapy and viral suppression amongst HIV-infected prisoners in South Ethiopia. METHODS A comparative cross-sectional study was conducted between June 1, 2019 and May 31, 2020 to compare the level of adherence and viral suppression between incarcerated and non-incarcerated PLWH. Patient information including demographic, socio-economic, behavioral, and incarceration-related characteristics were collected using a structured questionnaire. Medication adherence was assessed according to self-report and pharmacy refill. Plasma viral load measurements undertaken within the study period were prospectively extracted to determine viral suppression. Univariate and multivariate logistic and fractional regression models were used to analyse data. RESULTS Seventy-four inmates living with HIV (ILWH) and 296 non-incarcerated PLWH participated in the study. While ILWH had a significantly higher pharmacy refill adherence compared to non-incarcerated PLWH (89 vs 75%), they had a slightly lower dose adherence (81% vs 83%). The prevalence of viral non-suppression was also slightly higher in ILWH (6.0%; 95% confidence interval (CI): 1.7-14.6%) compared to non-incarcerated PLWH (4.5%; 95%CI: 2.4-7.5%). Overall, missing ART appointments, dissatisfaction with ART services, inability to comply with a specified medication schedule, and types of methods used to monitor the schedule (e.g., news time on radio/TV or other social cues) were significantly associated with non-adherence according to self-report. In ILWH specifically, accessing ART services from a hospital, inability to properly attend clinic appointments, depressive symptoms, and lack of social support predicted NA. Viral non-suppression was significantly higher in males, people of age 31to 35 years and in those who experienced social stigma, regardless of their incarceration status. CONCLUSIONS Sub-optimal dose adherence and viral suppression are generally higher in HIV-infected prisoners in South Ethiopia compared to their non-incarcerated counterparts. A multitude of factors were found to be responsible for this requiring multilevel intervention strategies focusing on the specific needs of prisoners.
Collapse
Affiliation(s)
- Terefe Gone Fuge
- College of Medicine and Public Health, Flinders University, Adelaide, Australia.
| | - George Tsourtos
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Emma R Miller
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| |
Collapse
|
6
|
Adawiyah RA, Saweri OPM, Boettiger DC, Applegate TL, Probandari A, Guy R, Guinness L, Wiseman V. The costs of scaling up HIV and syphilis testing in low- and middle-income countries: a systematic review. Health Policy Plan 2021; 36:939-954. [PMID: 33693731 PMCID: PMC8227996 DOI: 10.1093/heapol/czab030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2021] [Indexed: 12/18/2022] Open
Abstract
Around two-thirds of all new HIV infections and 90% of syphilis cases occur in low- and middle-income countries (LMICs). Testing is a key strategy for the prevention and treatment of HIV and syphilis. Decision-makers in LMICs face considerable uncertainties about the costs of scaling up HIV and syphilis testing. This paper synthesizes economic evidence on the costs of scaling up HIV and syphilis testing interventions in LMICs and evidence on how costs change with the scale of delivery. We systematically searched multiple databases (Medline, Econlit, Embase, EMCARE, CINAHL, Global Health and the NHS Economic Evaluation Database) for peer-reviewed studies examining the costs of scaling up HIV and syphilis testing in LMICs. Thirty-five eligible studies were identified from 4869 unique citations. Most studies were conducted in Sub-Saharan Africa (N = 17) and most explored the costs of rapid HIV in facilities targeted the general population (N = 19). Only two studies focused on syphilis testing. Seventeen studies were cost analyses, 17 were cost-effectiveness analyses and 1 was cost-benefit analysis of HIV or syphilis testing. Most studies took a modelling approach (N = 25) and assumed costs increased linearly with scale. Ten studies examined cost efficiencies associated with scale, most reporting short-run economies of scale. Important drivers of the costs of scaling up included testing uptake and the price of test kits. The 'true' cost of scaling up testing is likely to be masked by the use of short-term decision frameworks, linear unit-cost projections (i.e. multiplying an average cost by a factor reflecting activity at a larger scale) and availability of health system capacity and infrastructure to supervise and support scale up. Cost data need to be routinely collected alongside other monitoring indicators as HIV and syphilis testing continues to be scaled up in LMICs.
Collapse
Affiliation(s)
- Rabiah Al Adawiyah
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia
| | - Olga P M Saweri
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia.,Population Health and Demography, Papua New Guinea Institute of Medical Research, PO Box 60 Homate Street, Goroka, Papua New Guinea
| | - David C Boettiger
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia
| | - Tanya L Applegate
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia
| | - Ari Probandari
- Department of Public Health, Faculty of Medicine, Universitas Sebelas Maret, Jl. Ir. Sutami 36A. Surakarta, 57126, Indonesia
| | - Rebecca Guy
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia
| | - Lorna Guinness
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.,Centre for Global DevelopmentEurope, Great Peter House, Great College St, London SW1P 3SE, UK
| | - Virginia Wiseman
- The Kirby Institute, University New South Wales, High St, Kensington 2052, New South Wales, Australia.,London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| |
Collapse
|
7
|
Hoang NT, Nguyen NTT, Nguyen QN, Bollinger JW, Tran BX, Do NT, Nguyen THT, Nguyen HLT, Nguyen TH, Latkin CA, Ho CSH, Ho RCM. Survival Outcomes of Vietnamese People with HIV after Initiating Antiretroviral Treatment: Role of Clinic-Related Factors. AIDS Behav 2021; 25:1626-1635. [PMID: 33244641 DOI: 10.1007/s10461-020-03079-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2020] [Indexed: 01/04/2023]
Abstract
Given the rapid development of HIV clinics in Vietnam, this study evaluates the infrastructure surrounding this expansion, identifying clinic-related factors that impact survival outcomes. A retrospective longitudinal study was conducted among people living with HIV (PLWH) who initiated antiretroviral therapy (ART) between 2011 and 2015 among 62 ART clinics in 15 provinces. The mortality rate during the 717674.1 person-years of observation (PYO) was 0.29/100 PYO. Location in rural areas (versus urban) and in Central Vietnam (versus Northern Vietnam) were associated with higher risk of mortality. The risk was lower among clinics that had peer-educators. As Vietnam's HIV/AIDS program continues to expand, this data supports increasing resource allocation for rural clinics, incorporation of ART with the community's existing healthcare infrastructure in its efforts to decentralize, and integration of services to reflect patients' anticipated needs.
Collapse
Affiliation(s)
| | | | - Quang Nhat Nguyen
- Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam
- Université, Claude Bernard Lyon 1, Villeurbanne, France
| | | | - Bach Xuan Tran
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Nhan Thi Do
- Vietnam Authority of HIV/AIDS Control, Hanoi, Vietnam
| | - Trang Huyen Thi Nguyen
- Center of Excellence in Pharmacoeconomics and Management, Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam
| | - Huong Lan Thi Nguyen
- Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam.
- Faculty of Nursing, Duy Tan University, Da Nang, Vietnam.
| | - Trang Ha Nguyen
- Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam
- Faculty of Nursing, Duy Tan University, Da Nang, Vietnam
| | - Carl A Latkin
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Cyrus S H Ho
- Department of Psychological Medicine, National University Hospital, Singapore, Singapore
| | - Roger C M Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, Singapore
| |
Collapse
|
8
|
LEVINTOW SN, PENCE BW, POWERS KA, BRESKIN A, SRIPAIPAN T, HA TV, CHU VA, QUAN VM, LATKIN CA, GO VF. Depression, antiretroviral therapy initiation, and HIV viral suppression among people who inject drugs in Vietnam. J Affect Disord 2021; 281:208-215. [PMID: 33333474 PMCID: PMC7855445 DOI: 10.1016/j.jad.2020.12.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 11/23/2020] [Accepted: 12/05/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The burden of depression is high among people who inject drugs (PWID) and may contribute to the spread of HIV through poor treatment engagement and persistent viremia. We estimated the effects of depression on antiretroviral therapy (ART) initiation and viral suppression among PWID living with HIV. METHODS Longitudinal data were collected from 455 PWID living with HIV in Vietnam during 2009-2013. We estimated the 6- and 12-month cumulative incidence of ART initiation and viral suppression, accounting for time-varying confounding, competing events, and missing data. The cumulative incidence difference (CID) contrasted the incidence of each outcome had participants always vs. never experienced severe depressive symptoms across study visits to date. RESULTS Severe depressive symptoms decreased the cumulative incidence of ART initiation, with CID values comparing always vs. never having severe depressive symptoms of -7.5 percentage points (95% CI: -17.2, 2.2) at 6 months and -7.1 (95% CI: -17.9, 3.7) at 12 months. There was no appreciable difference in the cumulative incidence of viral suppression at 6 months (CID = 0.3, 95% CI: -11.3, 11.9) or 12 months (CID = 2.0, 95% CI: -21.8, 25.8). LIMITATIONS Discrepancies between the ART initiation and viral suppression outcomes could be due to under-reporting of ART use and missing data on viral load. CONCLUSIONS Future work probing the seemingly antagonistic effect of depression on treatment uptake - but not viral suppression - will inform the design of interventions promoting HIV clinical outcomes and reducing onward transmission among PWID.
Collapse
Affiliation(s)
- Sara N. LEVINTOW
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill NC, USA
| | - Brian W. PENCE
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill NC, USA
| | - Kimberly A. POWERS
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill NC, USA
| | | | - Teerada SRIPAIPAN
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill NC, USA
| | - Tran Viet HA
- UNC Project Vietnam, University of North Carolina, Hanoi, Vietnam
| | - Viet Anh CHU
- UNC Project Vietnam, University of North Carolina, Hanoi, Vietnam
| | - Vu Minh QUAN
- Centers for Disease Control and Prevention, Atlanta GA, USA
| | - Carl A. LATKIN
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA
| | - Vivian F. GO
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill NC, USA
| |
Collapse
|
9
|
Ying R, Fekadu L, Schackman BR, Verguet S. Spatial distribution and characteristics of HIV clusters in Ethiopia. Trop Med Int Health 2020; 25:301-307. [PMID: 31808592 PMCID: PMC7079229 DOI: 10.1111/tmi.13356] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Ethiopia's HIV prevalence has decreased by 75% in the past 20 years with the implementation of antiretroviral therapy, but HIV transmission continues in high-risk clusters. Identifying the spatial and temporal trends, and epidemiologic correlates, of these clusters can lead to targeted interventions. METHODS We used biomarker and survey data from the 2005, 2011 and 2016 Ethiopia Demographic and Health Surveys (DHS). The spatial-temporal distribution of HIV was estimated using the Kulldorff spatial scan statistic, a likelihood-based method for determining clustering. Significant clusters (P < 0.05) were identified and compared based on HIV risk factors to non-cluster areas. RESULTS In 2005, 2011 and 2016, respectively, 219, 568 and 408 individuals tested positive for HIV. Four HIV clusters were identified, representing 17% of the total population and 43% of all HIV cases. The clusters were centred around Addis Ababa (1), Afar (2), Dire Dawa (3) and Gambella (4). Cluster 1 had higher rates of unsafe injections (4.9% vs. 2.2%, P < 0.001) and transactional sex (6.0% vs. 1.6%, P < 0.001) than non-cluster regions, but more male circumcision (98.5% vs. 91.3%, P < 0.001). Cluster 2 had higher levels of transactional sex (4.9% vs. 1.6%, P < 0.01), but lower levels of unsafe injections (0.8% vs. 2.2%, P < 0.01). Cluster 3 had fewer individuals with> 1 sexual partner (0% vs. 1.7%, P < 0.001) and more male circumcision (100% vs. 91.3%, P < 0.001). Cluster 4 had less male circumcision (59.1% vs. 91.3%, P < 0.01). CONCLUSIONS In Ethiopia, geographic HIV clusters are driven by different risk factors. Decreasing the HIV burden requires targeted interventions.
Collapse
Affiliation(s)
- Roger Ying
- Yale School of MedicineYale UniversityNew HavenCTUSA
| | - Lelisa Fekadu
- Department of Global Health and Primary CareUniversity of BergenBergenNorway
- Federal Ministry of HealthAddis AbabaEthiopia
| | - Bruce R. Schackman
- Department of Healthcare Policy and ResearchWeill Cornell Medical CollegeCornell UniversityNew YorkNYUSA
| | - Stéphane Verguet
- Department of Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonMAUSA
| |
Collapse
|
10
|
Tran BX, Dang AK, Vu GT, Tran TT, Latkin CA, Ho CSH, Ho RCM. Patient satisfaction with HIV services in Vietnam: Status, service models and association with treatment outcome. PLoS One 2019; 14:e0223723. [PMID: 31703089 PMCID: PMC6839840 DOI: 10.1371/journal.pone.0223723] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 09/26/2019] [Indexed: 01/13/2023] Open
Abstract
This study assessed the satisfaction of patients receiving antiretroviral treatment (ART) in Vietnam and its multilevel predictors. Cross-sectional data were collected from January to September 2013 in eight outpatient clinics in Hanoi and Nam Dinh provinces. Patient satisfaction was evaluated using the Satisfaction with HIV/AIDS Treatment Interview Scale. Multivariable Tobit regression was utilized to measure the associations between these factors and satisfaction with treatment services. Generalized Mixed-effect Regression model was used to estimate the effect of satisfaction with the quality of service on the change between the initial and the latest CD4 cell count. Among 1133 patients, most of them were completely satisfied with the 10 domains measured (65.5% to 82.5%). "Service quality and convenience" domain which was attributed by the waiting time and administrative procedure had the lowest score of complete satisfaction. Compared to central clinics, provincial clinics were negatively associated with the overall satisfaction (Coef = -0.58; 95%CI = -0.95; -0.21). Patients rating higher score in "Consultation, explanation, and guidance of health care workers", "Responsiveness of health care workers to patients' questions and requests" and "Perceived overall satisfaction with the quality of service" were related to improvement in immunological treatment outcomes. Our results revealed the high level of satisfaction among ART patients towards HIV care and treatment services, and this had a high correlation to treatment outcomes. Interventions should focus on reducing administrative procedures, providing sufficient guidance and comprehensive services which integrate physical with psychological care for improving the health outcome of the ART program.
Collapse
Affiliation(s)
- Bach Xuan Tran
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail:
| | - Anh Kim Dang
- Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam
| | - Giang Thu Vu
- Center of Excellence in Evidence-based Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam
| | - Tung Thanh Tran
- Center of Excellence in Evidence-based Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam
| | - Carl A. Latkin
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Cyrus S. H. Ho
- Department of Psychological Medicine, National University Hospital, Singapore, Singapore
| | - Roger C. M. Ho
- Center of Excellence in Behavioral Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, Singapore
| |
Collapse
|
11
|
Krebs E, Enns B, Wang L, Zang X, Panagiotoglou D, Del Rio C, Dombrowski J, Feaster DJ, Golden M, Granich R, Marshall B, Mehta SH, Metsch L, Schackman BR, Strathdee SA, Nosyk B. Developing a dynamic HIV transmission model for 6 U.S. cities: An evidence synthesis. PLoS One 2019; 14:e0217559. [PMID: 31145752 PMCID: PMC6542533 DOI: 10.1371/journal.pone.0217559] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 05/14/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Dynamic HIV transmission models can provide evidence-based guidance on optimal combination implementation strategies to treat and prevent HIV/AIDS. However, these models can be extremely data intensive, and the availability of good-quality data characterizing regional microepidemics varies substantially within and across countries. We aim to provide a comprehensive and transparent description of an evidence synthesis process and reporting framework employed to populate and calibrate a dynamic, compartmental HIV transmission model for six US cities. METHODS We executed a mixed-method evidence synthesis strategy to populate model parameters in six categories: (i) initial HIV-negative and HIV-infected populations; (ii) parameters used to calculate the probability of HIV transmission; (iii) screening, diagnosis, treatment and HIV disease progression; (iv) HIV prevention programs; (v) the costs of medical care; and (vi) health utility weights for each stage of HIV disease progression. We identified parameters that required city-specific data and stratification by gender, risk group and race/ethnicity a priori and sought out databases for primary analysis to augment our evidence synthesis. We ranked the quality of each parameter using context- and domain-specific criteria and verified sources and assumptions with our scientific advisory committee. FINDINGS To inform the 1,667 parameters needed to populate our model, we synthesized evidence from 59 peer-reviewed publications and 24 public health and surveillance reports and executed primary analyses using 11 data sets. Of these 1,667 parameters, 1,517 (91%) were city-specific and 150 (9%) were common for all cities. Notably, 1,074 (64%), 201 (12%) and 312 (19%) parameters corresponded to categories (i), (ii) and (iii), respectively. Parameters ranked as best- to moderate-quality evidence comprised 39% of the common parameters and ranged from 56%-60% across cities for the city-specific parameters. We identified variation in parameter values across cities as well as within cities across risk and race/ethnic groups. CONCLUSIONS Better integration of modelling in decision making can be achieved by systematically reporting on the evidence synthesis process that is used to populate models, and by explicitly assessing the quality of data entered into the model. The effective communication of this process can help prioritize data collection of the most informative components of local HIV prevention and care services in order to reduce decision uncertainty and strengthen model conclusions.
Collapse
Affiliation(s)
- Emanuel Krebs
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Benjamin Enns
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Linwei Wang
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Xiao Zang
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Dimitra Panagiotoglou
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Carlos Del Rio
- Hubert Department of Global Health, Emory Center for AIDS Research, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Julia Dombrowski
- Department of Medicine, Division of Allergy & Infectious Disease, adjunct in Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Daniel J. Feaster
- Center for Family Studies, Department of Epidemiology and Public Health, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States of America
| | - Matthew Golden
- Department of Medicine, Division of Allergy & Infectious Disease, adjunct in Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Reuben Granich
- International Association of Providers of AIDS Care, Washington, DC, United States of America
| | - Brandon Marshall
- Department of Epidemiology, Brown School of Public Health, Providence, RI, United States of America
| | - Shruti H. Mehta
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States of America
| | - Lisa Metsch
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Bruce R. Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, United States of America
| | - Steffanie A. Strathdee
- School of Medicine, University of California San Diego, La Jolla, CA, United States of America
| | - Bohdan Nosyk
- Health Economic Research Unit at the British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | | |
Collapse
|
12
|
GARIRA WINSTON, MAFUNDA MARTINCANAAN. FROM INDIVIDUAL HEALTH TO COMMUNITY HEALTH: TOWARDS MULTISCALE MODELING OF DIRECTLY TRANSMITTED INFECTIOUS DISEASE SYSTEMS. J BIOL SYST 2019. [DOI: 10.1142/s0218339019500074] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In this paper, we present a new method for developing a class of nested multiscale models for directly transmitted infectious disease systems that integrates within-host scale and between-host scale using community pathogen load (CPL) as a new public health measure of a community’s level of infectiousness and as an indicator of the effectiveness of health interventions. The approach develops a multiscale modeling science base for directly transmitted infectious disease systems (where the inside-host environment’s biological entities such as cells, tissues, organs, body fluids, whole body are the reservoir of infective pathogen in the community) that is comparable to an existing multiscale modeling science base for environmentally transmitted infectious diseases (where the outside-host geographical environment’s physical entities such as soil, air, formites/contact surfaces, food and water are the reservoir of infective pathogen in the community) where pathogen load in the environment is explicitly incorporated into the model. This is achieved by assuming that infected hosts in the community are homogeneous and unevenly distributed microbial habitats. We illustrate the utility of this multiscale modeling methodology by evaluating the comparative effectiveness of HIV/AIDS preventive and treatment interventions as a case study.
Collapse
Affiliation(s)
- WINSTON GARIRA
- Modelling Health and Environmental Linkages Research Group (MHELRG), Department of Mathematics and Applied Mathematics, University of Venda, Private Bag X5050, Thohoyandou 0950, South Africa
| | - MARTIN CANAAN MAFUNDA
- Modelling Health and Environmental Linkages Research Group (MHELRG), Department of Mathematics and Applied Mathematics, University of Venda, Private Bag X5050, Thohoyandou 0950, South Africa
| |
Collapse
|
13
|
The Dark Side of Female HIV Patient Care: Sexual and Reproductive Health Risks in Pre- and Post-Clinical Treatments. J Clin Med 2018; 7:jcm7110402. [PMID: 30384413 PMCID: PMC6262424 DOI: 10.3390/jcm7110402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 10/26/2018] [Accepted: 10/28/2018] [Indexed: 12/22/2022] Open
Abstract
This study examines the pre- and post-clinical issues in human immunodeficiency virus (HIV) care and treatment for women and girls of high-risk population groups—namely sex workers, injecting drug users, women living with HIV, primary sexual partners of people living with HIV, adolescent girls who are children of these groups, and migrant young girls and women—in five provinces and cities in Vietnam. Through a sample of 241 surveyed participants and 48 respondents for in-depth interviews and 32 respondents in the focus group discussions, the study identifies multiple barriers that keep these groups from receiving the proper health care that is well within their human rights. Most respondents rated HIV testing as easily accessible, yet only 18.9% of the surveyed women living with HIV disclosed their infection status, while 37.8% gave no information at the most recent prenatal care visit. The level of knowledge and proper practices of sexual and reproductive health (SRH) care also remains limited. Meanwhile, modern birth control methods have yet to be widely adopted among these populations: only 30.7% of respondents reported using condoms when having sex with their husband. This increases the risks of unwanted pregnancy and abortion, as well as vulnerability to sexually transmitted infections (STIs) and HIV transmission. On the other hand, HIV-related stigma and discrimination at health care settings are still pervasive, which create significant barriers for patients to access proper care services. Based on these results, six recommendations to improve SRH status of women and girls of populations at high risk are put forward.
Collapse
|
14
|
Tran BX, Fleming M, Nguyen CT, Latkin CA. Financial mobilization for antiretroviral therapy program: multi-level predictors of willingness to pay among patients with HIV/AIDS in Vietnam. AIDS Care 2018; 30:1488-1497. [PMID: 30047280 DOI: 10.1080/09540121.2018.1503633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
In Vietnam, significant progress has been made in increasing the number of patients receiving antiretroviral therapy (ART) in the last number of years. As this number increases and international aid and funding for HIV services declines, a greater proportion of ART funding will need to be provided by the government budget, health insurance or by the patients themselves. This study aims to evaluate the willingness of HIV patients to pay for ART. A cross-sectional study which included 1133 HIV-positive patients was conducted across 8 outpatient centers in Hanoi and Nam Binh in Northern Vietnam in 2013. Contingent valuation method was used to assess the willingness to pay (WTP) of patient for ART. Over 90% of the patients were willing to pay for ART for an average amount of 19.7 USD per month. Regression models showed that the willingness of patients to pay for ART was influenced by factors such as employment, income, quality of life and social factors. The amount patients were willing to pay was also associated with gender, living place and level of HIV service administration. By establishing these factors which influence the amount of WTP for ART, plans for the future can be effectively designed and patient groups at risk can be appropriately managed.
Collapse
Affiliation(s)
- Bach Xuan Tran
- a Department of Health Economics, Institute for Preventive Medicine and Public Health , Hanoi Medical University , Hanoi , Vietnam.,b Department of Health, Behavior and Society ,, Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Mercedes Fleming
- c School of Medicine and Medical Science , University College Dublin , Dublin , Ireland
| | - Cuong Tat Nguyen
- d Institute for Global Health Innovations, Duy Tan University , Danang , Vietnam
| | - Carl A Latkin
- b Department of Health, Behavior and Society ,, Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| |
Collapse
|
15
|
Nguyen HH, Bui DD, Dinh TTT, Pham LQ, Nguyen VTT, Tran TH, Pham TH, Nguyen SM, Suthar AB, Do NT, Ford N, Lo Y, Nguyen LH, Giang LM, Kato M. A prospective "test-and-treat" demonstration project among people who inject drugs in Vietnam. J Int AIDS Soc 2018; 21:e25151. [PMID: 29984473 PMCID: PMC6036396 DOI: 10.1002/jia2.25151] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 05/15/2018] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Modelling suggests that early diagnosis and immediate antiretroviral therapy (ART) among key populations would have a substantial impact in reducing HIV transmission and mortality in Vietnam. An implementation research project of "test-and-treat" among people who inject drugs (PWID) was developed to inform effective roll-out of such interventions. METHODS "Test-and-treat" was offered to PWID in two high burden provinces, Thai Nguyen and Thanh Hoa. The interventions comprised the offer of biannual HIV testing and immediate ART, irrespective of CD4 count. PWID were enrolled between April 2014 and July 2015 and followed up for 12 months, and retention, HIV viral load (VL) and risk behaviours were assessed. Retention in care of this prospective cohort was compared with the retention among men enrolled in care in the preceding period (April 2012 to March 2013) at the same clinics when ART was initiated at CD4 cell count ≤350 cells/mm3 . RESULTS In total, 287 HIV positive PWID started immediate ART. The majority (98%) were men; median age was 34; and median (interquartile range) CD4 count was 199 (50 to 402) cells/mm3 . After 12 months, 238 participants (83%) were retained on ART, and 205 achieved viral suppression (<1000 copies/mL) (92% among those in whom VL was measured, 71% overall). Baseline CD4 count ≤100 cells/mm3 and history of imprisonment were associated with lower retention and viral suppression, while engagement in methadone maintenance was associated with higher retention. Retention in care was higher in the "test-and-treat" cohort (83%) compared with men enrolled in care in the preceding period (78%), primarily because lost-to-follow-up during pre-ART care was eliminated. No decline in consistent condom use and clean needle use was observed. CONCLUSIONS Early ART initiation resulted in successful treatment outcomes among PWID, with no observed increase in self-reported risk behaviours, suggesting feasibility and potential effectiveness of "test-and-treat" approach. The results also call for differentiated care for PWID, including promoting early diagnosis and engagement in methadone maintenance therapy while enhancing care for those with advanced HIV disease and history of imprisonment.
Collapse
Affiliation(s)
- Hai H Nguyen
- Viet Nam Authority of HIV/AIDS ControlMinistry of HealthHanoiVietnam
| | - Duong D Bui
- Viet Nam Authority of HIV/AIDS ControlMinistry of HealthHanoiVietnam
| | | | | | - Van TT Nguyen
- Vietnam Country OfficeWorld Health OrganizationHanoiVietnam
| | - Tram H Tran
- National Institute of Hygiene and EpidemiologyHanoiVietnam
| | - Thang H Pham
- National Institute of Hygiene and EpidemiologyHanoiVietnam
| | | | | | - Nhan T Do
- Viet Nam Authority of HIV/AIDS ControlMinistry of HealthHanoiVietnam
| | - Nathan Ford
- HIV DepartmentWorld Health OrganizationGenevaSwitzerland
| | - Ying‐Ru Lo
- Regional Office for the Western PacificWorld Health OrganizationManilaPhilippines
| | - Long Hoang Nguyen
- Viet Nam Authority of HIV/AIDS ControlMinistry of HealthHanoiVietnam
| | | | - Masaya Kato
- Vietnam Country OfficeWorld Health OrganizationHanoiVietnam
| | | |
Collapse
|
16
|
Fox MP, Bor J, Brennan AT, MacLeod WB, Maskew M, Stevens WS, Carmona S. Estimating retention in HIV care accounting for patient transfers: A national laboratory cohort study in South Africa. PLoS Med 2018; 15:e1002589. [PMID: 29889844 PMCID: PMC5995345 DOI: 10.1371/journal.pmed.1002589] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 05/17/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Systematic reviews have described high rates of attrition in patients with HIV receiving antiretroviral therapy (ART). However, migration and clinical transfer may lead to an overestimation of attrition (death and loss to follow-up). Using a newly linked national laboratory database in South Africa, we assessed national retention in South Africa's national HIV program. METHODS AND FINDINGS Patients receiving care in South Africa's national HIV program are monitored through regular CD4 count and viral load testing. South Africa's National Health Laboratory Service has maintained a database of all public-sector CD4 count and viral load results since 2004. We linked individual laboratory results to patients using probabilistic matching techniques, creating a national HIV cohort. Validation of our approach in comparison to a manually matched dataset showed 9.0% undermatching and 9.5% overmatching. We analyzed data on patients initiating ART in the public sector from April 1, 2004, to December 31, 2006, when ART initiation could be determined based on first viral load among those whose treatment followed guidelines. Attrition occurred on the date of a patient's last observed laboratory measure, allowing patients to exit and reenter care prior to that date. All patients had 6 potential years of follow-up, with an additional 2 years to have a final laboratory measurement to be retained at 6 years. Data were censored at December 31, 2012. We assessed (a) national retention including all laboratory tests regardless of testing facility and (b) initiating facility retention, where laboratory tests at other facilities were ignored. We followed 55,836 patients initiating ART between 2004 and 2006. At ART initiation, median age was 36 years (IQR: 30-43), median CD4 count was 150 cells/mm3 (IQR: 81-230), and 66.7% were female. Six-year initiating clinic retention was 29.1% (95% CI: 28.7%-29.5%). After allowing for transfers, national 6-year retention was 63.3% (95% CI: 62.9%-63.7%). Results differed little when tightening or relaxing matching procedures. We found strong differences in retention by province, ranging from 74.2% (95% CI: 73.2%-75.2%) in Western Cape to 52.2% (95% CI: 50.6%-53.7%) in Mpumalanga at 6 years. National attrition was higher among patients initiating at lower CD4 counts and higher viral loads, and among patients initiating ART at larger facilities. The study's main limitation is lack of perfect cohort matching, which may lead to over- or underestimation of retention. We also did not have data from KwaZulu-Natal province prior to 2010. CONCLUSIONS In this study, HIV care retention was substantially higher when viewed from a national perspective than from a facility perspective. Our results suggest that traditional clinical cohorts underestimate retention.
Collapse
Affiliation(s)
- Matthew P. Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Alana T. Brennan
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - William B. MacLeod
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Wendy S. Stevens
- National Health Laboratory Service, Johannesburg, South Africa
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa
| | - Sergio Carmona
- National Health Laboratory Service, Johannesburg, South Africa
| |
Collapse
|
17
|
Alemu G, Alelign D, Abossie A. Prevalence of Opportunistic Intestinal Parasites and Associated Factors among HIV Patients while Receiving ART at Arba Minch Hospital in Southern Ethiopia: A Cross-sectional Study. Ethiop J Health Sci 2018; 28:147-156. [PMID: 29983512 PMCID: PMC6016335 DOI: 10.4314/ejhs.v28i2.6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 10/06/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Opportunistic Intestinal Parasites (OIPs) commonly cause morbidity in HIV/AIDS patients due to the decline of CD4+T-cells. The burden of Opportunistic Intestinal Parasitic Infections (OIPIs) in Ethiopia is expected to be high due to poor sanitation and co-pandemicity of HIV/AIDs. Therefore, frequent assessment of the magnitude and associated factors for intestinal parasitosis is essential for the management of HIV/AIDS patients. METHODS A hospital based cross-sectional study was conducted among patients attending Arba Minch Hospital Antiretroviral Therapy (ART) Clinic from March to June 2016. Stool specimens were processed for parasitological examination using direct wet mount, formol-ether sedimentation and modified Ziehl-Neelsen staining techniques. CD4+ T-cell count data were taken from patients' medical records. A structured questionnaire was used to collect data on socio-demographic characteristics and possible associated factors for OIPIs. All the data were analyzed using SPSS version 20. RESULTS Two hundred and twenty ART patients participated in the study. The overall prevalence of intestinal parasitic infections was 28.18% while that of OIPIs alone was 17.72%. Among identified intestinal parasites, Cryptosporidium species accounts for the highest frequency (19/220, 8.63%), followed by Cyclospora species (13/220, 5.90%). Presence of domestic animals (AOR=2.07, 95%CI:1.07-8.40, P= 0.032) and CD4+ T-cell count <500cell/µl (AOR=4.66, 95%CI:1.17-5.35, P= 0.001) were significantly associated with OIPIs. CONCLUSION The study indicated that co-infection rate of OIPs is high among ART patients. It also found that contact with domestic animals and having CD4+ count <500 cell/µl predict for the presence of OIPs.
Collapse
Affiliation(s)
- Getaneh Alemu
- Department of Medical Laboratory Science, Arba Minch University, Arba Minch, Ethiopia
| | - Dagninet Alelign
- Department of Medical Laboratory Science, Arba Minch University, Arba Minch, Ethiopia
| | - Ashenafi Abossie
- Department of Medical Laboratory Science, Arba Minch University, Arba Minch, Ethiopia
| |
Collapse
|
18
|
Kumi Smith M, Jewell BL, Hallett TB, Cohen MS. Treatment of HIV for the Prevention of Transmission in Discordant Couples and at the Population Level. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1075:125-162. [PMID: 30030792 DOI: 10.1007/978-981-13-0484-2_6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The scientific breakthrough proving that antiretroviral therapy (ART) can halt heterosexual HIV transmission came in the form of a landmark clinical trial conducted among serodiscordant couples. Study findings immediately informed global recommendations for the use of treatment as prevention in serodiscordant couples. The extent to which these findings are generalizable to other key populations or to groups exposed to HIV through nonsexual transmission routes (i.e., anal intercourse or unsafe injection of drugs) has since driven a large body of research. This review explores the history of HIV research in serodiscordant couples, the implications for management of couples, subsequent research on treatment as prevention in other key populations, and challenges in community implementation of these strategies.
Collapse
Affiliation(s)
- M Kumi Smith
- University of North Carolina Chapel Hill, Chapel Hill, NC, USA.
| | | | | | - Myron S Cohen
- University of North Carolina Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
19
|
Dynamics and control of infections on social networks of population types. Epidemics 2017; 23:11-18. [PMID: 29137859 DOI: 10.1016/j.epidem.2017.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 10/18/2017] [Indexed: 11/24/2022] Open
Abstract
Random mixing in host populations has been a convenient simplifying assumption in the study of epidemics, but neglects important differences in contact rates within and between population groups. For HIV/AIDS, the assumption of random mixing is inappropriate for epidemics that are concentrated in groups of people at high risk, including female sex workers (FSW) and their male clients (MCF), injecting drug users (IDU) and men who have sex with men (MSM). To find out who transmits infection to whom and how that affects the spread and containment of infection remains a major empirical challenge in the epidemiology of HIV/AIDS. Here we develop a technique, based on the routine sampling of infection in linked population groups (a social network of population types), which shows how an HIV/AIDS epidemic in Can Tho Province of Vietnam began in FSW, was propagated mainly by IDU, and ultimately generated most cases among the female partners of MCF (FPM). Calculation of the case reproduction numbers within and between groups, and for the whole network, provides insights into control that cannot be deduced simply from observations on the prevalence of infection. Specifically, the per capita rate of HIV transmission was highest from FSW to MCF, and most HIV infections occurred in FPM, but the number of infections in the whole network is best reduced by interrupting transmission to and from IDU. This analysis can be used to guide HIV/AIDS interventions using needle and syringe exchange, condom distribution and antiretroviral therapy. The method requires only routine data and could be applied to infections in other populations.
Collapse
|
20
|
Abstract
This study assessed the prevalence of exchanging sex for money or drugs among men who have sex with men (MSM) in the 2011 US National HIV Behavioral Surveillance system. Prevalence of HIV, being HIV-positive but unaware (HIV-positive-unaware), risk behaviors and use of services were compared between MSM who did and did not receive money or drugs from one or more casual male partners in exchange for oral or anal sex in the past 12 months. Among 8411 MSM, 7.0 % exchanged sex. MSM who exchanged sex were more likely to be non-Hispanic black, live in poverty, have injected drugs, have multiple condomless anal sex partners, be HIV-positive and be HIV-positive-unaware. In multivariable analysis, exchange sex was associated with being HIV-positive-unaware (aPR 1.34, 95 % CI 1.05-1.69) after adjusting for race/ethnicity, age, education, poverty, and injecting drugs. MSM who exchange sex represent an important group to reach with HIV prevention, testing, and care services as they were more likely to report behavioral risk factors that put them at risk of HIV.
Collapse
|
21
|
High HIV Prevalence and Risk Among Male Clients of Female Sex Workers in Hanoi and Ho Chi Minh City, Vietnam. AIDS Behav 2017; 21:2381-2393. [PMID: 28324199 DOI: 10.1007/s10461-017-1751-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In Vietnam's concentrated HIV epidemic, female sex workers (FSWs) are at increased risk for acquiring and transmitting HIV, largely through their male clients. A high proportion of males in Vietnam report being clients of FSWs. Studying HIV-related risk factors and prevalence among male clients is important, particularly given the potential for male clients to be a 'bridge' of HIV transmission to the more general population or to sex workers. Time-location sampling was used to identify FSW in Hanoi and Ho Chi Minh City, Vietnam's largest cities, in 2013-2014. Recruited FSWs were asked to refer one male client to the study. Demographic and risk behavior data were collected from FSWs and male clients by administered questionnaires. Biologic specimens collected from male clients were tested for HIV and opiates. Sampling weights, calculated based on the FSWs probability of being selected for enrolment, were applied to prevalence estimates for both FSWs and male clients. Logistic regression models were developed to obtain odds ratios for HIV infection among male clients. A total of 804 male clients were enrolled. Overall, HIV prevalence among male clients was 10.2%; HIV prevalence was 20.7% (95% confidence interval (CI) 15.0-27.9%) among those reporting a history of illegal drug use and 32.4% (95% CI 20.2-47.7%) among those with opioids detected in urine. HIV prevalence among male clients did not differ across 'bridging' categories defined by condom use with FSWs and regular partners over the previous 6 months. HIV among male clients was associated with a reported history of illegal drug use (OR 3.76; 95% CI 1.87-7.56), current opioid use (OR 2.55; 95% CI 1.02-6.36), and being referred by an FSW who self-reported as HIV-positive (OR 5.37; 95% CI 1.46-19.75). Self-reported HIV prevalence among enrolled FSWs was 2.8%. Based on HIV test results of male clients and self-reported status from FSWs, an estimated 12.1% of male client-FSW pairs were sero-discordant. These results indicate high HIV prevalence among male clients of FSWs, particularly among those with a history of drug use. Programs to expand HIV testing, drug-use harm reduction, and HIV treatment for HIV-infected male clients of FSWs should be considered as key interventions for controlling the HIV epidemic in Vietnam.
Collapse
|
22
|
Nong VM, Boggiano VL, Nguyen LHT, Nguyen CT, Nguyen LH, Xuan Bach T, Nguyen HV, Hoang CD, Latkin CA, Vu MTT. Ability to join the workforce and work productivity among drug users under methadone maintenance treatment in a mountainous area of Northern Vietnam: a cross-sectional study. BMJ Open 2017; 7:e016153. [PMID: 28751487 PMCID: PMC5642751 DOI: 10.1136/bmjopen-2017-016153] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 06/09/2017] [Accepted: 06/13/2017] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES A major measure of treatment success for drug users undergoing rehabilitation is the ability to enter the workforce and generate income. This study examines the absenteeism and productivity among people who inject drugs (PWID) enrolled in methadone maintenance treatment (MMT) in Northern Vietnam. SETTING We conducted a cross-sectional study in two clinics in Tuyen Quang province. PARTICIPANTS A total of 241 patients enrolled in MMT. PRIMARY AND SECONDARY OUTCOME MEASURES Patients' work productivity was measured using the WPAI-GH instrument (Work Productivity and Activity Impairment Questionnaire: General Health V2.0). We also collected additional characteristics about participants' employment history, such as proficient jobs, whether they actively found a new job and be accepted by employers. RESULTS Most of the participants (>90%) were employed at the time of the study. Rates of absenteeism (missed work), presenteeism (impairment while working) and overall loss of productivity were 15.8%, 5.6% and 11.2%, respectively, as measured by the WPAI-GH questionnaire. The most proficient job was 'freelancer' (17.5%), followed by 'blue-collar worker' (10.6%) and 'farmer' (10.2%). Only 26.8% of patients reported that they actively sought jobs in the past. About half of them had been refused by employers because of their drug use history and/or HIV status. We found no statistically significant difference between patients enrolled in MMT for <1 year and those who had been enrolled >1 year. Factors associated with higher work productivity included not endorsing problems in mobility, self-care or pain; being HIV-negative and having greater MMT treatment adherence. CONCLUSION Our study highlights the high employment rate and work productivity among PWID in MMT programmes in remote areas of Northern Vietnam. The results can help to improve the quality and structure of MMT programmes across Vietnam and in other countries.
Collapse
Affiliation(s)
- Vuong Minh Nong
- Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam
| | - Victoria L Boggiano
- University of California Berkeley School of Public Health, Berkeley, California, USA
| | - Lan Huong Thi Nguyen
- Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam
- School of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | - Cuong Tat Nguyen
- Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam
| | - Long Hoang Nguyen
- School of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | - Tran Xuan Bach
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
| | - Hung Van Nguyen
- Authority of HIV/AIDS Control, Ministry of Health, Hanoi, Vietnam
| | - Canh Dinh Hoang
- Authority of HIV/AIDS Control, Ministry of Health, Hanoi, Vietnam
| | - Carl A Latkin
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
| | - Minh Thuc Thi Vu
- Department of Immunology and Allergy, National Otolaryngology Hospital, Hanoi, Vietnam
| |
Collapse
|
23
|
The impact of HCV therapy in a high HIV-HCV prevalence population: A modeling study on people who inject drugs in Ho Chi Minh City, Vietnam. PLoS One 2017; 12:e0177195. [PMID: 28493917 PMCID: PMC5426709 DOI: 10.1371/journal.pone.0177195] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 04/23/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Human Immunodeficiency Virus (HIV) and Hepatitis C Virus (HCV) coinfection is a major global health problem especially among people who inject drugs (PWID), with significant clinical implications. Mathematical models have been used to great effect to shape HIV care, but few have been proposed for HIV/HCV. METHODS We constructed a deterministic compartmental ODE model that incorporated layers for HIV disease progression, HCV disease progression and PWID demography. Antiretroviral therapy (ART) and Methadone Maintenance Therapy (MMT) scale-ups were modeled as from 2016 and projected forward 10 years. HCV treatment roll-out was modeled beginning in 2026, after a variety of MMT scale-up scenarios, and projected forward 10 years. RESULTS Our results indicate that scale-up of ART has a major impact on HIV though not on HCV burden. MMT scale-up has an impact on incidence of both infections. HCV treatment roll-out has a measurable impact on reductions of deaths, increasing multifold the mortality reductions afforded by just ART/MMT scale-ups. CONCLUSION HCV treatment roll-out can have major and long-lasting effects on averting PWID deaths on top of those averted by ART/MMT scale-up. Efficient intervention scale-up of HCV alongside HIV interventions is critical in Vietnam.
Collapse
|
24
|
Zhao Y, Wood DT, Kojouharov HV, Kuang Y, Dimitrov DT. Impact of Population Recruitment on the HIV Epidemics and the Effectiveness of HIV Prevention Interventions. Bull Math Biol 2016; 78:2057-2090. [PMID: 27704329 DOI: 10.1007/s11538-016-0211-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 09/21/2016] [Indexed: 10/20/2022]
Abstract
Mechanistic mathematical models are increasingly used to evaluate the effectiveness of different interventions for HIV prevention and to inform public health decisions. By focusing exclusively on the impact of the interventions, the importance of the demographic processes in these studies is often underestimated. In this paper, we use simple deterministic models to assess the effectiveness of pre-exposure prophylaxis in reducing the HIV transmission and to explore the influence of the recruitment mechanisms on the epidemic and effectiveness projections. We employ three commonly used formulas that correspond to constant, proportional and logistic recruitment and compare the dynamical properties of the resulting models. Our analysis exposes substantial differences in the transient and asymptotic behavior of the models which result in 47 % variation in population size and more than 6 percentage points variation in HIV prevalence over 40 years between models using different recruitment mechanisms. We outline the strong influence of recruitment assumptions on the impact of HIV prevention interventions and conclude that detailed demographic data should be used to inform the integration of recruitment processes in the models before HIV prevention is considered.
Collapse
Affiliation(s)
- Yuqin Zhao
- School of Mathematics, University of Minnesota, Minneapolis, MN, USA
| | - Daniel T Wood
- Statistical Center for HIV/AIDS Research and Prevention (SCHARP), Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Hristo V Kojouharov
- Department of Mathematics, The University of Texas at Arlington, Arlington, TX, USA
| | - Yang Kuang
- Department of Mathematics and Statistics, Arizona State University, Tempe, AZ, USA
| | - Dobromir T Dimitrov
- Statistical Center for HIV/AIDS Research and Prevention (SCHARP), Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
| |
Collapse
|
25
|
Mishra S, Boily MC, Schwartz S, Beyrer C, Blanchard JF, Moses S, Castor D, Phaswana-Mafuya N, Vickerman P, Drame F, Alary M, Baral SD. Data and methods to characterize the role of sex work and to inform sex work programs in generalized HIV epidemics: evidence to challenge assumptions. Ann Epidemiol 2016; 26:557-569. [PMID: 27421700 DOI: 10.1016/j.annepidem.2016.06.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 05/06/2016] [Accepted: 06/03/2016] [Indexed: 01/15/2023]
Abstract
In the context of generalized human immunodeficiency virus (HIV) epidemics, there has been limited recent investment in HIV surveillance and prevention programming for key populations including female sex workers. Often implicit in the decision to limit investment in these epidemic settings are assumptions including that commercial sex is not significant to the sustained transmission of HIV, and HIV interventions designed to reach "all segments of society" will reach female sex workers and clients. Emerging empiric and model-based evidence is challenging these assumptions. This article highlights the frameworks and estimates used to characterize the role of sex work in HIV epidemics as well as the relevant empiric data landscape on sex work in generalized HIV epidemics and their strengths and limitations. Traditional approaches to estimate the contribution of sex work to HIV epidemics do not capture the potential for upstream and downstream sexual and vertical HIV transmission. Emerging approaches such as the transmission population attributable fraction from dynamic mathematical models can address this gap. To move forward, the HIV scientific community must begin by replacing assumptions about the epidemiology of generalized HIV epidemics with data and more appropriate methods of estimating the contribution of unprotected sex in the context of sex work.
Collapse
Affiliation(s)
- Sharmistha Mishra
- Division of Infectious Diseases, Department of Medicine, St. Michael's Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada; Department of Infectious Disease Epidemiology, Imperial College, London, UK
| | - Marie-Claude Boily
- Department of Infectious Disease Epidemiology, Imperial College, London, UK
| | - Sheree Schwartz
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Chris Beyrer
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - James F Blanchard
- Centre for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Stephen Moses
- Centre for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Delivette Castor
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC
| | - Nancy Phaswana-Mafuya
- HIV/AIDS, STI, and Tuberculosis Department, Human Sciences Research Council, Port Elizabeth, South Africa
| | - Peter Vickerman
- School of Social and Community Medicine, Bristol University, Bristol, UK
| | - Fatou Drame
- Department of Geography, Université Gaston-Berger, St. Louis, Senegal
| | - Michel Alary
- Département de médecine sociale et préventive, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
| | - Stefan D Baral
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD.
| |
Collapse
|
26
|
Des Jarlais D, Duong HT, Pham Minh K, Khuat OHT, Nham TTT, Arasteh K, Feelemyer J, Heckathorn DD, Peries M, Moles JP, Laureillard D, Nagot N. Integrated respondent-driven sampling and peer support for persons who inject drugs in Haiphong, Vietnam: a case study with implications for interventions. AIDS Care 2016; 28:1312-5. [PMID: 27178119 DOI: 10.1080/09540121.2016.1178698] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Combined prevention for HIV among persons who inject drugs (PWID) has led to greatly reduced HIV transmission among PWID in many high-income settings, but these successes have not yet been replicated in resource-limited settings. Haiphong, Vietnam experienced a large HIV epidemic among PWID, with 68% prevalence in 2006. Haiphong has implemented needle/syringe programs, methadone maintenance treatment (MMT), and anti-retroviral treatment (ART), but there is an urgent need to identify high-risk PWID and link them to services. We examined integration of respondent-driven sampling (RDS) and strong peer support groups as a mechanism for identifying high-risk PWID and linking them to services. The peer support staff performed the key tasks that required building and maintaining trust with the participants, including recruiting the RDS seeds, greeting and registering participants at the research site, taking electronic copies of participant fingerprints (to prevent multiple participation in the study), and conducting urinalyses. A 6-month cohort study with 250 participants followed the RDS cross-sectional study. The peer support staff maintained contact with these participants, tracking them if they missed appointments, and providing assistance in accessing methadone and ART. The RDS recruitment was quite rapid, with 603 participants recruited in three weeks. HIV prevalence was 25%, Hepatitis C (HCV) prevalence 67%, and participants reported an average of 2.7 heroin injections per day. Retention in the cohort study was high, with 86% of participants re-interviewed at 6-month follow-up. Assistance in accessing services led to half of the participants in need of methadone enrolled in methadone clinics, and half of HIV-positive participants in need of ART enrolled in HIV clinics by the 6-month follow-up. This study suggests that integrating large-scale RDS and strong peer support may provide a method for rapidly linking high-risk PWID to combined prevention and care, and greatly reducing HIV transmission among PWID in resource-limited settings.
Collapse
Affiliation(s)
- Don Des Jarlais
- a The Baron Edmond de Rothschild Chemical Dependency Institute, Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - Huong Thi Duong
- b Hai Phong University of Medicine and Pharmacy , Hai Phong , Vietnam
| | - Khue Pham Minh
- b Hai Phong University of Medicine and Pharmacy , Hai Phong , Vietnam
| | | | | | - Kamyar Arasteh
- a The Baron Edmond de Rothschild Chemical Dependency Institute, Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - Jonathan Feelemyer
- a The Baron Edmond de Rothschild Chemical Dependency Institute, Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | | | - Marianne Peries
- e Inserm U1058, Etablissement Français du Sang , University of Montpellier , Montpellier , France
| | - Jean Pierre Moles
- e Inserm U1058, Etablissement Français du Sang , University of Montpellier , Montpellier , France
| | - Didier Laureillard
- e Inserm U1058, Etablissement Français du Sang , University of Montpellier , Montpellier , France.,f Infectious Diseases Department , Caremeau University Hospital , Nîmes , France
| | - Nicolas Nagot
- e Inserm U1058, Etablissement Français du Sang , University of Montpellier , Montpellier , France
| | | |
Collapse
|
27
|
Prospects for ending the HIV epidemic among persons who inject drugs in Haiphong, Vietnam. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2016; 32:50-6. [PMID: 27006257 DOI: 10.1016/j.drugpo.2016.02.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 02/11/2016] [Accepted: 02/19/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND To examine the prospects for "ending the HIV epidemic" among persons who inject drugs (PWID) in Haiphong, Vietnam. Reaching an incidence of <0.5/100 person-years at risk (PY) was used as an operational definition for "ending the epidemic." METHODS A respondent driven sampling study of 603 PWID was conducted from September to October 2014. Current heroin use (verified with urine testing and marks of injection) was an eligibility requirement. A structured questionnaire was administered by trained interviewers to obtain demographic, drug use, and risk behavior data; HIV counseling and testing and HCV testing was also conducted. Two methods (by assuming all new injectors were HIV negative at first injection and by slope of prevalence by years injecting) were used for estimating HIV among persons injecting for <5 years ("new injectors"). Comparisons were made to the HIV epidemic among PWID in New York City and modeling of the HIV epidemic in Can Tho province. RESULTS HIV prevalence was 25% in 2014, down from 68% in 2006 and 48% in 2009; overall HCV prevalence in the study was 67%. Among HIV seropositive PWID, 33% reported receiving antiretroviral treatment. The great majority (83%) of subjects reported pharmacies as their primary source of needles and syringes and self-reported receptive and distributive syringe sharing were quite low (<6%). Estimating HIV incidence among non-MSM male new injectors with the assumption that all were HIV negative at first injection gave a rate of 1.2/100 person-years (95% CI -0.24, 3.4). Estimating HIV incidence by the slope of prevalence by years injecting gave a rate of 0.8/100 person-years at risk (95% CI -0.9, 2.5). CONCLUSIONS The current HIV epidemic among PWID in Haiphong is in a declining phase, but estimated incidence among non-MSM new injectors is approximately 1/100 person-years and there is a substantial gap in provision of ART for HIV seropositives. Scaling up interventions, particularly HIV counseling and testing and antiretroviral treatment for all seropositive PWID, should accelerate the decline. Ending the epidemic is an attainable public health goal.
Collapse
|
28
|
Drake TL, Devine A, Yeung S, Day NPJ, White LJ, Lubell Y. Dynamic Transmission Economic Evaluation of Infectious Disease Interventions in Low- and Middle-Income Countries: A Systematic Literature Review. HEALTH ECONOMICS 2016; 25 Suppl 1:124-39. [PMID: 26778620 PMCID: PMC5066646 DOI: 10.1002/hec.3303] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Economic evaluation using dynamic transmission models is important for capturing the indirect effects of infectious disease interventions. We examine the use of these methods in low- and middle-income countries, where infectious diseases constitute a major burden. This review is comprised of two parts: (1) a summary of dynamic transmission economic evaluations across all disease areas published between 2011 and mid-2014 and (2) an in-depth review of mosquito-borne disease studies focusing on health economic methods and reporting. Studies were identified through a systematic search of the MEDLINE database and supplemented by reference list screening. Fifty-seven studies were eligible for inclusion in the all-disease review. The most common subject disease was HIV/AIDS, followed by malaria. A diverse range of modelling methods, outcome metrics and sensitivity analyses were used, indicating little standardisation. Seventeen studies were included in the mosquito-borne disease review. With notable exceptions, most studies did not employ economic evaluation methods beyond calculating a cost-effectiveness ratio or net benefit. Many did not adhere to health care economic evaluations reporting guidelines, particularly with respect to full model reporting and uncertainty analysis. We present a summary of the state-of-the-art and offer recommendations for improved implementation and reporting of health economic methods in this crossover discipline.
Collapse
Affiliation(s)
- Tom L Drake
- University of Oxford, Oxford, UK
- Mahidol University, Bangkok, Thailand
| | - Angela Devine
- University of Oxford, Oxford, UK
- Mahidol University, Bangkok, Thailand
| | - Shunmay Yeung
- London School of Hygiene and Tropical Medicine, London, UK
| | - Nicholas P J Day
- University of Oxford, Oxford, UK
- Mahidol University, Bangkok, Thailand
| | - Lisa J White
- University of Oxford, Oxford, UK
- Mahidol University, Bangkok, Thailand
| | - Yoel Lubell
- University of Oxford, Oxford, UK
- Mahidol University, Bangkok, Thailand
| |
Collapse
|
29
|
Tello-Velásquez JR, Díaz-Llanes BE, Mezones-Holguín E, Rodríguez-Morales AJ, Huamaní C, Hernández AV, Arévalo-Abanto J. [Poor quality of sleep associated with low adherence to highly active antiretroviral therapy in Peruvian patients with HIV/AIDS]. CAD SAUDE PUBLICA 2015; 31:989-1002. [PMID: 26083174 DOI: 10.1590/0102-311x00010014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 12/01/2014] [Indexed: 01/25/2023] Open
Abstract
This cross-sectional study analyzed the association between poor quality of sleep and adherence to highly active antiretroviral therapy (HAART) in 389 Peruvian patients with HIV/AIDS. Poor quality of sleep was measured with the Pittsburgh Sleep Quality Index (PSQI) and adherence with the CEAT-VIH (Peruvian adaptation). A Poisson generalized linear model with robust standard errors was used to estimate prevalence ratios and 95%CI. A crude model showed that mild, moderate, and severe poor quality of sleep were associated with inadequate treatment adherence. In the adjusted model for variables associated in the bivariate analysis or variables theoretically associated with adherence, only moderate/severe poor quality of sleep remained associated (PR = 1.34, 95%CI: 1.17-1.54; and PR = 1.34, 95%CI: 1.16-1.57, respectively). The study concluded that moderate/severe poor quality of sleep was independently associated with adherence to HAART. Assessing quality of sleep may be helpful in the comprehensive evaluation of HIV patients.
Collapse
Affiliation(s)
| | | | | | | | - Charles Huamaní
- Centro Nacional de Salud Pública, Instituto Nacional de Salud, Lima, Perú
| | - Adrián V Hernández
- Escuela de Medicina, Universidad Peruana de Ciencias Aplicadas, Lima, Perú
| | | |
Collapse
|
30
|
"Seek, Test, Treat" Lessons From Australia: A Study of HIV Testing Patterns From a Cohort of Men Who Have Sex With Men. J Acquir Immune Defic Syndr 2015; 69:460-5. [PMID: 25835608 DOI: 10.1097/qai.0000000000000613] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE HIV diagnoses are increasing in Australia, mostly among men who have sex with men (MSM). Similar to many countries, Australia's HIV prevention strategies emphasize a "seek, test, treat" approach including enhancing HIV testing frequency. We describe HIV testing among MSM and correlates of returning for testing within 12 months in the context of new HIV prevention paradigms. METHODS Testing and behavioral data (2007-2013) contributed by MSM aged ≥ 16 years were included. Total HIV tests by calendar year and repeat tests within 12 months were described, alongside negative binomial regression for trend. A 2-level mixed-effects logistic regression model examined correlates of testing within 12 months. Median (days) between HIV tests was compared between MSM diagnosed with HIV and persistently HIV-negative MSM. RESULTS The study included 46,060 tests from 17,904 MSM. There was an increase in annual tests (P < 0.01), repeat tests within 12 months (P < 0.01), and the proportion of tests within 12 months of an index test (P < 0.01), although only to 53.3% in 2013. Return rates were higher in MSM aged 16-29 years (adjusted odds ratio 1.30, 95% confidence interval: 1.1 to 1.5) and those reporting higher numbers of partners (adjusted odds ratio 3.5, 95% confidence interval: 3.0 to 4.0). Median time between tests among MSM diagnosed with HIV (233 days) was greater than for HIV-negative MSM (189 days) (P = 0.03). CONCLUSIONS Although testing has increased, testing frequency among many MSM remains suboptimal. To optimize "seek, test, treat"-based HIV prevention strategies, new approaches to increase testing uptake and early HIV detection among MSM are needed.
Collapse
|
31
|
Abstract
PURPOSE OF REVIEW To benefit very early treatment for an HIV cure, HIV infection must be diagnosed immediately after infection. We review potential strategies for expansion of HIV testing in preparation for a potential HIV cure in the distant future. RECENT FINDINGS Very early antiretroviral therapy (ART) initiated during acute or early HIV infection may result in long-term viral control. Such strategies will require programmatic systems for very early diagnosis and very early ART. Yet, most HIV-infected individuals start treatment late and presumably are diagnosed late. Operational issues will have to address the treatment cascade much earlier starting from HIV testing, test result notification, posttest counseling, immunological and clinical assessment and ultimately starting treatment. Well designed implementation research studies are needed to determine effective interventions to diagnose HIV as early as during acute and early HIV infection. SUMMARY Approaches for earlier HIV diagnosis and very early ART for a potential functional HIV cure remain elusive unless early HIV diagnosis can be radically expanded.
Collapse
|
32
|
Reaching the unreached: treatment as prevention as a workable strategy to mitigate HIV and its consequences in high-risk groups. Curr HIV/AIDS Rep 2015; 11:505-12. [PMID: 25342571 DOI: 10.1007/s11904-014-0238-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
While there have been significant advances in curbing the HIV disease epidemic worldwide, there continues to be significant number of incident cases with 2.3 million new infections in the year 2012 alone. Treatment as prevention (TasP), which involves the use of antiretroviral drugs to decrease the likelihood of HIV illness, death and transmission from infected individuals to their noninfected sexual and /or drug paraphernalia-sharing injecting partners, must be incorporated into any HIV prevention strategy that is going to be successful on a large scale. Especially in resource-limited settings, the focus of the prevention approach should be on high-risk groups who contribute disproportionately to community HIV transmission, including people who inject drugs (PWID), men who have sex with men (MSM) and sex workers. Innovative strategies including integrated care services adapted to different patient care settings have to and can be employed to reach these at-risk populations.
Collapse
|
33
|
Kato M, Long NH, Duong BD, Nhan DT, Nguyen TTV, Hai NH, Giang LM, Hoa DM, Van NT, Suthar AB, Fontaine C, Nadol P, Lo YR, McConnell MS. Enhancing the benefits of antiretroviral therapy in Vietnam: towards ending AIDS. Curr HIV/AIDS Rep 2015; 11:487-95. [PMID: 25472886 PMCID: PMC4264957 DOI: 10.1007/s11904-014-0235-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Vietnam has a concentrated HIV epidemic, with the highest HIV prevalence being observed among people who inject drugs (PWID). Based on its experience scaling-up robust HIV interventions, Vietnam aims to further strengthen its response by harnessing the preventive benefits of antiretroviral therapy (ART). Mathematical modelling suggests that prioritizing key populations for earlier access to ART, combined with other prevention interventions, may have significant impact on the epidemic, cost-effectively reducing new HIV infections and deaths. Pilot studies are being conducted to assess feasibility and acceptability of expansion of HIV testing and counselling (HTC) and early ART among key populations and to demonstrate innovative service delivery models to address challenges in uptake of services across the care cascade. Earlier access of key populations to combination prevention interventions, combined with sustained political commitment and supportive environment for key populations, are essential for maximum impact of ART on the HIV epidemic in Vietnam.
Collapse
Affiliation(s)
- Masaya Kato
- World Health Organization Vietnam Country Office, 6 3 Tran Hung Dao Street, Hanoi, Vietnam,
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Pham QD, Wilson DP, Kerr CC, Shattock AJ, Do HM, Duong AT, Nguyen LT, Zhang L. Estimating the Cost-Effectiveness of HIV Prevention Programmes in Vietnam, 2006-2010: A Modelling Study. PLoS One 2015. [PMID: 26196290 PMCID: PMC4510535 DOI: 10.1371/journal.pone.0133171] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Introduction Vietnam has been largely reliant on international support in its HIV response. Over 2006-2010, a total of US$480 million was invested in its HIV programmes, more than 70% of which came from international sources. This study investigates the potential epidemiological impacts of these programmes and their cost-effectiveness. Methods We conducted a data synthesis of HIV programming, spending, epidemiological, and clinical outcomes. Counterfactual scenarios were defined based on assumed programme coverage and behaviours had the programmes not been implemented. An epidemiological model, calibrated to reflect the actual epidemiological trends, was used to estimate plausible ranges of programme impacts. The model was then used to estimate the costs per averted infection, death, and disability adjusted life-year (DALY). Results Based on observed prevalence reductions amongst most population groups, and plausible counterfactuals, modelling suggested that antiretroviral therapy (ART) and prevention programmes over 2006-2010 have averted an estimated 50,600 [95% uncertainty bound: 36,300–68,900] new infections and 42,600 [36,100–54,100] deaths, resulting in 401,600 [312,200–496,300] fewer DALYs across all population groups. HIV programmes in Vietnam have cost an estimated US$1,972 [1,447–2,747], US$2,344 [1,843–2,765], and US$248 [201–319] for each averted infection, death, and DALY, respectively. Conclusions Our evaluation suggests that HIV programmes in Vietnam have most likely had benefits that are cost-effective. ART and direct HIV prevention were the most cost-effective interventions in reducing HIV disease burden.
Collapse
Affiliation(s)
- Quang Duy Pham
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- Department for Disease Control and Prevention, Pasteur Institute, Ho Chi Minh City, Vietnam
| | - David P. Wilson
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Cliff C. Kerr
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew J. Shattock
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Hoa Mai Do
- Department of Health System, Hanoi School of Public Health, Hanoi, Vietnam
| | - Anh Thuy Duong
- Department of Planning and Finance, Vietnam Administration of HIV/AIDS Control, Hanoi, Vietnam
| | | | - Lei Zhang
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- * E-mail:
| |
Collapse
|
35
|
McMillan KE, Worth H. Problematics of empowerment: sex worker HIV prevention in the Pacific. Health Promot Int 2015; 31:946-953. [PMID: 26135585 DOI: 10.1093/heapro/dav069] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
A recent overview of HIV/STI prevention programmes for sex workers in the Pacific region indicates that, despite a regional policy shift from universal to targeted interventions, Pacific Island countries currently lack core HIV/STI prevention services for sex workers. Across the region, condom distribution, peer outreach and support services for sex workers have ceased even in countries where such programmes had previously existed. This article cautions that the endorsement of empowerment projects does not negate the important role of condom access in HIV and STI prevention efforts for Pacific sex workers. While community empowerment underpins, and is essential to the sustainability of, effective interventions, it does not constitute an adequate form of HIV and STI prevention in and of itself. We contend that in the context of the Pacific Islands, timely and effective HIV prevention measures must specifically attend to the implementation of, and sustained support for, behavioural interventions such as sex-worker-specific peer education, condom and lubricant distribution, and access to appropriate sexual health services. Further, the responsibility for delivery of these should not be borne solely by fledgling sex worker organizations and communities. The evolution of targeted interventions in the Pacific and the current lack of funded condom distribution programmes highlight a more generalizable imperative within HIV prevention to ensure that behaviour change efforts are not considered to be extraneous to, or rendered redundant by, empowerment-based interventions.
Collapse
Affiliation(s)
- Karen E McMillan
- School of Public Health and Community Medicine, UNSW, Sydney, Australia
| | - Heather Worth
- School of Public Health and Community Medicine, UNSW, Sydney, Australia
| |
Collapse
|
36
|
Chas J, Hema A, Slama L, Kabore NF, Lescure FX, Fontaine C, Pialoux G, Sawadogo A. The Day-Hospital of the University Hospital, Bobo Dioulasso: An Example of Optimized HIV Management in Southern Burkina Faso. PLoS One 2015; 10:e0125588. [PMID: 25970181 PMCID: PMC4430172 DOI: 10.1371/journal.pone.0125588] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 03/18/2015] [Indexed: 01/12/2023] Open
Abstract
Objectives To evaluate the epidemiological evolution of patients with HIV (PtHIV), between 2002 and 2012, in a day-hospital that became an HIV reference centre for south-west Burkina Faso. Materials and Methods This was a retrospective study of PtHIV followed in the Bobo Dioulasso university hospital since 2002. The study was based on clinical data recorded using ESOPE software and analysed using Excel and SAS. Results A total of 7320 patients have been treated at the centre since 2002; the active file of patients increased from 147 in 2002 to 3684 patients in 2012. Mean age was stable at 38.4 years and the majority were female (71%). The delay to initiation of antiretroviral (ARV) treatment after HIV diagnosis decreased from 12.9 months in 2002 to 7.2 months in 2012. The percentage of PtHIV lost to follow-up, untreated for HIV and deaths all decreased after 2005. Voluntary anonymous screening and/or an evocative clinical picture were the main reasons for HIV diagnosis, usually at a late stage (41.1% at WHO stage 3). Virological success increased due to a decrease in time to initiation of ARV treatment and an increase in percentage of patients treated (90.5% in 2012, mainly with 1st line drugs). However, there was also a slight increase in the rate of therapeutic failures and the percentage of patients who progressed to 2nd or 3rd line-ARVs. Conclusion Our day-hospital is a good example of the implementation of a specialist centre for the management of PtHIV in a resource-limited country (Burkina Faso).
Collapse
Affiliation(s)
- Julie Chas
- Service des Maladies Infectieuses et Tropicales, Hôpital Tenon, Paris, France
| | - Arsène Hema
- Hôpital de Jour, CHU Sourô Sanou, Bobo Dioulasso, Burkina Faso
| | - Laurence Slama
- Service des Maladies Infectieuses et Tropicales, Hôpital Tenon, Paris, France
| | | | - François-Xavier Lescure
- AP-HP, Service de Maladies Infectieuses et Tropicales et IAME, Hôpital Bichat-Claude Bernard, UMR 1137, INSERM, Univ Paris Diderot, Sorbonne Paris Cité, F-75018 Paris, France
| | | | - Gilles Pialoux
- Service des Maladies Infectieuses et Tropicales, Hôpital Tenon, Paris, France
- UPMC, Paris, France
- * E-mail:
| | - Adrien Sawadogo
- Hôpital de Jour, CHU Sourô Sanou, Bobo Dioulasso, Burkina Faso
| |
Collapse
|
37
|
Blower S, Palk L. Combination HIV prevention and the battle of the sexes. THE LANCET. INFECTIOUS DISEASES 2015; 15:261-3. [PMID: 25749218 DOI: 10.1016/s1473-3099(15)70037-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Sally Blower
- Center for Biomedical Modeling, Semel Institute of Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles, CA 90024, USA.
| | - Laurence Palk
- Center for Biomedical Modeling, Semel Institute of Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles, CA 90024, USA
| |
Collapse
|
38
|
Potential impact of existing interventions and of antiretroviral use in female sex workers on transmission of HIV in Burkina Faso: a modeling study. J Acquir Immune Defic Syndr 2015; 68 Suppl 2:S180-8. [PMID: 25723983 DOI: 10.1097/qai.0000000000000441] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The impact and cost-effectiveness of antiretroviral treatment (ART) as prevention is likely to vary depending on the local context. Burkina Faso has a concentrated mature HIV epidemic where female sex workers (FSW) are thought to have driven HIV transmission. METHODS A dynamic HIV transmission model was developed using data from the Yerelon FSW cohort in Bobo-Dioulasso and population surveys. Compared with current ART provision [status quo (SQ)], the model estimated the proportion of HIV infections averted or incremental life-years gained per additional person-year of ART over 20 years for ART targeting different subgroups or expanding eligibility to all HIV-infected individuals compared with SQ. RESULTS Modeling suggests that condom use within commercial sex has averted 40% of past HIV infections. Continuing SQ averts 35%-47% of new infections over 20 years compared with no ART. Expanding ART eligibility to all HIV-infected individuals and increasing recruitment (80% per year) could avert a further 65% of new infections, whereas targeting full-time FSW or all FSWs achieved less impact but was more efficient in terms of life-years gained per 100 person-years of ART. Local HIV elimination is possible with expanded ART provision to FSWs but requires condom use within commercial sex to be maintained at high levels. CONCLUSIONS Increasing FSW recruitment onto ART could be a highly efficient method for reducing HIV transmission in concentrated epidemic settings but should not be undertaken at the expense of existing interventions for FSWs. Specialized clinics providing multiple interventions for FSWs should be a fundamental component of prevention in concentrated epidemics.
Collapse
|
39
|
Zhang L, Phanuphak N, Henderson K, Nonenoy S, Srikaew S, Shattock AJ, Kerr CC, Omune B, van Griensven F, Osornprasop S, Oelrichs R, Ananworanich J, Wilson DP. Scaling up of HIV treatment for men who have sex with men in Bangkok: a modelling and costing study. Lancet HIV 2015; 2:e200-7. [PMID: 26423002 DOI: 10.1016/s2352-3018(15)00020-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 02/03/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite the high prevalence of HIV in men who have sex with men (MSM) in Bangkok, little investment in HIV prevention for MSM has been made. HIV testing and treatment coverage remains low. Through a pragmatic programme-planning approach, we assess possible service linkage and provision of HIV testing and antiretroviral treatment (ART) to MSM in Bangkok, and the most cost-effective scale-up strategy. METHODS We obtained epidemiological and service capacity data from the Thai National Health Security Office database for 2011. We surveyed 13 representative medical facilities for detailed operational costs of HIV-related services for sexually active MSM (defined as having sex with men in the past 12 months) in metropolitan Bangkok. We estimated the costs of various ART scale-up scenarios, accounting for geographical accessibility across Bangkok. We used an HIV transmission population-based model to assess the cost-effectiveness of the scenarios. FINDINGS For present HIV testing (23% [95% CI 17-36] of MSM at high risk in 2011) and ART provision (20% of treatment-eligible MSM at high risk on ART in 2011) to be sustained, a US$73·8 million ($51·0 million to $97·0 million) investment during the next decade would be needed, which would link an extra 43,000 (27,900-58,000) MSM at high risk to HIV testing and 5100 (3500-6700) to ART, achieving an ART coverage of 44% for MSM at high risk in 2022. An additional $55·3 million investment would link an extra 46,700 (30,300-63,200) MSM to HIV testing and 12,600 (8800-16,600) to ART, achieving universal ART coverage of this population by 2022. This increased investment is achievable within present infrastructure capacity. Consequently, an estimated 5100 (3600-6700) HIV-related deaths and 3700 (2600-4900) new infections could be averted in MSM by 2022, corresponding to a 53% reduction in deaths and a 35% reduction in infections from 2012 levels. The expansion would cost an estimated $10,809 (9071-13,274) for each HIV-related death, $14,783 (12,389-17,960) per new infection averted, and $351 (290-424) per disability-adjusted life-year averted. INTERPRETATION Spare capacity in Bangkok's medical facilities can be used to expand ART access for MSM with large epidemiological benefits. The expansion needs increased funding directed to MSM services, but given the epidemiological trends, is probably cost effective. Our modelling approach and outcomes are likely to be applicable to other settings. FUNDING World Bank Group and Australian National Health and Medical Research Council.
Collapse
Affiliation(s)
- Lei Zhang
- The Kirby Institute, University of New South Wales, Kensington, NSW, Australia
| | | | - Klara Henderson
- The Kirby Institute, University of New South Wales, Kensington, NSW, Australia
| | | | - Sasiwan Srikaew
- Thai Red Cross Society AIDS Research Centre, Bangkok, Thailand
| | - Andrew J Shattock
- The Kirby Institute, University of New South Wales, Kensington, NSW, Australia
| | - Cliff C Kerr
- The Kirby Institute, University of New South Wales, Kensington, NSW, Australia
| | - Brenda Omune
- Thai Red Cross Society AIDS Research Centre, Bangkok, Thailand
| | | | | | | | - Jintanat Ananworanich
- Thai Red Cross Society AIDS Research Centre, Bangkok, Thailand; US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA; Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - David P Wilson
- The Kirby Institute, University of New South Wales, Kensington, NSW, Australia.
| |
Collapse
|
40
|
Childs LM, Abuelezam NN, Dye C, Gupta S, Murray MB, Williams BG, Buckee CO. Modelling challenges in context: lessons from malaria, HIV, and tuberculosis. Epidemics 2015; 10:102-7. [PMID: 25843394 PMCID: PMC4451070 DOI: 10.1016/j.epidem.2015.02.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 02/09/2015] [Accepted: 02/09/2015] [Indexed: 02/08/2023] Open
Abstract
Malaria, HIV, and tuberculosis (TB) collectively account for several million deaths each year, with all three ranking among the top ten killers in low-income countries. Despite being caused by very different organisms, malaria, HIV, and TB present a suite of challenges for mathematical modellers that are particularly pronounced in these infections, but represent general problems in infectious disease modelling, and highlight many of the challenges described throughout this issue. Here, we describe some of the unifying challenges that arise in modelling malaria, HIV, and TB, including variation in dynamics within the host, diversity in the pathogen, and heterogeneity in human contact networks and behaviour. Through the lens of these three pathogens, we provide specific examples of the other challenges in this issue and discuss their implications for informing public health efforts.
Collapse
Affiliation(s)
- Lauren M Childs
- Center for Communicable Disease Dynamics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, United States; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA 02115, United States
| | - Nadia N Abuelezam
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA 02115, United States
| | - Christopher Dye
- Office of the Director General, World Health Organization, Avenue Appia, 1211 Geneva 27, Switzerland
| | - Sunetra Gupta
- Department of Zoology, University of Oxford, Oxford OX1 3PS, United Kingdom
| | - Megan B Murray
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA 02115, United States; Division of Global Health Equity, Brigham & Women's Hospital, Boston, MA 02115, United States
| | - Brian G Williams
- South African Centre for Epidemiological Modelling and Analysis, Stellenbosch, South Africa; Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Caroline O Buckee
- Center for Communicable Disease Dynamics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, United States; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA 02115, United States.
| |
Collapse
|
41
|
Beyrer C, Crago AL, Bekker LG, Butler J, Shannon K, Kerrigan D, Decker MR, Baral SD, Poteat T, Wirtz AL, Weir BW, Barré-Sinoussi F, Kazatchkine M, Sidibé M, Dehne KL, Boily MC, Strathdee SA. An action agenda for HIV and sex workers. Lancet 2015; 385:287-301. [PMID: 25059950 PMCID: PMC4302059 DOI: 10.1016/s0140-6736(14)60933-8] [Citation(s) in RCA: 145] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The women, men, and transgender people who sell sex globally have disproportionate risks and burdens of HIV in countries of low, middle, and high income, and in concentrated and generalised epidemic contexts. The greatest HIV burdens continue to be in African female sex workers. Worldwide, sex workers still face reduced access to needed HIV prevention, treatment, and care services. Legal environments, policies, police practices, absence of funding for research and HIV programmes, human rights violations, and stigma and discrimination continue to challenge sex workers' abilities to protect themselves, their families, and their sexual partners from HIV. These realities must change to realise the benefits of advances in HIV prevention and treatment and to achieve global control of the HIV pandemic. Effective combination prevention and treatment approaches are feasible, can be tailored for cultural competence, can be cost-saving, and can help to address the unmet needs of sex workers and their communities in ways that uphold their human rights. To address HIV in sex workers will need sustained community engagement and empowerment, continued research, political will, structural and policy reform, and innovative programmes. But such actions can and must be achieved for sex worker communities everywhere.
Collapse
Affiliation(s)
- Chris Beyrer
- Center for Public Health and Human Rights, Johns Hopkins University, Baltimore, MD, USA.
| | | | - Linda-Gail Bekker
- Desmond Tutu HIV Research Centre, University of Cape Town, Cape Town, South Africa
| | - Jenny Butler
- United Nations Population Fund, New York, NY, USA
| | - Kate Shannon
- BC Center for Excellence in HIV/AIDS, University of British Columbia, Vancouver, BC, Canada
| | - Deanna Kerrigan
- Center for Public Health and Human Rights, Johns Hopkins University, Baltimore, MD, USA; Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Michele R Decker
- Center for Public Health and Human Rights, Johns Hopkins University, Baltimore, MD, USA
| | - Stefan D Baral
- Center for Public Health and Human Rights, Johns Hopkins University, Baltimore, MD, USA
| | - Tonia Poteat
- Center for Public Health and Human Rights, Johns Hopkins University, Baltimore, MD, USA
| | - Andrea L Wirtz
- Center for Public Health and Human Rights, Johns Hopkins University, Baltimore, MD, USA; Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Brian W Weir
- Center for Public Health and Human Rights, Johns Hopkins University, Baltimore, MD, USA
| | | | - Michel Kazatchkine
- UN Special Envoy for HIV in eastern Europe and central Asia, Geneva, Switzerland
| | | | | | | | | |
Collapse
|
42
|
Ahmed T, Long NT, Huong PTT, Stewart DE. HIV and Injecting Drug Users in Vietnam: An Overview of Policies and Responses. WORLD MEDICAL & HEALTH POLICY 2014. [DOI: 10.1002/wmh3.122] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
43
|
HIV treatment as prevention: contradictory perspectives from dynamic mathematical models. ScientificWorldJournal 2014; 2014:760734. [PMID: 25580461 PMCID: PMC4279253 DOI: 10.1155/2014/760734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Accepted: 11/26/2014] [Indexed: 12/20/2022] Open
Abstract
The preventative effects of antiretroviral therapy for people with HIV have been debated since they were first raised. Models commenced studying the preventive effects of treatment in the 1990s, prior to initial public reports. However, the outcomes of the preventive effects of antiretroviral use were not consistent. Some outcomes of dynamic models were based on unfeasible assumptions, such as no consideration of drug resistance, behavior disinhibition, or economic inputs in poor countries, and unrealistic input variables, for example, overstated initiation time, adherence, coverage, and efficacy of treatment. This paper reviewed dynamic mathematical models to ascertain the complex effects of ART on HIV transmission. This review discusses more conservative inputs and outcomes relative to antiretroviral use in HIV infections in dynamic mathematical models. ART alone cannot eliminate HIV transmission.
Collapse
|
44
|
Antiretroviral therapy uptake, attrition, adherence and outcomes among HIV-infected female sex workers: a systematic review and meta-analysis. PLoS One 2014; 9:e105645. [PMID: 25265158 PMCID: PMC4179256 DOI: 10.1371/journal.pone.0105645] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 07/16/2014] [Indexed: 11/19/2022] Open
Abstract
Purpose We aimed to characterize the antiretroviral therapy (ART) cascade among female sex workers (FSWs) globally. Methods We systematically searched PubMed, Embase and MEDLINE in March 2014 to identify studies reporting on ART uptake, attrition, adherence, and outcomes (viral suppression or CD4 count improvements) among HIV-infected FSWs globally. When possible, available estimates were pooled using random effects meta-analyses (with heterogeneity assessed using Cochran's Q test and I2 statistic). Results 39 studies, reporting on 21 different FSW study populations in Asia, Africa, North America, South America, and Central America and the Caribbean, were included. Current ART use among HIV-infected FSWs was 38% (95% CI: 29%–48%, I2 = 96%, 15 studies), and estimates were similar between high-, and low- and middle-income countries. Ever ART use among HIV-infected FSWs was greater in high-income countries (80%; 95% CI: 48%–94%, I2 = 70%, 2 studies) compared to low- and middle-income countries (36%; 95% CI: 7%–81%, I2 = 99%, 3 studies). Loss to follow-up after ART initiation was 6% (95% CI: 3%–11%, I2 = 0%, 3 studies) and death after ART initiation was 6% (95% CI: 3%–11%, I2 = 0%, 3 studies). The fraction adherent to ≥95% of prescribed pills was 76% (95% CI: 68%–83%, I2 = 36%, 4 studies), and 57% (95% CI: 46%–68%, I2 = 82%, 4 studies) of FSWs on ART were virally suppressed. Median gains in CD4 count after 6 to 36 months on ART, ranged between 103 and 241 cells/mm3 (4 studies). Conclusions Despite global increases in ART coverage, there is a concerning lack of published data on HIV treatment for FSWs. Available data suggest that FSWs can achieve levels of ART uptake, retention, adherence, and treatment response comparable to that seen among women in the general population, but these data are from only a few research settings. More routine programme data on HIV treatment among FSWs across settings should be collected and disseminated.
Collapse
|
45
|
Sabin KM, Johnston LG. Epidemiological challenges to the assessment of HIV burdens among key populations: respondent-driven sampling, time-location sampling and demographic and health surveys. Curr Opin HIV AIDS 2014; 9:101-6. [PMID: 24464090 DOI: 10.1097/coh.0000000000000046] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Measuring the burden of HIV among key populations is subject to many challenges. Sufficient quantities of valid HIV prevalence and programme coverage data are required to effectively respond to the epidemic. RECENT FINDINGS Ability to validate exposure to unprotected sex through the innovative use of prostate-specific antigen provides confirmation of condom use. A new weighting scheme based on frequency of venue attendance for time location samples should improve validity of data obtained with this method. Two new proportion estimators, new diagnostic methods, a new population size estimator and new analysis software will provide more robust results from respondent-driven sampling (RDS). SUMMARY Analytical advances have improved the potential quality of results from surveys using time location and RDS. However, data from sufficient numbers of sites over sufficient number of years are still needed to provide clear national pictures of distribution and trends of HIV infection.
Collapse
Affiliation(s)
- Keith M Sabin
- aUNAIDS, Geneva Switzerland bGlobal Health Sciences, University of California, San Francisco, California, USA
| | | |
Collapse
|
46
|
Modelling in concentrated epidemics: informing epidemic trajectories and assessing prevention approaches. Curr Opin HIV AIDS 2014; 9:134-49. [PMID: 24468893 DOI: 10.1097/coh.0000000000000036] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF THE REVIEW This review summarizes recent mathematical modelling studies conducted among key populations including MSM, people who inject drugs (PWID), and female sex workers (FSWs) in low prevalence settings used as a marker of concentrated epidemics. RECENT FINDINGS Most recent studies focused on MSM, Asian settings or high-income countries, studied the transmission dynamics or modelled pre-exposure prophylaxis, treatment as prevention or behavioural interventions specific to each key population (e.g., needle exchange programme or use of low-dead space syringes for PWID). Biological interventions were deemed effective and cost-effective, though still expensive, and often deemed unlikely to result in HIV elimination if used alone. Targeting high-risk individuals even within key populations improved efficiency. Some studies made innovative use of models to formally evaluate HIV prevention programmes, to interpret genetic or co-infection data, and to address methodological questions and validate epidemiological tools. CONCLUSION More work is needed to optimize combination prevention focusing on key populations in different settings. The gaps identified include the limited number of studies modelling drug resistance, structural interventions, treatment as prevention among FSWs, and estimating the contribution of key populations to overall transmission in different settings.
Collapse
|
47
|
Mountain E, Pickles M, Mishra S, Vickerman P, Alary M, Boily MC. The HIV care cascade and antiretroviral therapy in female sex workers: implications for HIV prevention. Expert Rev Anti Infect Ther 2014; 12:1203-19. [PMID: 25174997 DOI: 10.1586/14787210.2014.948422] [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: 01/15/2023]
Abstract
To achieve viral suppression and fully benefit from antiretroviral therapy (ART), it is important that individuals with HIV know that they are HIV infected, link to and remain in HIV care, start and remain on ART and adhere to treatment. In HIV epidemics where female sex workers (FSWs) are key drivers of HIV transmission, the extent to which FSWs use ART and engage in the HIV care cascade could have a considerable impact on HIV transmission from FSWs to the wider population. In this article we review the spectrum of FSW engagement in the HIV care cascade, look at the impact of the HIV care cascade and ART use among FSWs on population-level HIV transmission and discuss HIV prevention for FSWs in the context of ART and the HIV care cascade.
Collapse
Affiliation(s)
- Elisa Mountain
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | | | | | | | | | | |
Collapse
|
48
|
Dimitrov D, Kuang Y, Mâsse BR. Assessing the Public Health impact of HIV interventions: the critical role of demographics. J Acquir Immune Defic Syndr 2014; 66:e60-2. [PMID: 24828270 PMCID: PMC4053692 DOI: 10.1097/qai.0000000000000133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Dobromir Dimitrov
- *Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA †Department of Applied Mathematics, University of Washington, Seattle, WA ‡School of Mathematical and Statistical Sciences, Arizona State University, Tempe, AZ §Department of Mathematics, King Abdulaziz University, Jeddah, Saudi Arabia ‖CHU Sainte-Justine Research Centre, University of Montreal, Montreal, Quebec, Canada
| | | | | |
Collapse
|
49
|
The potential impact of expanding antiretroviral therapy and combination prevention in Vietnam: the modeling approach. J Acquir Immune Defic Syndr 2014; 66:e62-3. [PMID: 24828271 DOI: 10.1097/qai.0000000000000139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
50
|
Abstract
OBJECTIVE To determine the potential of treatment as prevention for reducing HIV incidence among injecting drug users (IDU). METHODS Transmission dynamics of HIV as influenced by cART uptake and demographic changes were studied using an individual-based model. Parameters were based on data of the Amsterdam Cohort Study, and counterfactual treatment scenarios were examined for this city. Demography of the modeled population was also varied to allow for more general conclusions. RESULTS We estimated that over the complete HIV epidemic among IDU in Amsterdam the historic use of cART has led to only 2% less incidence. As individuals were treated from low CD4 cell counts, their decreased infectiousness was offset by increased infectious lifetime. Large reduction in incidence could result from a test and immediate treat strategy, with elimination of HIV occurring when the average time from infection to starting treatment was less than 2 months. However, substantial proportions of new infections were prevented only if the test and treat intervention was implemented within the first few years after HIV-epidemic onset, especially for a declining IDU population. Ignoring heterogeneity in risk-behavior led to overly optimistic expectations of the prevention effects of treatment. In general, treatment led to much greater reduction in incidence compared with stopping HIV-infected IDU from lending out syringes. CONCLUSION A test and immediate treat strategy for HIV among IDU could lead to great reductions in incidence. To fully eliminate the spread of HIV, treatment as prevention should be combined with other interventions, with behavioral intervention directed at those not yet HIV infected.
Collapse
|