1
|
Ngure K, Ongolly F, Dolla A, Awour M, Mugwanya KK, Irungu E, Mugo N, Bukusi EA, Morton J, Odoyo J, Wamoni E, Barnabee G, Peebles K, O'Malley G, Baeten JM. "I just believe there is a risk" understanding of undetectable equals untransmissible (U = U) among health providers and HIV-negative partners in serodiscordant relationships in Kenya. J Int AIDS Soc 2020; 23:e25466. [PMID: 32144888 PMCID: PMC7060133 DOI: 10.1002/jia2.25466] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 02/05/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction Sustained HIV viral suppression resulting from antiretroviral therapy (ART) eliminates the risk of HIV transmission, a concept popularly framed as Undetectable = Untransmittable (U = U). We explored knowledge and acceptance of information around the elimination of HIV transmission risk with ART (U = U) in Kenya. Methods Our qualitative study was conducted within a project evaluating the use of pre‐exposure prophylaxis (PrEP) integrated into ART care for HIV serodiscordant couples in public clinics in Kenya (the Partners Scale Up Project). From February 2017 to April 2019, we conducted semi‐structured key informant interviews with 83 health providers and in‐depth interviews with 61 HIV‐negative people in serodiscordant relationships receiving PrEP services. Transcripts were coded using thematic analysis. Results Health providers reported being aware of reduced risk of HIV transmission as a result of consistent ART use and used words such as “very low,” “minimal” and “like zero” to describe HIV transmission risk after viral suppression. Providers reported finding viral load results helpful when counselling clients about the risk of HIV transmission. Many lacked confidence in U = U and counselled on consistent condom use even after viral suppression while some expressed concerns that communicating this message to people living with HIV (PLHIV) would lead them to engage in multiple sexual relationships. Other providers reported that they did not counsel about the reduced risk of HIV transmission after viral suppression for fear of being blamed if HIV transmission occurred. HIV‐negative partners reported being informed about U = U by providers but they did not believe nor trust the message. Even after their partners achieved viral suppression, some HIV‐negative partners were unwilling to stop PrEP, while others indicated that they would use condoms if they stopped PrEP to be sure that they were protected from HIV. Conclusions Despite awareness that effective ART use eliminates HIV transmission risk, there is both a lack of in‐depth knowledge and conviction about the strategy among health providers and HIV‐negative partners in serodiscordant relationships. New strategies that go beyond communicating the science of U = U to consider the local social and clinical environments could maximize the effectiveness of U = U.
Collapse
Affiliation(s)
- Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Fernandos Ongolly
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Annabell Dolla
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Merceline Awour
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Elizabeth Irungu
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Nelly Mugo
- Department of Global Health, University of Washington, Seattle, WA, USA.,Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth A Bukusi
- Department of Global Health, University of Washington, Seattle, WA, USA.,Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jennifer Morton
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Josephine Odoyo
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth Wamoni
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Gena Barnabee
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kathryn Peebles
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | | | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | | |
Collapse
|
2
|
Brenner BG, Ibanescu RI, Hardy I, Roger M. Genotypic and Phylogenetic Insights on Prevention of the Spread of HIV-1 and Drug Resistance in "Real-World" Settings. Viruses 2017; 10:v10010010. [PMID: 29283390 PMCID: PMC5795423 DOI: 10.3390/v10010010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 12/22/2017] [Accepted: 12/24/2017] [Indexed: 12/15/2022] Open
Abstract
HIV continues to spread among vulnerable heterosexual (HET), Men-having-Sex with Men (MSM) and intravenous drug user (IDU) populations, influenced by a complex array of biological, behavioral and societal factors. Phylogenetics analyses of large sequence datasets from national drug resistance testing programs reveal the evolutionary interrelationships of viral strains implicated in the dynamic spread of HIV in different regional settings. Viral phylogenetics can be combined with demographic and behavioral information to gain insights on epidemiological processes shaping transmission networks at the population-level. Drug resistance testing programs also reveal emergent mutational pathways leading to resistance to the 23 antiretroviral drugs used in HIV-1 management in low-, middle- and high-income settings. This article describes how genotypic and phylogenetic information from Quebec and elsewhere provide critical information on HIV transmission and resistance, Cumulative findings can be used to optimize public health strategies to tackle the challenges of HIV in “real-world” settings.
Collapse
Affiliation(s)
- Bluma G Brenner
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Montreal, QC H3T 1E2, Canada.
| | - Ruxandra-Ilinca Ibanescu
- McGill University AIDS Centre, Lady Davis Institute for Medical Research, Montreal, QC H3T 1E2, Canada.
| | - Isabelle Hardy
- Département de Microbiologie et d'Immunologie et Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC H2X 0A9, Canada.
| | - Michel Roger
- Département de Microbiologie et d'Immunologie et Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC H2X 0A9, Canada.
| |
Collapse
|
3
|
Plazy M, Perriat D, Gumede D, Boyer S, Pillay D, Dabis F, Seeley J, Orne-Gliemann J. Implementing universal HIV treatment in a high HIV prevalence and rural South African setting - Field experiences and recommendations of health care providers. PLoS One 2017; 12:e0186883. [PMID: 29155832 PMCID: PMC5695789 DOI: 10.1371/journal.pone.0186883] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 10/09/2017] [Indexed: 12/18/2022] Open
Abstract
Background We aimed to describe the field experiences and recommendations of clinic-based health care providers (HCP) regarding the implementation of universal antiretroviral therapy (ART) in rural KwaZulu-Natal, South Africa. Methods In Hlabisa sub-district, the local HIV programme of the Department of Health (DoH) is decentralized in 18 clinics, where ART was offered at a CD4 count ≤500 cells/μL from January 2015 to September 2016. Within the ANRS 12249 TasP trial, implemented in part of the sub-district, universal ART (no eligibility criteria) was offered in 11 mobile clinics between March 2012 and June 2016. A cross-sectional qualitative survey was conducted in April–July 2016 among clinic-based nurses and counsellors providing HIV care in the DoH and TasP trial clinics. In total, 13 individual interviews and two focus groups discussions (including 6 and 7 participants) were conducted, audio-recorded, transcribed, and thematically analyzed. Results All HCPs reported an overall good experience of delivering ART early in the course of HIV infection, with most patients willing to initiate ART before being symptomatic. Yet, HCPs underlined that not feeling sick could challenge early ART initiation and adherence, and thus highlighted the need to take time for counselling as an important component to achieve universal ART. HCPs also foresaw logistical challenges of universal ART, and were especially concerned about increasing workload and ART shortage. HCPs finally recommended the need to strengthen the existing model of care to facilitate access to ART, e.g., community-based and integrated HIV services. Conclusions The provision of universal ART is feasible and acceptable according to HCPs in this rural South-African area. However their experiences suggest that universal ART, and more generally the 90-90-90 UNAIDS targets, will be difficult to achieve without the implementation of new models of health service delivery.
Collapse
Affiliation(s)
- Melanie Plazy
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
- Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
- * E-mail:
| | - Delphine Perriat
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
- Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
| | - Dumile Gumede
- Africa Health Research Institute, Somkhele, South Africa
| | - Sylvie Boyer
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France
| | - Deenan Pillay
- Africa Health Research Institute, Somkhele, South Africa
- University College London, Division of Infection and Immunity, London, United Kingdom
| | - François Dabis
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
- Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
| | - Janet Seeley
- Africa Health Research Institute, Somkhele, South Africa
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Joanna Orne-Gliemann
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
- Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
| |
Collapse
|
4
|
Abstract
OBJECTIVE HIV-1 epidemics among MSM remain unchecked despite advances in treatment and prevention paradigms. This study combined viral phylogenetic and behavioural risk data to better understand underlying factors governing the temporal growth of the HIV epidemic among MSM in Quebec (2002-2015). METHODS Phylogenetic analysis of pol sequences was used to deduce HIV-1 transmission dynamics (cluster size, size distribution and growth rate) in first genotypes of treatment-naïve MSM (2002-2015, n = 3901). Low sequence diversity of first genotypes (0-0.44% mixed base calls) was used as an indication of early-stage infection. Behavioural risk data were obtained from the Montreal rapid testing site and primary HIV-1-infection cohorts. RESULTS Phylogenetic analyses uncovered high proportion of clustering of new MSM infections. Overall, 27, 45, 48, 53 and 57% of first genotypes within one (singleton, n = 1359), 2-4 (n = 692), 5-9 (n = 367), 10-19 (n = 405) and 20+ (n = 1277) cluster size groups were early infections (<0.44% diversity). Thirty viruses within large 20+ clusters disproportionately fuelled the epidemic, representing 13, 25 and 42% of infections, first genotyped in 2004-2007 (n = 1314), 2008-2011 (n = 1356) and 2012-2015 (n = 1033), respectively. Of note, 35, 21 and 14% of MSM belonging to 20+, 2-19 and one (singleton) cluster groups were under 30 years of age, respectively. Half of persons seen at the rapid testing site (2009-2011, n = 1781) were untested in the prior year. Poor testing propensity was associated with fewer reported partnerships. CONCLUSION Addressing the heterogeneity in transmission dynamics among HIV-1-infected MSM populations may help guide testing, treatment and prevention strategies.
Collapse
|
5
|
Newman CE, Mao L, Persson A, Holt M, Slavin S, Kidd MR, Post JJ, Wright E, de Wit J. 'Not Until I'm Absolutely Half-Dead and Have To:' Accounting for Non-Use of Antiretroviral Therapy in Semi-Structured Interviews with People Living with HIV in Australia. AIDS Patient Care STDS 2015; 29:267-78. [PMID: 25806574 DOI: 10.1089/apc.2014.0301] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Current debates regarding the use of antiretroviral therapy (ART) to promote both individual- and population-level health benefits underscore the importance of understanding why a subpopulation of people with diagnosed HIV and access to treatment choose not to use it. Semi-structured interviews were conducted between 2012 and 2014 with 27 people living with HIV in Australia who were not using ART at the time of interview. Analytic triangulation permitted an appreciation of not only the varied personal reasons for non-use of treatment, but also underlying views on HIV treatment, and the ideal conditions imagined necessary for treatment initiation. Policy goals to increase the number of people with HIV using ART must recognize the diverse explanations for non-use of ART, which include concerns about the various impacts of committing to lifelong pharmaceutical treatment use. Our research identified distinctive subgroups among people who are not using antiretroviral therapy, with a range of individual and social needs that may affect treatment decisions. These findings challenge assumptions about treatment non-use in resource-rich settings, revealing persistent consumer fears about the potent and unknown effects of HIV medications that deserve greater recognition in policy debate on treatment uptake.
Collapse
Affiliation(s)
- Christy E. Newman
- Centre for Social Research in Health, UNSW Australia, Sydney, Australia
| | - Limin Mao
- Centre for Social Research in Health, UNSW Australia, Sydney, Australia
| | - Asha Persson
- Centre for Social Research in Health, UNSW Australia, Sydney, Australia
| | - Martin Holt
- Centre for Social Research in Health, UNSW Australia, Sydney, Australia
| | - Sean Slavin
- Australian Federation of AIDS Organisations, Sydney, Australia
| | - Michael R. Kidd
- Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Jeffrey J. Post
- Department of Infectious Diseases, The Prince of Wales Hospital, Sydney, Australia
- Prince of Wales Clinical School, UNSW Australia, Sydney, Australia
| | - Edwina Wright
- Department of Infectious Diseases, The Alfred Hospital and Monash University, Melbourne, Australia
- The Burnet Institute, Melbourne, Australia
| | - John de Wit
- Centre for Social Research in Health, UNSW Australia, Sydney, Australia
| |
Collapse
|
6
|
Evans C, Bennett J, Croston M, Brito-Ault N, Bruton J. "In reality, it is complex and difficult": UK nurses' perspectives on "treatment as prevention" within HIV care. AIDS Care 2015; 27:753-7. [PMID: 25650545 DOI: 10.1080/09540121.2014.1002826] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Globally, clinical guidelines for HIV treatment are being altered to reflect new research showing that successful treatment with antiretroviral therapies (ART) can prevent the onward transmission of HIV. As a result, health care services are being challenged to find ways to roll out "treatment as prevention" (TasP) as a public health measure. In theory, TasP requires individuals to start ART as soon as they are diagnosed - for public health reasons - which may be some time before ART for that individual is required for clinical reasons. There is currently little research on the acceptability of TasP from a patient or provider perspective. This paper reports findings from a qualitative study that sought to explore UK nurses' views and experiences of TasP in HIV care. Ten HIV specialist nurses, purposively selected from across the country, were interviewed. Results suggest that, although positive about TasP in principle, nurses hold several reservations about its implementation in practice. Perceived benefits of TasP include reassurance for patients that their loved ones are protected and that immediate care is available. Concerns include the possibility of sexual dis-inhibition or coercion within sexual relationships. In the UK context, decisions around TasP are still being made on a highly individualised patient by patient basis, within a philosophy of holistic care and partnership working. As such, the research participants called for more resources to support information giving, risk assessment and decision-making. The results show that translating a public health treatment approach into individual patient care is complex, potentially time-consuming and may alter traditional provider-patient dynamics. The findings from this study suggest that in-depth research is needed to understand better the patient, community and provider experience as TasP becomes more widely rolled out.
Collapse
Affiliation(s)
- Catrin Evans
- a Queens Medical Centre, School of Health Sciences , University of Nottingham , Nottingham , UK
| | | | | | | | | |
Collapse
|
7
|
Persson A. Significant ambivalence: perspectives of Australian HIV service providers on universal treatment-as-prevention (TasP) for serodiscordant couples. CRITICAL PUBLIC HEALTH 2014. [DOI: 10.1080/09581596.2014.886005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|