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Kerschberger B, Vambe D, Schomaker M, Mabhena E, Daka M, Dlamini T, Ngwenya S, Mamba B, Nxumalo B, Sibanda J, Dube S, Dlamini LM, Mukooza E, Ellman T, Ciglenecki I. Sustained high fatality during TB therapy amid rapid decline in TB mortality at population level: A retrospective cohort and ecological analysis from Shiselweni, Eswatini. Trop Med Int Health 2024; 29:192-205. [PMID: 38100203 DOI: 10.1111/tmi.13961] [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] [Indexed: 03/12/2024]
Abstract
OBJECTIVES Despite declining TB notifications in Southern Africa, TB-related deaths remain high. We describe patient- and population-level trends in TB-related deaths in Eswatini over a period of 11 years. METHODS Patient-level (retrospective cohort, from 2009 to 2019) and population-level (ecological analysis, 2009-2017) predictors and rates of TB-related deaths were analysed in HIV-negative and HIV-coinfected first-line TB treatment cases and the population of the Shiselweni region. Patient-level TB treatment data, and population and HIV prevalence estimates were combined to obtain stratified annual mortality rates. Multivariable Poisson regressions models were fitted to identify patient-level and population-level predictors of deaths. RESULTS Of 11,883 TB treatment cases, 1302 (11.0%) patients died during treatment: 210/2798 (7.5%) HIV-negative patients, 984/8443 (11.7%) people living with HIV (PLHIV), and 108/642 (16.8%) patients with unknown HIV-status. The treatment case fatality ratio remained above 10% in most years. At patient-level, fatality risk was higher in PLHIV (aRR 1.74, 1.51-2.02), and for older age and extra-pulmonary TB irrespective of HIV-status. For PLHIV, fatality risk was higher for TB retreatment cases (aRR 1.38, 1.18-1.61) and patients without antiretroviral therapy (aRR 1.70, 1.47-1.97). It decreases with increasing higher CD4 strata and the programmatic availability of TB-LAM testing (aRR 0.65, 0.35-0.90). At population-level, mortality rates decreased 6.4-fold (-147/100,000 population) between 2009 (174/100,000) and 2017 (27/100,000), coinciding with a decline in TB treatment cases (2785 in 2009 to 497 in 2017). Although the absolute decline in mortality rates was most pronounced in PLHIV (-826/100,000 vs. HIV-negative: -23/100,000), the relative population-level mortality risk remained higher in PLHIV (aRR 4.68, 3.25-6.72) compared to the HIV-negative population. CONCLUSIONS TB-related mortality rapidly decreased at population-level and most pronounced in PLHIV. However, case fatality among TB treatment cases remained high. Further strategies to reduce active TB disease and introduce improved TB therapies are warranted.
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Affiliation(s)
- Bernhard Kerschberger
- Médecins sans Frontières, Mbabane, Eswatini
- Médecins sans Frontières/Ärzte ohne Grenzen, Vienna Evaluation Unit, Vienna, Austria
| | - Debrah Vambe
- National TB Control Programme (NTCP), Manzini, Eswatini
| | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Department of Statistics, Ludwig-Maximilians University Munich, Munich, Germany
| | | | | | | | | | - Bheki Mamba
- National TB Control Programme (NTCP), Manzini, Eswatini
| | | | - Joyce Sibanda
- National TB Control Programme (NTCP), Manzini, Eswatini
| | - Sisi Dube
- National TB Control Programme (NTCP), Manzini, Eswatini
| | | | | | - Tom Ellman
- Médecins sans Frontières, Cape Town, South Africa
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Giddings R, Indravudh P, Medley GF, Bozzani F, Gafos M, Malhotra S, Terris-Prestholt F, Torres-Rueda S, Quaife M. Infectious Disease Modelling of HIV Prevention Interventions: A Systematic Review and Narrative Synthesis of Compartmental Models. PHARMACOECONOMICS 2023; 41:693-707. [PMID: 36988896 PMCID: PMC10163138 DOI: 10.1007/s40273-023-01260-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/26/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND The HIV epidemic remains a major public health problem. Critical to transmission control are HIV prevention strategies with new interventions continuing to be developed. Mathematical models are important for understanding the potential impact of these interventions and supporting policy decisions. This systematic review aims to answer the following question: when a new HIV prevention intervention is being considered or designed, what information regarding it is necessary to include in a compartmental model to provide useful insights to policy makers? The primary objective of this review is therefore to assess suitability of current compartmental HIV prevention models for informing policy development. METHODS Articles published in EMBASE, Medline, Econlit, and Global Health were screened. Included studies were identified using permutations of (i) HIV, (ii) pre-exposure prophylaxis (PrEP), circumcision (both voluntary male circumcision [VMMC] and early-infant male circumcision [EIMC]), and vaccination, and (iii) modelling. Data extraction focused on study design, model structure, and intervention incorporation into models. Article quality was assessed using the TRACE (TRAnsparent and Comprehensive Ecological modelling documentation) criteria for mathematical models. RESULTS Of 837 articles screened, 48 articles were included in the review, with 32 unique mathematical models identified. The substantial majority of studies included PrEP (83%), whilst fewer modelled circumcision (54%), and only a few focussed on vaccination (10%). Data evaluation, implementation verification, and model output corroboration were identified as areas of poorer model quality. Parameters commonly included in the mathematical models were intervention uptake and effectiveness, with additional intervention-specific common parameters identified. We identified key modelling gaps; critically, models insufficiently incorporate multiple interventions acting simultaneously. Additionally, population subgroups were generally poorly represented-with future models requiring improved incorporation of ethnicity and sexual risk group stratification-and many models contained inappropriate data in parameterisation which will affect output accuracy. CONCLUSIONS This review identified gaps in compartmental models to date and suggests areas of improvement for models focusing on new prevention interventions. Resolution of such gaps within future models will ensure greater robustness and transparency, and enable more accurate assessment of the impact that new interventions may have, thereby providing more meaningful guidance to policy makers.
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Affiliation(s)
| | | | | | | | - Mitzy Gafos
- London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - Matthew Quaife
- London School of Hygiene & Tropical Medicine, London, UK
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Mosha NR, Todd J, Mukerebe C, Marston M, Colombe S, Clark B, Beard J, Mtenga B, Slaymaker E, Boerma T, Zaba B, Urassa M. The prevalence and incidence of HIV in the ART era (2006-2016) in North West Tanzania. Int J STD AIDS 2022; 33:337-346. [PMID: 35040735 PMCID: PMC7612632 DOI: 10.1177/09564624211065232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background Sub-Saharan countries bears a disproportionate percentage of HIV infections and HIV related deaths despite the efforts to strengthen HIV prevention and treatments services, including ART. It is important to demonstrate how these services have contributed to reducing the epidemic using available population data. Methods We estimated the prevalence and incidence rates from a cohort running over 23 years in Magu District, Mwanza Region-North West Tanzania. Adults 15 years and over who were residents of the Kisesa observational HIV cohort study between 2006 and 2016 were eligible for inclusion. Survival analysis was used to calculate person-time at risk, incidence rates and 95% confidence intervals (CI). Cox regression models were used for the risk factor analyses disaggregated by sex and age group. Results The HIV prevalence in the sero-surveys decreased from 7.2% in 2006/07 to 6.6% in 2016, with a notable decrease of over 50% for both men and women aged 15-24 years. The incidence rate for HIV was estimated to be 5.5 (95% CI 4.6 - 6.6) per 1000 person-years in women compared to 4.6 (95% CI 3.5 – 5.8) in men, with a decrease over time. Despite the availability of ART services, the uptake is still small. Conclusions New infections are still occurring, with high HIV incidence in individuals aged below 45 years. With new guidelines and the 95-95-95 UNAIDS target, prevalence and incidence must be adequately assessed. In addition, there is a need for additional efforts to assess the impact of HIV/AIDS prevention programmes and intervention services, especially in these areas where resources are limited.
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Affiliation(s)
- Neema R Mosha
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, 121470Stellenbosch University, Cape Town, South Africa.,Mwanza Intervention Trials Unit, Mwanza, Tanzania.,119151National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
| | - Jim Todd
- 119151National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania.,Department of Population Health, 4906London School of Hygiene and Tropical Medicine, London, UK
| | - Crispin Mukerebe
- 119151National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
| | - Milly Marston
- Department of Population Health, 4906London School of Hygiene and Tropical Medicine, London, UK
| | | | - Benjamin Clark
- Department of Population Health, 4906London School of Hygiene and Tropical Medicine, London, UK
| | - James Beard
- Department of Population Health, 4906London School of Hygiene and Tropical Medicine, London, UK
| | - Baltazar Mtenga
- 119151National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
| | - Emma Slaymaker
- Department of Population Health, 4906London School of Hygiene and Tropical Medicine, London, UK
| | - Ties Boerma
- University of Manitoba, Winnipeg, MB, Canada
| | - Basia Zaba
- Department of Population Health, 4906London School of Hygiene and Tropical Medicine, London, UK
| | - Mark Urassa
- 119151National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
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Defining the Global Research and Programmatic Agenda and Priority Actions for Voluntary Medical Male Circumcision for HIV Prevention. Curr HIV/AIDS Rep 2022; 19:537-547. [PMID: 36367637 PMCID: PMC9651117 DOI: 10.1007/s11904-022-00640-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 11/13/2022]
Abstract
PURPOSE OF REVIEW Since 2007, voluntary medical male circumcision (VMMC) programs have been associated with substantially reduced HIV incidence across 15 prioritized countries in Eastern and Southern Africa. Drawing on the programmatic experience of global VMMC leaders, this report reviews progress made in the first 15 years of the program, describes programmatic and research gaps, and presents considerations to maximize the impact of VMMC. RECENT FINDINGS Overall, key programmatic and research gaps include a lack of robust male circumcision coverage estimates due to limitations to the data and a lack of standardized approaches across programs; challenges enhancing VMMC uptake include difficulties reaching populations at higher risk for HIV infection and men 30 years and older; limitations to program and procedural quality and safety including variations in approaches used by programs; and lastly, sustainability with limited evidence-based practices. Considerations to address these gaps include the need for global guidance on estimating coverage, conducting additional research on specific sub-populations to improve VMMC uptake, implementation of responsive and comprehensive approaches to adverse event surveillance, and diversifying financing streams to progress towards sustainability. This report's findings may help establish a global VMMC research and programmatic agenda to inform policy, research, and capacity-building activities at the national and global levels.
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Ngongo NM, Nani-Tuma HS, Mambimbi MM, Mashi ML, Izizag BB, Ndolumingu FK, Maes N, Moutschen M, Darcis G. Decrease in late presentation for HIV care in Kinshasa, DRC, 2006-2020. AIDS Res Ther 2021; 18:41. [PMID: 34271957 PMCID: PMC8283988 DOI: 10.1186/s12981-021-00366-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/07/2021] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Late presentation for HIV care is a well-described issue for the success of ART outcomes and the cause of higher morbidity, mortality and further transmission. Monitoring the level of late presentation and understanding the factors associated with it would help to tailor screening and information strategies for better efficiency. We performed a retrospective cohort study in Kinshasa, the capital of the DRC. The studied population included HIV-positive adults newly enrolled in HIV care between January 2006 and June 2020 at 25 HIV urban care facilities. Patient information collected at presentation for HIV care included age, sex, WHO clinical stage and screening context. We used 2 definitions of late presentation: the WHO definition of advanced HIV disease (WHO stage 3/4 or CD4 cell count < 200 cells/mm3) and a more inclusive definition (WHO stage 3/4 or CD4 cell count < 350 cells/mm3). RESULTS A total of 10,137 HIV-infected individuals were included in the analysis. The median age was 40 years; 68% were female. A total of 45.9% or 47.5% of the patients were late presenters, depending on the definition used. The percentage of patients with late presentation (defined as WHO stage 3/4 or CD4 cell count < 350 cells/mm3) decreased during recent years, from 70.7% in 2013 to 46.5% in 2017 and 23.4% in 2020. Age was associated with a significantly higher risk of LP (p < 0.0001). We did not observe any impact of sex. CONCLUSIONS The frequency of late presentation for care is decreasing in Kinshasa, DRC. Efforts have to be continued. In particular, the issue of late diagnosis in older individuals should be addressed.
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Affiliation(s)
- Nadine Mayasi Ngongo
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo.
| | - Hippolyte Situakibanza Nani-Tuma
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Marcel Mbula Mambimbi
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Murielle Longokolo Mashi
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Ben Bepouka Izizag
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Faustin Kitetele Ndolumingu
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Nathalie Maes
- Biostatistics and Medico-economic Information Department, University Hospital of Liege, Liège, Belgium
| | - Michel Moutschen
- Department of Internal Medicine and Infectious Diseases, Liège University Hospital, Liège, Belgium
- AIDS reference laboratory, University of Liège, Liège, Belgium
| | - Gilles Darcis
- Department of Internal Medicine and Infectious Diseases, Liège University Hospital, Liège, Belgium.
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Kerschberger B, Schomaker M, Jobanputra K, Kabore SM, Teck R, Mabhena E, Mthethwa-Hleza S, Rusch B, Ciglenecki I, Boulle A. HIV programmatic outcomes following implementation of the 'Treat-All' policy in a public sector setting in Eswatini: a prospective cohort study. J Int AIDS Soc 2020; 23:e25458. [PMID: 32128964 PMCID: PMC7054447 DOI: 10.1002/jia2.25458] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/04/2019] [Accepted: 01/22/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The Treat-All policy - antiretroviral therapy (ART) initiation irrespective of CD4 cell criteria - increases access to treatment. Many ART programmes, however, reported increasing attrition and viral failure during treatment expansion, questioning the programmatic feasibility of Treat-All in resource-limited settings. We aimed to describe and compare programmatic outcomes between Treat-All and standard of care (SOC) in the public sectors of Eswatini. METHODS This is a prospective cohort study of ≥16-year-old HIV-positive patients initiated on first-line ART under Treat-All and SOC in 18 health facilities of the Shiselweni region, from October 2014 to March 2016. SOC followed the CD4 350 and 500 cells/mm3 treatment eligibility thresholds. Kaplan-Meier estimates were used to describe crude programmatic outcomes. Multivariate flexible parametric survival models were built to assess associations of time from ART initiation with the composite unfavourable outcome of all-cause attrition and viral failure. RESULTS Of the 3170 patients, 1888 (59.6%) initiated ART under Treat-All at a median CD4 cell count of 329 (IQR 168 to 488) cells/mm3 compared with 292 (IQR 161 to 430) (p < 0.001) under SOC. Although crude programme retention at 36 months tended to be lower under Treat-All (71%) than SOC (75%) (p = 0.002), it was similar in covariate-adjusted analysis (adjusted hazard ratio [aHR] 1.06, 95% CI 0.91 to 1.23). The hazard of viral suppression was higher for Treat-All (aHR 1.12, 95% CI 1.01 to 1.23), while the hazard of viral failure was comparable (Treat-All: aHR 0.89, 95% CI 0.53 to 1.49). Among patients with advanced HIV disease (n = 1080), those under Treat-All (aHR 1.13, 95% CI 0.88 to 1.44) had a similar risk of an composite unfavourable outcome to SOC. Factors increasing the risk of the composite unfavourable outcome under both interventions were aged 16 to 24 years, being unmarried, anaemia, ART initiation on the same day as HIV care enrolment and CD4 ≤ 100 cells/mm3 . Under Treat-All only, the risk of the unfavourable outcome was higher for pregnant women, WHO III/IV clinical stage and elevated creatinine. CONCLUSIONS Compared to SOC, Treat-All resulted in comparable retention, improved viral suppression and comparable composite outcomes of retention without viral failure.
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Affiliation(s)
- Bernhard Kerschberger
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Kiran Jobanputra
- The Manson Unit, Médecins Sans Frontières, London, United Kingdom
| | - Serge M Kabore
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini
| | - Roger Teck
- The Manson Unit, Médecins Sans Frontières, London, United Kingdom
| | - Edwin Mabhena
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini
| | | | - Barbara Rusch
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | - Iza Ciglenecki
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Gilbertson A, Ongili B, Odongo FS, Hallfors DD, Rennie S, Kwaro D, Luseno WK. Voluntary medical male circumcision for HIV prevention among adolescents in Kenya: Unintended consequences of pursuing service-delivery targets. PLoS One 2019; 14:e0224548. [PMID: 31682626 PMCID: PMC6827911 DOI: 10.1371/journal.pone.0224548] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 10/16/2019] [Indexed: 12/15/2022] Open
Abstract
Introduction Voluntary medical male circumcision (VMMC) provides significant reductions in the risk of female-to-male HIV transmission. Since 2007, VMMC has been a key component of the United States President’s Emergency Plan for AIDS Relief’s (PEPFAR) strategy to mitigate the HIV epidemic in countries with high HIV prevalence and low circumcision rates. To ensure intended effects, PEPFAR sets ambitious annual circumcision targets and provides funding to implementation partners to deliver local VMMC services. In Kenya to date, 1.9 million males have been circumcised; in 2017, 60% of circumcisions were among 10-14-year-olds. We conducted a qualitative field study to learn more about VMMC program implementation in Kenya. Methods and results The study setting was a region in Kenya with high HIV prevalence and low male circumcision rates. From March 2017 through April 2018, we carried out in-depth interviews with 29 VMMC stakeholders, including “mobilizers”, HIV counselors, clinical providers, schoolteachers, and policy professionals. Additionally, we undertook observation sessions at 14 VMMC clinics while services were provided and observed mobilization activities at 13 community venues including, two schools, four public marketplaces, two fishing villages, and five inland villages. Analysis of interview transcripts and observation field notes revealed multiple unintended consequences linked to the pursuit of targets. Ebbs and flows in the availability of school-age youths together with the drive to meet targets may result in increased burdens on clinics, long waits for care, potentially misleading mobilization practices, and deviations from the standard of care. Conclusion Our findings indicate shortcomings in the quality of procedures in VMMC programs in a low-resource setting, and more importantly, that the pursuit of ambitious public health targets may lead to compromised service delivery and protocol adherence. There is a need to develop improved or alternative systems to balance the goal of increasing service uptake with the responsible conduct of VMMC.
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Affiliation(s)
- Adam Gilbertson
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, North Carolina, United States of America
- UNC Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | | | | | - Denise D. Hallfors
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, North Carolina, United States of America
| | - Stuart Rennie
- UNC Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Daniel Kwaro
- Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Winnie K. Luseno
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, North Carolina, United States of America
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Kerschberger B, Jobanputra K, Schomaker M, Kabore SM, Teck R, Mabhena E, Lukhele N, Rusch B, Boulle A, Ciglenecki I. Feasibility of antiretroviral therapy initiation under the treat-all policy under routine conditions: a prospective cohort study from Eswatini. J Int AIDS Soc 2019; 22:e25401. [PMID: 31647613 PMCID: PMC6812490 DOI: 10.1002/jia2.25401] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 09/03/2019] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The World Health Organization recommends the Treat-All policy of immediate antiretroviral therapy (ART) initiation, but questions persist about its feasibility in resource-poor settings. We assessed the feasibility of Treat-All compared with standard of care (SOC) under routine conditions. METHODS This prospective cohort study from southern Eswatini followed adults from HIV care enrolment to ART initiation. Between October 2014 and March 2016, Treat-All was offered in one health zone and SOC according to the CD4 350 and 500 cells/mm3 treatment eligibility thresholds in the neighbouring health zone, each of which comprised one secondary and eight primary care facilities. We used Kaplan-Meier estimates, multivariate flexible parametric survival models and standardized survival curves to compare ART initiation between the two interventions. RESULTS Of the 1726 (57.3%) patients enrolled under Treat-All and 1287 (42.7%) under SOC, cumulative three-month ART initiation was higher under Treat-All (91%) than SOC (74%; p < 0.001) with a median time to ART of 1 (IQR 0 to 14) and 10 (IQR 2 to 117) days respectively. Under Treat-All, ART initiation was higher in pregnant women (vs. non-pregnant women: adjusted hazard ratio (aHR) 1.96, 95% confidence interval (CI) 1.70 to 2.26), those with secondary education (vs. no formal education: aHR 1.48, 95% CI 1.12 to 1.95), and patients with an HIV-positive diagnosis before care enrolment (aHR 1.22, 95% CI 1.10 to 1.36). ART initiation was lower in patients attending secondary care facilities (aHR 0.64, 95% CI 0.58 to 0.72) and for CD4 351 to 500 when compared with CD4 201 to 350 cells/mm3 (aHR 0.84, 95% CI 0.72 to 1.00). ART initiation varied over time for TB cases, with lower hazard during the first two weeks after HIV care enrolment and higher hazards thereafter. Of patients with advanced HIV disease (n = 1085; 36.0%), crude 3-month ART initiation was similar in both interventions (91% to 92%) although Treat-All initiated patients more quickly during the first month after HIV care enrolment. CONCLUSIONS ART initiation was high under Treat-All and without evidence of de-prioritization of patients with advanced HIV disease. Additional studies are needed to understand the long-term impact of Treat-All on patient outcomes.
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Affiliation(s)
- Bernhard Kerschberger
- Médecins Sans Frontières (Operational Centre Geneva)MbabaneEswatini
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | | | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Institute of Public Health, Medical Decision Making and HealthTechnology AssessmentMedical Informatics and TechnologyUMIT – University for Health SciencesHall in TirolAustria
| | - Serge M Kabore
- Médecins Sans Frontières (Operational Centre Geneva)MbabaneEswatini
| | - Roger Teck
- The Manson UnitMédecins Sans FrontièresLondonUnited Kingdom
| | - Edwin Mabhena
- Médecins Sans Frontières (Operational Centre Geneva)MbabaneEswatini
| | | | - Barbara Rusch
- Médecins Sans Frontières (Operational Centre Geneva)GenevaSwitzerland
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Iza Ciglenecki
- Médecins Sans Frontières (Operational Centre Geneva)GenevaSwitzerland
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Case KK, Gomez GB, Hallett TB. The impact, cost and cost-effectiveness of oral pre-exposure prophylaxis in sub-Saharan Africa: a scoping review of modelling contributions and way forward. J Int AIDS Soc 2019; 22:e25390. [PMID: 31538407 PMCID: PMC6753289 DOI: 10.1002/jia2.25390] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 08/06/2019] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Oral pre-exposure prophylaxis (PrEP) is a new form of HIV prevention being considered for inclusion in national prevention portfolios. Many mathematical modelling studies have been undertaken that speak to the impact, cost and cost-effectiveness of PrEP programmes. We assess the available evidence from mathematical modelling studies to inform programme planning and policy decision making for PrEP and further research directions. METHODS We conducted a scoping review of the published modelling literature. Articles published in English which modelled oral PrEP in sub-Saharan Africa, or non-specific settings with relevance to generalized HIV epidemic settings, were included. Data were extracted for the strategies of PrEP use modelled, and the impact, cost and cost-effectiveness of PrEP for each strategy. We define an algorithm to assess the quality and relevance of studies included, summarize the available evidence and identify the current gaps in modelling. Recommendations are generated for future modelling applications and data collection. RESULTS AND DISCUSSION We reviewed 1924 abstracts and included 44 studies spanning 2007 to 2017. Modelling has reported that PrEP can be a cost-effective addition to HIV prevention portfolios for some use cases, but also that it would not be cost-effective to fund PrEP before other prevention interventions are expanded. However, our assessment of the quality of the modelling indicates cost-effectiveness analyses failed to comply with standards of reporting for economic evaluations and the assessment of relevance highlighted that both key parameters and scenarios are now outdated. Current evidence gaps include modelling to inform service development using updated programmatic information and ex post modelling to evaluate and inform efficient deployment of resources in support of PrEP, especially among key populations, using direct evidence of cost, adherence and uptake patterns. CONCLUSIONS Updated modelling which more appropriately captures PrEP programme delivery, uses current intervention scenarios, and is parameterized with data from demonstration and implementation projects is needed in support of more conclusive findings and actionable recommendations for programmes and policy. Future analyses should address these issues, aligning with countries to support the needs of programme planners and decision makers for models to more directly inform programme planning and policy.
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Affiliation(s)
- Kelsey K Case
- Department of Infectious Disease EpidemiologyImperial College LondonLondonUK
| | - Gabriela B Gomez
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUK
| | - Timothy B Hallett
- Department of Infectious Disease EpidemiologyImperial College LondonLondonUK
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Kerschberger B, Schomaker M, Telnov A, Vambe D, Kisyeri N, Sikhondze W, Pasipamire L, Ngwenya SM, Rusch B, Ciglenecki I, Boulle A. Decreased risk of HIV-associated TB during antiretroviral therapy expansion in rural Eswatini from 2009 to 2016: a cohort and population-based analysis. Trop Med Int Health 2019; 24:1114-1127. [PMID: 31310029 PMCID: PMC6852273 DOI: 10.1111/tmi.13290] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Objectives This paper assesses patient‐ and population‐level trends in TB notifications during rapid expansion of antiretroviral therapy in Eswatini which has an extremely high incidence of both TB and HIV. Methods Patient‐ and population‐level predictors and rates of HIV‐associated TB were examined in the Shiselweni region in Eswatini from 2009 to 2016. Annual population‐level denominators obtained from projected census data and prevalence estimates obtained from population‐based surveys were combined with individual‐level TB treatment data. Patient‐ and population‐level predictors of HIV‐associated TB were assessed with multivariate logistic and multivariate negative binomial regression models. Results Of 11 328 TB cases, 71.4% were HIV co‐infected and 51.8% were women. TB notifications decreased fivefold between 2009 and 2016, from 1341 to 269 cases per 100 000 person‐years. The decline was sixfold in PLHIV vs. threefold in the HIV‐negative population. Main patient‐level predictors of HIV‐associated TB were recurrent TB treatment (adjusted odds ratio [aOR] 1.40, 95% confidence interval [CI]: 1.19–1.65), negative (aOR 1.31, 1.15–1.49) and missing (aOR 1.30, 1.11–1.53) bacteriological status and diagnosis at secondary healthcare level (aOR 1.18, 1.06–1.33). Compared with 2009, the probability of TB decreased for all years from 2011 (aOR 0.69, 0.58–0.83) to 2016 (aOR 0.54, 0.43–0.69). The most pronounced population‐level predictor of TB was HIV‐positive status (adjusted incidence risk ratio 19.47, 14.89–25.46). Conclusions This high HIV‐TB prevalence setting experienced a rapid decline in TB notifications, most pronounced in PLHIV. Achievements in HIV‐TB programming were likely contributing factors.
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Affiliation(s)
- Bernhard Kerschberger
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Institute of Public Health, Medical Decision Making and HealthTechnology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Alex Telnov
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | - Debrah Vambe
- National TB Control Program, Ministry of Health, Manzini, Eswatini
| | - Nicholas Kisyeri
- Eswatini National AIDS Programme, Ministry of Health, Mbabane, Eswatini
| | - Welile Sikhondze
- National TB Control Program, Ministry of Health, Manzini, Eswatini
| | | | | | - Barbara Rusch
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | - Iza Ciglenecki
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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11
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Kimmel AD, Bono RS, Keiser O, Sinayobye JD, Estill J, Mujwara D, Tymejczyk O, Nash D. Mathematical modelling to inform 'treat all' implementation in sub-Saharan Africa: a scoping review. J Virus Erad 2018; 4:47-54. [PMID: 30515314 PMCID: PMC6248854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE Despite widespread uptake, only half of sub-Saharan African countries have fully implemented the World Health Organization's 'treat all' policy, hindering achievement of global HIV targets. We examined literature on mathematical modelling studies that sought to inform scale-up and implementation of 'treat all' in sub-Saharan Africa. METHODS We conducted a scoping review, a research synthesis to assess emerging evidence and identify gaps, of peer-reviewed literature, extracting study characteristics on 'treat all' policies and assumptions, setting, key populations, outcomes and findings. Studies were narratively summarised and potential gaps characterised. RESULTS We identified 16 studies examining 'treat all' alone (n=12) or with expanded testing (n=7) and/or care continuum improvements (n=6). Twelve studies examined 'treat all' for Southern African countries, while none did so for Central Africa. Four included the role of resistance; one evaluated any key population. A range of health and economic outcomes were reported, although fewer studies formally assessed budget impact. Fourteen studies involved co-authors with any in-country affiliation; one study also had co-authors with local government affiliation. Overall, 'treat all' improves health outcomes and is cost-effective compared to deferred HIV treatment; 'treat all' with expanded testing or care continuum improvements may provide further health benefits. However, studies generally used optimistic assumptions about the implementation of expanded testing or care continuum improvements. CONCLUSIONS The modelling literature demonstrates improved health and economic benefits of 'treat all'. Using mathematical modelling to inform real-world implementation of 'treat all' requires realistic assumptions about expanded testing and care continuum interventions across a wide range of settings and populations.
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Affiliation(s)
- April D Kimmel
- Department of Health Behavior and Policy, Virginia Commonwealth University,
Richmond VA,
USA
| | - Rose S Bono
- Department of Health Behavior and Policy, Virginia Commonwealth University,
Richmond VA,
USA
| | - Olivia Keiser
- Institute of Global Health, University of Geneva,
Switzerland
| | - Jean D Sinayobye
- Research and Clinical Education Division, Rwanda Military Hospital,
Kigali,
Rwanda
| | | | - Deo Mujwara
- Department of Health Behavior and Policy, Virginia Commonwealth University,
Richmond VA,
USA
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12
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Kimmel AD, Bono RS, Keiser O, Sinayobye JD, Estill J, Mujwara D, Tymejczyk O, Nash D. Mathematical modelling to inform ‘treat all’ implementation in sub-Saharan Africa: a scoping review. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30345-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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13
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Wachira J, Genberg B, Kafu C, Koech B, Akinyi J, Owino RK, Laws MB, Wilson IB, Braitstein P. The Perspective of HIV Providers in Western Kenya on Provider-Patient Relationships. JOURNAL OF HEALTH COMMUNICATION 2018; 23:591-596. [PMID: 29979930 PMCID: PMC6094379 DOI: 10.1080/10810730.2018.1493061] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Enhancing effective adherence dialogue with HIV patients in an environment that promotes good provider-patient relationships, is key to optimizing the benefits of antiretroviral therapy (ART). The study examines the perspectives of HIV providers in western Kenya on provider-patient relationships. Sixty healthcare providers were sampled using convenience sampling methods from three Academic Model for Providing Access to Healthcare (AMPATH) sites (one urban and two rural). In-depth interviews conducted in either Swahili or English were audio recorded, transcribed, and translated into English. Content analysis was performed after thematic coding. Providers perceived that they had good relationships with most patients, and tended to identify negative patient attributes as the source of poor provider-patient relationships. Providers preferred patients who adhered to treatment guidelines. They did not like patients who challenged their authority, and did not see it as their responsibility to find more effective ways of interacting with patients who they found difficult. Structural barriers to collaborative physician-patient relationships included noncontinuity of relationships, lack of specific appointment times, high provider-patient ratio, and management of provider fatigue and job dissatisfaction. There is need for HIV care programs to identify culturally appropriate interventions to enhance better provider-patient relationship.
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Affiliation(s)
- Juddy Wachira
- a School of Medicine , Moi University , Eldoret , Kenya
- b Academic Model Providing Access to Healthcare (AMPATH) Partnership , Eldoret , Kenya
| | - Becky Genberg
- c Bloomberg School of Public Health , Johns Hopkins University , Baltimore , MD , USA
| | - Catherine Kafu
- b Academic Model Providing Access to Healthcare (AMPATH) Partnership , Eldoret , Kenya
| | - Beatrice Koech
- b Academic Model Providing Access to Healthcare (AMPATH) Partnership , Eldoret , Kenya
| | - Jacqueline Akinyi
- b Academic Model Providing Access to Healthcare (AMPATH) Partnership , Eldoret , Kenya
| | - Regina K Owino
- b Academic Model Providing Access to Healthcare (AMPATH) Partnership , Eldoret , Kenya
| | - Michael Barton Laws
- d Department of Health Services, Policy & Practice , Brown University , Providence, RI, USA
| | - Ira B Wilson
- d Department of Health Services, Policy & Practice , Brown University , Providence, RI, USA
| | - Paula Braitstein
- e Dalla Lana School of Public Health , University of Toronto , Toronto, Ontario , Canada
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14
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Bershteyn A, Mutai KK, Akullian AN, Klein DJ, Jewell BL, Mwalili SM. The influence of mobility among high-risk populations on HIV transmission in Western Kenya. Infect Dis Model 2018; 3:97-106. [PMID: 30839863 PMCID: PMC6326217 DOI: 10.1016/j.idm.2018.04.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 04/09/2018] [Accepted: 04/10/2018] [Indexed: 12/01/2022] Open
Abstract
Western Kenya suffers a highly endemic and also very heterogeneous epidemic of human immunodeficiency virus (HIV). Although female sex workers (FSW) and their male clients are known to be at high risk for HIV, HIV prevalence across regions in Western Kenya is not strongly correlated with the fraction of women engaged in commercial sex. An agent-based network model of HIV transmission, geographically stratified at the county level, was fit to the HIV epidemic, scale-up of interventions, and populations of FSW in Western Kenya under two assumptions about the potential mobility of FSW clients. In the first, all clients were assumed to be resident in the same geographies as their interactions with FSW. In the second, some clients were considered non-resident and engaged only in interactions with FSW, but not in longer-term non-FSW partnerships in these geographies. Under both assumptions, the model successfully reconciled disparate geographic patterns of FSW and HIV prevalence. Transmission patterns in the model suggest a greater role for FSW in local transmission when clients were resident to the counties, with 30.0% of local HIV transmissions attributable to current and former FSW and clients, compared to 21.9% when mobility of clients was included. Nonetheless, the overall epidemic drivers remained similar, with risky behavior in the general population dominating transmission in high-prevalence counties. Our modeling suggests that co-location of high-risk populations and generalized epidemics can further amplify the spread of HIV, but that large numbers of formal FSW and clients are not required to observe or mechanistically explain high HIV prevalence in the general population.
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Affiliation(s)
- Anna Bershteyn
- Institute for Disease Modeling, 3150 139 Ave. SE, Bellevue, WA 98005, USA
| | - Kennedy K Mutai
- National Aids Control Council, P.O. Box 61307-00200, Argwings Kodhek Rd, Nairobi, Kenya
| | - Adam N Akullian
- Institute for Disease Modeling, 3150 139 Ave. SE, Bellevue, WA 98005, USA
| | - Daniel J Klein
- Institute for Disease Modeling, 3150 139 Ave. SE, Bellevue, WA 98005, USA
| | - Britta L Jewell
- Institute for Disease Modeling, 3150 139 Ave. SE, Bellevue, WA 98005, USA.,Department of Medicine, University of California and San Francisco, Zuckerberg San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110, USA
| | - Samuel M Mwalili
- Centers for Disease Control and Prevention, PO Box 606, Village Market, Nairobi, 00621, Kenya
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15
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Borgdorff MW, Kwaro D, Obor D, Otieno G, Kamire V, Odongo F, Owuor P, Muthusi J, Mills LA, Joseph R, Schmitz ME, Young PW, Zielinski-Gutierrez E, De Cock KM. HIV incidence in western Kenya during scale-up of antiretroviral therapy and voluntary medical male circumcision: a population-based cohort analysis. Lancet HIV 2018; 5:e241-e249. [PMID: 29650451 DOI: 10.1016/s2352-3018(18)30025-0] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 02/14/2018] [Accepted: 02/15/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND In Kenya, coverage of antiretroviral therapy (ART) among people with HIV infection has increased from 7% in 2006, to 57% in 2016; and, in western Kenya, coverage of voluntary medical male circumcision (VMMC) increased from 45% in 2008, to 72% in 2014. We investigated trends in HIV prevalence and incidence in a high burden area in western Kenya in 2011-16. METHODS In 2011, 2012, and 2016, population-based surveys were done via a health and demographic surveillance system and home-based counselling and testing in Gem, Siaya County, Kenya, including 28 688, 17 021, and 16 772 individuals aged 15-64 years. Data on demographic variables, self-reported HIV status, and risk factors were collected. Rapid HIV testing was offered to survey participants. Participants were tracked between surveys by use of health and demographic surveillance system identification numbers. HIV prevalence was calculated as a proportion, and HIV incidence was expressed as number of new infections per 1000 person-years of follow-up. FINDINGS HIV prevalence was stable in participants aged 15-64 years: 15% (4300/28 532) in 2011, 12% (2051/16 875) in 2012, and 15% (2312/15 626) in 2016. Crude prevalences in participants aged 15-34 years were 11% (1893/17 197) in 2011, 10% (1015/10 118) in 2012, and 9% (848/9125) in 2016; adjusted for age and sex these prevalences were 11%, 9%, and 8%. 12 606 (41%) of the 30 520 non-HIV-infected individuals enrolled were seen again in at least one more survey round, and were included in the analysis of HIV incidence. HIV incidence was 11·1 (95% CI 9·1-13·1) per 1000 person-years from 2011 to 2012, and 5·7 (4·6-6·9) per 1000 person-years from 2012 to 2016. INTERPRETATION With increasing coverage of ART and VMMC, HIV incidence declined substantially in Siaya County between 2011 and 2016. VMMC, but not ART, was suggested to have a direct protective effect, presumably because ART tended to be given to individuals with advanced HIV infection. HIV incidence is still high and not close to the elimination target of one per 1000 person-years. The effect of further scale-up of ART and VMMC needs to be monitored. FUNDING Data were collected under Cooperative Agreements with the US Centers for Disease Control and Prevention, with funding from the President's Emergency Fund for AIDS Relief.
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Affiliation(s)
- Martien W Borgdorff
- US Centers for Disease Control and Prevention, Nairobi, Kenya; Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Daniel Kwaro
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - David Obor
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - George Otieno
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Viviane Kamire
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Frederick Odongo
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Patrick Owuor
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Jacques Muthusi
- US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Lisa A Mills
- US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Rachael Joseph
- US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Mary E Schmitz
- US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Peter W Young
- US Centers for Disease Control and Prevention, Nairobi, Kenya
| | | | - Kevin M De Cock
- US Centers for Disease Control and Prevention, Nairobi, Kenya.
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16
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Blaizot S, Huerga H, Riche B, Ellman T, Shroufi A, Etard JF, Ecochard R. Combined interventions to reduce HIV incidence in KwaZulu-Natal: a modelling study. BMC Infect Dis 2017; 17:522. [PMID: 28747167 PMCID: PMC5530541 DOI: 10.1186/s12879-017-2612-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 07/18/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Combined prevention interventions, including early antiretroviral therapy initiation, may substantially reduce HIV incidence in hyperendemic settings. Our aim was to assess the potential short-term impact of combined interventions on HIV spreading in the adult population of Mbongolwane and Eshowe (KwaZulu-Natal, South Africa) using sex- and age-specific scenarios, and age-targeted interventions. METHODS A mathematical model was used with data on adults (15-59 years) from the Mbongolwane and Eshowe HIV Impact in Population Survey to compare the effects of various interventions on the HIV incidence rate. These interventions included increase in antiretroviral therapy (ART) coverage with extended eligibility criteria, increase in voluntary medical male circumcision (VMMC), and implementation of pre-exposure prophylaxis (PrEP) among women. RESULTS With no additional interventions to the ones in place at the time of the survey (ART at CD4 < 350 and VMMC), incidence will decrease by 24% compared to the baseline rate. The implementation of "ART at CD4<500" or "ART for all" would reduce further the incidence rate by additional 8% and 15% respectively by 4 years and 20% and 34% by 10 years. Impacts would be higher with age-targeted scenarios than without. CONCLUSIONS In Mbongolwane and Eshowe, implementation of the new South African guidelines, recommending ART initiation regardless of CD4 count, would accelerate incidence reduction. In this setting, combining these guidelines, VMMC, and PrEP among young women could be an effective strategy in reducing the incidence to low levels.
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Affiliation(s)
- Stéphanie Blaizot
- Service de Biostatistique, Hospices Civils de Lyon, F-69003 Lyon, France
- Université de Lyon, F-69000 Lyon, France
- Université Lyon 1, F-69100 Villeurbanne, France
- CNRS UMR 5558, Equipe Biostatistique-Santé, Laboratoire de Biométrie et Biologie Evolutive, F-69100 Villeurbanne, France
| | | | - Benjamin Riche
- Service de Biostatistique, Hospices Civils de Lyon, F-69003 Lyon, France
- Université de Lyon, F-69000 Lyon, France
- Université Lyon 1, F-69100 Villeurbanne, France
- CNRS UMR 5558, Equipe Biostatistique-Santé, Laboratoire de Biométrie et Biologie Evolutive, F-69100 Villeurbanne, France
| | - Tom Ellman
- Médecins Sans Frontières, Cape Town, South Africa
| | - Amir Shroufi
- Médecins Sans Frontières, Cape Town, South Africa
| | - Jean-François Etard
- Epicentre, F-75011 Paris, France
- IRD UMI 233, INSERM U1175, Université de Montpellier, Unité TransVIHMI, F-34000 Montpellier, France
| | - René Ecochard
- Service de Biostatistique, Hospices Civils de Lyon, F-69003 Lyon, France
- Université de Lyon, F-69000 Lyon, France
- Université Lyon 1, F-69100 Villeurbanne, France
- CNRS UMR 5558, Equipe Biostatistique-Santé, Laboratoire de Biométrie et Biologie Evolutive, F-69100 Villeurbanne, France
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17
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Abstract
Male circumcision is one of the most commonly performed procedures in Africa, with a wide variation between the different regions on the practice. This is because circumcision is often done for religious and cultural or traditional reasons, which includes being part of rituals or rite of passage to adulthood. There had been few medical indications for the procedure until the human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) pandemic, which is prevalent in many of the countries in the region. Evidence from randomized controlled trials conducted in the continent had shown that male circumcision could be instrumental to reducing the transmission of HIV/AIDS in heterosexual couples in high disease prevalent and low circumcision prevalent areas. This had led to the roll-out of large population-based adult male circumcisions as well as the development of tools to facilitate the procedure. Circumcision, however, is not without complications and the incidence appears related to the age of the patient, where the procedure was done, technique used and level of proficiency of the practitioners. This article reviews the practice of circumcision in Africa and highlights the impact of the procedure on the continent.
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Affiliation(s)
- Taiwo Akeem Lawal
- Department of Surgery, University of Ibadan and University College Hospital, Ibadan, Nigeria
| | - E Oluwabunmi Olapade-Olaopa
- Department of Surgery, University of Ibadan and University College Hospital, Ibadan, Nigeria.,PIUTA Ibadan Centre, University of Ibadan and University College Hospital, Ibadan, Nigeria
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18
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Global implementation of PrEP as part of combination HIV prevention - Unsolved challenges. J Int AIDS Soc 2016. [DOI: 10.7448/ias.19.7.21479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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19
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Cáceres CF, Borquez A, Klausner JD, Baggaley R, Beyrer C. Implementation of pre-exposure prophylaxis for human immunodeficiency virus infection: progress and emerging issues in research and policy. J Int AIDS Soc 2016; 19:21108. [PMID: 27760685 PMCID: PMC5071779 DOI: 10.7448/ias.19.7.21108] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 06/30/2016] [Accepted: 07/12/2016] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND In this article, we present recent evidence from studies focused on the implementation, effectiveness and cost-effectiveness of pre-exposure prophylaxis (PrEP) for HIV infection; discuss PrEP scale-up to date, including the observed levels of access and policy development; and elaborate on key emerging policy and research issues to consider for further scale-up, with a special focus on lower-middle income countries. DISCUSSION The 2015 WHO Early Release Guidelines for HIV Treatment and Prevention reflect both scientific evidence and new policy perspectives. Those guidelines present a timely challenge to health systems for the scaling up of not only treatment for every person living with HIV infection but also the offer of PrEP to those at substantial risk. Delivery and uptake of both universal antiretroviral therapy (ART) and PrEP will require nation-wide commitment and could reinvigorate health systems to develop more comprehensive "combination prevention" programmes and support wider testing linked to both treatments and other prevention options for populations at highest risk who are currently not accessing services. Various gaps in current health systems will need to be addressed to achieve strategic scale-up of PrEP, including developing prioritization strategies, strengthening drug regulations, determining cost and funding sources, training health providers, supporting user adherence and creating demand. CONCLUSIONS The initial steps in the scale-up of PrEP globally suggest feasibility, acceptability and likely impact. However, to prevent setbacks in less well-resourced settings, countries will need to anticipate and address challenges such as operational and health systems barriers, drug cost and regulatory policies, health providers' openness to prescribing PrEP to populations at substantial risk, demand and legal and human rights issues. Emerging problems will require creative solutions and will continue to illustrate the complexity of PrEP implementation.
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Affiliation(s)
- Carlos F Cáceres
- Center for Interdisciplinary Studies in Sexuality, AIDS and Society, Universidad Peruana Cayetano Heredia, Lima, Peru;
| | - Annick Borquez
- Division of Global Public Health, University of California, San Diego, CA, USA
| | - Jeffrey D Klausner
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Rachel Baggaley
- HIV Department, World Health Organization, Geneva, Switzerland
| | - Chris Beyrer
- Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MA, USA
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