1
|
Huang TJ, Luedtke A. Improved efficiency for cross-arm comparisons via platform designs. Biostatistics 2023; 24:1106-1124. [PMID: 35939566 PMCID: PMC10583724 DOI: 10.1093/biostatistics/kxac030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 11/12/2022] Open
Abstract
Though platform trials have been touted for their flexibility and streamlined use of trial resources, their statistical efficiency is not well understood. We fill this gap by establishing their greater efficiency for comparing the relative efficacy of multiple interventions over using several separate, 2-arm trials, where the relative efficacy of an arbitrary pair of interventions is evaluated by contrasting their relative risks as compared to control. In theoretical and numerical studies, we demonstrate that the inference of such a contrast using data from a platform trial enjoys identical or better precision than using data from separate trials, even when the former enrolls substantially fewer participants. This benefit is attributed to the sharing of controls among interventions under contemporaneous randomization. We further provide a novel procedure for establishing the noninferiority of a given intervention relative to the most efficacious of the other interventions under evaluation, where this procedure is adaptive in the sense that it need not be a priori known which of these other interventions is most efficacious. Our numerical studies show that this testing procedure can attain substantially better power when the data arise from a platform trial rather than multiple separate trials. Our results are illustrated using data from two monoclonal antibody trials for the prevention of HIV.
Collapse
Affiliation(s)
- Tzu-Jung Huang
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Alex Luedtke
- Department of Statistics, University of Washington, Seattle, WA 98195, USA and Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | | |
Collapse
|
2
|
Choko AT, Coates TJ, Mphande M, Balakasi K, Robson I, Phiri K, Phiri S, Kulich M, Sweat M, Cornell M, Hoffman RM, Dovel K. Engaging men through HIV self-testing with differentiated care to improve ART initiation and viral suppression among men in Malawi (ENGAGE): A study protocol for a randomized control trial. PLoS One 2023; 18:e0281472. [PMID: 36827327 PMCID: PMC9956026 DOI: 10.1371/journal.pone.0281472] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/22/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Men experience twice the mortality of women while on ART in sub-Saharan Africa (SSA) largely due to late HIV diagnosis and poor retention. Here we propose to conduct an individually randomized control trial (RCT) to investigate the impact of three-month home-based ART (hbART) on viral suppression among men who were not engaged in care. METHODS AND DESIGN A programmatic, individually randomized non-blinded, non-inferiority-controlled trial design (ClinicalTrials.org NCT04858243). Through medical chart reviews we will identify "non-engaged" men living with HIV, ≥15years of age who are not currently engaged in ART care, including (1) men who have tested HIV-positive and have not initiated ART within 7 days; (2) men who have initiated ART but are at risk of immediate default; and (3) men who have defaulted from ART. With 1:1 computer block randomization to either hbART or facility-based ART (fbART) arms, we will recruit men from 10-15 high-burden health facilities in central and southern Malawi. The hbART intervention will consist of 3 home-visits in a 3-month period by a certified male study nurse ART provider. In the fbART arm, male participants will be offered counselling at male participant's home, or a nearby location that is preferred by participants, followed with an escort to the local health facility and facility navigation. The primary outcome is the proportion of men who are virally suppressed at 6-months after ART initiation. Assuming primary outcome achievement of 24.0% and 33.6% in the two arms, 350 men per arm will provide 80% power to detect the stated difference. DISCUSSION Identifying effective ART strategies that are convenient and accessible for men in SSA is a priority in the HIV world. Men may not (re-)engage in facility-based care due to a myriad of barriers. Two previous trials investigated the impact of hbART on viral suppression in the general population whereas this trial focuses on men. Additionally, this trial involves a longer duration of hbART i.e., three months compared to two weeks allowing men more time to overcome the initial psychological denial of taking ART.
Collapse
Affiliation(s)
- Augustine T. Choko
- Partners in Hope, Lilongwe, Malawi
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Thomas J. Coates
- David Geffen School of Medicine, Division of Infectious Diseases, Los Angeles, California, United States of America
| | | | | | | | | | | | - Michal Kulich
- Department of Probability and Statistics, Faculty of Mathematics and Physics, Charles University, Prague, Czech Republic
| | - Michael Sweat
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology & Research, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Risa M. Hoffman
- David Geffen School of Medicine, Division of Infectious Diseases, Los Angeles, California, United States of America
| | - Kathryn Dovel
- Partners in Hope, Lilongwe, Malawi
- David Geffen School of Medicine, Division of Infectious Diseases, Los Angeles, California, United States of America
- * E-mail:
| |
Collapse
|
3
|
Msukwa MT, MacLachlan EW, Gugsa ST, Theu J, Namakhoma I, Bangara F, Blair CL, Payne D, Curran KG, Arons M, Namachapa K, Wadonda N, Kabaghe AN, Dobbs T, Shanmugam V, Kim E, Auld A, Babaye Y, O'Malley G, Nyirenda R, Bello G. Characterising persons diagnosed with HIV as either recent or long-term using a cross-sectional analysis of recent infection surveillance data collected in Malawi from September 2019 to March 2020. BMJ Open 2022; 12:e064707. [PMID: 36153024 PMCID: PMC9511604 DOI: 10.1136/bmjopen-2022-064707] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES In Malawi, a recent infection testing algorithm (RITA) is used to characterise infections of persons newly diagnosed with HIV as recent or long term. This paper shares results from recent HIV infection surveillance and describes distribution and predictors. SETTING Data from 155 health facilities in 11 districts in Malawi were pooled from September 2019 to March 2020. PARTICIPANTS Eligible participants were ≥13 years, and newly diagnosed with HIV. Clients had RITA recent infections if the rapid test for recent infection (RTRI) test result was recent and viral load (VL) ≥1000 copies/mL; if VL was <1000 copies/mL the RTRI result was reclassified as long-term. Results were stratified by age, sex, pregnancy/breastfeeding status and district. RESULTS 13 838 persons consented to RTRI testing and 12 703 had valid RTRI test results and VL results after excluding clients not newly HIV-positive, RTRI negative or missing data (n=1135). A total of 12 365 of the 12 703 were included in the analysis after excluding those whose RTRI results were reclassified as long term (n=338/784 or 43.1%). The remainder, 446/12 703 or 3.5%, met the definition of RITA recent infection. The highest percentage of recent infections was among breastfeeding women (crude OR (COR) 3.2; 95% CI 2.0 to 5.0), young people aged 15-24 years (COR 1.6; 95% CI 1.3 to 1.9) and persons who reported a negative HIV test within the past 12 months (COR 3.3; 95% CI 2.6 to 4.2). Factors associated with recent infection in multivariable analysis included being a non-pregnant female (adjusted OR (AOR) 1.4; 95% CI 1.2 to 1.8), a breastfeeding female (AOR 2.2; 95% CI 1.4 to 3.5), aged 15-24 years (AOR 1.6; 95% CI 1.3 to 1.9) and residents of Machinga (AOR 2.0; 95% CI 1.2 to 3.5) and Mzimba (AOR 2.4; 95% CI 1.3 to 4.5) districts. CONCLUSIONS Malawi's recent HIV infection surveillance system demonstrated high uptake and identified sub-populations of new HIV diagnoses with a higher percentage of recent infections.
Collapse
Affiliation(s)
- Malango T Msukwa
- Department of Global Health, I-TECH, University of Washington, Lilongwe, Malawi
| | - Ellen W MacLachlan
- Department of Global Health, I-TECH, University of Washington, Seattle, Washington, USA
| | - Salem T Gugsa
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Joe Theu
- Department of Global Health, I-TECH, University of Washington, Lilongwe, Malawi
| | - Ireen Namakhoma
- Department of Global Health, I-TECH, University of Washington, Lilongwe, Malawi
| | - Fred Bangara
- Department of Global Health, I-TECH, University of Washington, Lilongwe, Malawi
| | - Christopher L Blair
- Department of Global Health, I-TECH, University of Washington, Lilongwe, Malawi
| | - Danielle Payne
- Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Kathryn G Curran
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Melissa Arons
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Khumbo Namachapa
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Central Region, Malawi
| | - Nellie Wadonda
- Centers for Disease Control and Prevention, Lilongwe, Malawi
| | | | - Trudy Dobbs
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Evelyn Kim
- Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Andrew Auld
- Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Yusuf Babaye
- Department of Global Health, I-TECH, University of Washington, Lilongwe, Malawi
| | - Gabrielle O'Malley
- Department of Global Health, I-TECH, University of Washington, Seattle, Washington, USA
| | - Rose Nyirenda
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Central Region, Malawi
| | - George Bello
- Department of Global Health, I-TECH, University of Washington, Lilongwe, Malawi
| |
Collapse
|
4
|
Applying Behavioural Insights to HIV Prevention and Management: a Scoping Review. Curr HIV/AIDS Rep 2022; 19:358-374. [PMID: 35930186 PMCID: PMC9508055 DOI: 10.1007/s11904-022-00615-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW This scoping review summarises the literature on HIV prevention and management interventions utilizing behavioural economic principles encapsulated in the MINDSPACE framework. RECENT FINDINGS MINDSPACE is an acronym developed by the UK's behavioural insights team to summarise nine key influences on human behaviour: Messenger, Incentives, Norms, Default, Salience, Priming, Affect, Commitment, and Ego. These effects have been used in various settings to design interventions that encourage positive behaviours. Currently, over 200 institutionalised behavioural insight teams exist internationally, which may draw upon the MINDSPACE framework to inform policy and improve public services. To date, it is not clear how behavioural insights have been applied to HIV prevention and management interventions. After screening 899 studies for eligibility, 124 were included in the final review. We identified examples of interventions that utilised all the MINDSPACE effects in a variety of settings and among various populations. Studies from high-income countries were most common (n = 54) and incentives were the most frequently applied effect (n = 100). The MINDSPACE framework is a useful tool to consider how behavioural science principles can be applied in future HIV prevention and management interventions. Creating nudges to enhance the design of HIV prevention and management interventions can help people make better choices as we strive to end the HIV/AIDS pandemic by 2030.
Collapse
|
5
|
Mannoh I, Amundsen D, Turpin G, Lyons CE, Viswasam N, Hahn E, Ryan S, Baral S, Hansoti B. A Systematic Review of HIV Testing Implementation Strategies in Sub-Saharan African Countries. AIDS Behav 2022; 26:1660-1671. [PMID: 34797449 PMCID: PMC9426653 DOI: 10.1007/s10461-021-03518-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2021] [Indexed: 11/25/2022]
Abstract
HIV/AIDS remains a looming presence in public health across the world, particularly in Sub-Saharan Africa. The HIV Care Cascade hinges on testing and knowledge of HIV status. Though significant advances have been made in diagnosing people living with HIV (PLHIV), limitations in understanding which strategies are best suited to certain regions or populations have contributed to the uneven distribution in the success of various HIV testing strategies. Here, we present a conceptual framework that outlines effective HIV testing strategies for four target groups. This framework is based on a systematic literature review of articles published from January 1st, 2008, to December 31st, 2019. The effectiveness of HIV testing strategies depends on various factors including the setting, type of test and service providers. Multiple strategies are needed to reach the UNAIDS target of 95% of individuals knowing their HIV status. Expansion of community-based approaches, self-testing and HIV testing services in antenatal care will further improve the state of HIV testing in Sub-Saharan Africa.
Collapse
Affiliation(s)
- Ivy Mannoh
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Gnilane Turpin
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Carrie E Lyons
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Nikita Viswasam
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Elizabeth Hahn
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Sofia Ryan
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Stefan Baral
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Medicine Suite 200, 5801 Smith Avenue, Baltimore, MD, 21209, USA.
- Department of International Health, Bloomberg School of Public Health, Baltimore, MD, USA.
| |
Collapse
|
6
|
Conserve DF, Kayuni S, Kumwenda MK, Dovel KL, Choko AT. Assessing the efficacy of an integrated intervention to create demand for fishermen’s schistosomiasis and HIV services (FISH) in Mangochi, Malawi: Study protocol for a cluster randomized control trial. PLoS One 2022; 17:e0262237. [PMID: 34995323 PMCID: PMC8741025 DOI: 10.1371/journal.pone.0262237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 12/06/2021] [Indexed: 11/19/2022] Open
Abstract
Background Both HIV and schistosomiasis are major public health problems worldwide with 1.8 million new HIV infections, and up to 110 million untreated schistosomiasis cases globally. Although a causal link has not been established, there are strong suggestions that having schistosomiasis increases onward transmission of HIV from co-infected men to women. With both HIV and schistosomiasis treatment readily available in Malawi, there is a need to investigate the feasibility, acceptability and health impacts of joint management of these two hazards, with special focus on health education and demand-creation for fishermen. The aim of this project is to identify optimal models of delivering integrated HIV and schistosomiasis services for fishermen, particularly investigating the effect of using social networks, HIV self-test kits and beach clinic services in Mangochi, Malawi. Methods We have mapped 45 boat teams or landing sites for a 3-arm cluster randomized trial using “boat team” as the unit of randomization. The three arms are: 1) Standard of care (SOC) with leaflets explaining the importance of receiving presumptive treatment for schistosomiasis (praziquantel) and HIV services for fishermen, and two intervention arms of 2) SOC + a peer explaining the leaflet to his fellow fishermen in a boat team; and 3) arm 2 with HIV self-test kits delivered to the boat team fishermen by the peer. The primary outcomes measured at 9 months of trial delivery will compare differences between arms in the proportions of boat-team fishermen: 1) who self-report starting antiretroviral therapy or undergoing voluntary medical male circumcision; and 2) who have ≥1 S. haematobium egg seen on light microscopy of the filtrate from 10mls urine (“egg-positive”). Discussion This is the first evaluation of an integrated HIV and schistosomiasis services intervention for fishermen, particularly investigating the effect of using social networks, HIVST kits and beach clinic services. The findings will support future efforts to integrate HIVST with other health services for fishermen in similar settings if found to be efficacious. Trial registration This trial is registered in the ISRCTN registry: ISRCTN14354324; date of registration: 05 October 2020. https://www.isrctn.com/ISRCTN14354324?q=ISRCTN14354324&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10&searchType=basic-search. Linked to protocol version number 1.4 of 11 January 2021.
Collapse
Affiliation(s)
- Donaldson F. Conserve
- Department of Prevention and Community Health, Milken Institute of Public Health, George Washington University, Washington, District of Columbia, United States of America
| | | | - Moses K. Kumwenda
- Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), Blantyre, Malawi
| | - Kathryn L. Dovel
- David Geffen School of Medicine, The University of California, Los Angeles, California, United States of America
| | - Augustine Talumba Choko
- Malawi Liverpool Wellcome Trust Clinical Research Programme (MLW), Blantyre, Malawi
- * E-mail:
| |
Collapse
|
7
|
Considerations for social accountability in the expansion of self-care for sexual and reproductive health and rights. Sex Reprod Health Matters 2022; 29:2083812. [PMID: 35975672 PMCID: PMC9387307 DOI: 10.1080/26410397.2022.2083812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
|
8
|
Muwanguzi PA, Nasuuna EM, Namimbi F, Osingada CP, Ngabirano TD. Venues and methods to improve professional men's access to HIV self-testing and linkage to HIV prevention or treatment: a qualitative study. BMC Health Serv Res 2021; 21:1217. [PMID: 34753460 PMCID: PMC8577403 DOI: 10.1186/s12913-021-07259-6] [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] [Received: 05/23/2021] [Accepted: 11/02/2021] [Indexed: 11/16/2022] Open
Abstract
Background HIV testing among men in sub-Saharan Africa is sub-optimal. Despite several strategies to improve access to underserved populations, evidence regarding engaging men in professional and formal occupations in HIV testing is limited. This study explored employed professional men’s preferences for uptake of HIV self-testing, and linkage to HIV care, or prevention services. Methods This was an explorative-descriptive qualitative study where a sample of 33 men from six Ugandan urban centres. Participants were purposively selected guided by the International Standard Classification of Occupations to participate in in-depth interviews. The data were collected using an interview guide and the sample size was determined by data saturation. Eligibility criteria included fulltime formal employment for over a year at that organization. The data were analyzed manually using thematic content analysis. Results Three categories emerged: uptake of HIV self-tests, process of HIV self-testing and linkage to post-test services. The different modes of distribution of HIV self-test kits included secondary distribution, self-tests at typically male dominated spaces, delivery to workplaces and technology-based delivery. The process of HIV self-testing may be optimized by providing collection bins, and mHealth or mobile phone applications. Linkage to further care or prevention services may be enhanced using medical insurance providers, giving incentives and tele counselling. Conclusion We recommend utilization of several channels for the uptake of HIV self-tests. These include distribution of test kits both to offices and men’s leisure and recreation ‘hot spots’, Additionally, female partners, peers and established men’s group including social media groups can play a role in improving the uptake of HIV self-testing. Mobile phones and digital technology can be applied in innovative ways for the return of test results and to strengthen linkage to care or prevention services. Partnership with medical insurers may be critical in engaging men in professional employment in HIV services.
Collapse
Affiliation(s)
- Patience A Muwanguzi
- School of Health Sciences, College of Health Sciences, Makerere University, Kampala, Uganda.
| | - Esther M Nasuuna
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Florence Namimbi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Charles Peter Osingada
- School of Health Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Tom Denis Ngabirano
- School of Health Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| |
Collapse
|
9
|
The role and challenges of cluster randomised trials for global health. LANCET GLOBAL HEALTH 2021; 9:e701-e710. [PMID: 33865475 DOI: 10.1016/s2214-109x(20)30541-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 12/07/2020] [Accepted: 12/10/2020] [Indexed: 12/13/2022]
Abstract
Evaluating whether an intervention works when trialled in groups of individuals can pose complex challenges for clinical research. Cluster randomised controlled trials involve the random allocation of groups or clusters of individuals to receive an intervention, and they are commonly used in global health research. In this paper, we describe the potential reasons for the increasing popularity of cluster trials in low-income and middle-income countries. We also draw on key areas of global health research for an assessment of common trial planning practices, and we address their methodological shortcomings and pitfalls. Lastly, we discuss alternative approaches for population-level intervention trials that could be useful for research undertaken in low-income and middle-income countries for situations in which the use of cluster randomisation might not be appropriate.
Collapse
|
10
|
Sindelar K, Maponga C, Lekoala F, Mandara E, Mohoanyane M, Sanders J, Joseph J. Beyond the facility: An evaluation of seven community-based pediatric HIV testing strategies and linkage to care outcomes in a high prevalence, resource-limited setting. PLoS One 2020; 15:e0236985. [PMID: 32877441 PMCID: PMC7467225 DOI: 10.1371/journal.pone.0236985] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 07/18/2020] [Indexed: 11/18/2022] Open
Abstract
Diverse challenges in expanding pediatric HIV testing and treatment coverage persist, making the investigation and adoption of innovative strategies urgent. Evidence is mounting for the effectiveness of community-based testing in bringing such lifesaving services to those in need, particularly in resource-limited settings. The Mobilizing HIV Identification and Treatment project piloted seven community-based testing strategies to assess their effectiveness in reaching HIV-positive children and linking them to care in two districts of Lesotho from October 2015 to March 2018. Children testing HIV-positive were enrolled into the project's mHealth system where they received e-vouchers for transportation assistance to the facility for treatment initiation and were followed-up for a minimum of three months. An average of 7,351 HIV tests were conducted per month across all strategies for all age groups, with 46% of these tests on children 0-14 years. An average of 141.65 individuals tested positive each month; 9% were children. Among the children tested 55% were over 5 years. The yield in children was low (0.38%), however facility-based yields were only slightly higher (0.72%). Seventy-five percent of children were first-time testers and 86% of those testing HIV-positive were first-time testers. Seventy-one percent of enrolled children linked to care, all but one initiated treatment, and 82% were retained in care at three months. As facility-based testing remains the core of HIV programs, this evaluation demonstrates the effectiveness of community-based strategies in finding previously untested children and those over 5 years who have limited interactions with the conventional health system. Utilizing active follow-up mechanisms, linkage rates were high suggesting accessing treatment in a facility after community testing is not a barrier. Overall, these community-based testing strategies contributed markedly to the HIV testing landscape in which they were implemented, demonstrating their potential to help close the gap of unidentified HIV-positive children and achieve universal testing coverage.
Collapse
Affiliation(s)
- Kathleen Sindelar
- Clinton Health Access Initiative, Maseru, Lesotho
- * E-mail: (KS); (JJ)
| | | | | | | | | | - Jill Sanders
- Baylor College of Medicine Children’s Foundation – Lesotho, Maseru, Lesotho
| | - Jessica Joseph
- Clinton Health Access Initiative, Boston, Massachusetts, United States of America
- * E-mail: (KS); (JJ)
| |
Collapse
|
11
|
Woods B, Schmitt L, Rothery C, Phillips A, Hallett TB, Revill P, Claxton K. Practical metrics for establishing the health benefits of research to support research prioritisation. BMJ Glob Health 2020; 5:e002152. [PMID: 32868268 PMCID: PMC7462234 DOI: 10.1136/bmjgh-2019-002152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 05/28/2020] [Accepted: 05/31/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION We present practical metrics for estimating the expected health benefits of specific research proposals. These can be used by research funders, researchers and healthcare decision-makers within low-income and middle-income countries to support evidence-based research prioritisation. METHODS The methods require three key assessments: (1) the current level of uncertainty around the endpoints the proposed study will measure; (2) how uncertainty impacts on the health benefits and costs of healthcare programmes and (3) the health opportunity costs imposed by programme costs. Research is valuable because it can improve health by informing the choice of which programmes should be implemented. We provide a Microsoft Excel tool to allow readers to generate estimates of the health benefits of research studies based on these three assessments. The tool can be populated using existing studies, existing cost-effectiveness models and expert opinion. Where such evidence is not available, the tool can quantify the value of research under different assumptions. Estimates of the health benefits of research can be considered alongside research costs, and the consequences of delaying implementation until research reports, to determine whether research is worthwhile. We illustrate the method using a case study of research on HIV self-testing programmes in Malawi. This analysis combines data from the literature with outputs from the HIV synthesis model. RESULTS For this case study, we found a costing study that could be completed and inform decision making within 1 year offered the highest health benefits (67 000 disability-adjusted life years (DALYs) averted). Research on outcomes improved population health to a lesser extent (12 000 DALYs averted) and only if carried out alongside programme implementation. CONCLUSION Our work provides a method for estimating the health benefits of research in a practical and timely fashion. This can be used to support accountable use of research funds.
Collapse
Affiliation(s)
- Beth Woods
- Centre for Health Economics, University of York, York, Yorkshire, UK
| | - Laetitia Schmitt
- Centre for Health Economics, University of York, York, Yorkshire, UK
| | - Claire Rothery
- Centre for Health Economics, University of York, York, Yorkshire, UK
| | - Andrew Phillips
- Institute for Global Health, University College London, London, UK
| | - Timothy B Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, London, London, UK
| | - Paul Revill
- Centre for Health Economics, University of York, York, Yorkshire, UK
| | - Karl Claxton
- Centre for Health Economics, University of York, York, Yorkshire, UK
| |
Collapse
|
12
|
Choko AT, Jamil MS, MacPherson P, Corbett E, Chitembo L, Ingold H, Bermudez Aza E, d’Elbee M, DiCarlo M, Majam M, Schewchuk T, Wong V, Baggaley R, Johnson C. Measuring linkage to HIV treatment services following HIV self-testing in low-income settings. J Int AIDS Soc 2020; 23:e25548. [PMID: 32579759 PMCID: PMC7314400 DOI: 10.1002/jia2.25548] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/05/2020] [Accepted: 05/14/2020] [Indexed: 11/09/2022] Open
Affiliation(s)
- Augustine T Choko
- TB/HIV GroupMalawi Liverpool Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
- Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Muhammad S Jamil
- Global HIV, Hepatitis and SITs ProgrammesWorld Health OrganizationGenevaSwitzerland
| | - Peter MacPherson
- TB/HIV GroupMalawi Liverpool Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
- Department of Clinical SciencesLiverpool School of Tropical MedicineLiverpoolUnited Kingdom
- Department of Clinical ResearchLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Elizabeth Corbett
- TB/HIV GroupMalawi Liverpool Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
- Department of Clinical ResearchLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | | | | | | | - Marc d’Elbee
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | | | - Mohammed Majam
- Wits Reproductive Health and HIV Research InstituteJohannesburgSouth Africa
| | | | - Vincent Wong
- Global Health BureauOffice of HIV/AIDS, Prevention Care and Treatment DivisionUnited States Agency for International Development (USAID)ArlingtonVAUSA
| | - Rachel Baggaley
- Global HIV, Hepatitis and SITs ProgrammesWorld Health OrganizationGenevaSwitzerland
| | - Cheryl Johnson
- Global HIV, Hepatitis and SITs ProgrammesWorld Health OrganizationGenevaSwitzerland
| | | |
Collapse
|
13
|
Lépine A, Treibich C. Risk aversion and HIV/AIDS: Evidence from Senegalese female sex workers. Soc Sci Med 2020; 256:113020. [PMID: 32454226 PMCID: PMC7306163 DOI: 10.1016/j.socscimed.2020.113020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/11/2020] [Accepted: 04/23/2020] [Indexed: 12/03/2022]
Abstract
HIV/AIDS is the second cause of mortality globally and there are 5000 new infections each day. Globally, sex workers are 13 times more at risk of HIV than the general population and in Senegal they have an HIV prevalence 16.5 times greater. Therefore, it is urgent to encourage behaviour change, which requires a better understanding of the reasons why sex workers engage in risky behaviours. We provide new evidence of the role of risk preferences on sexual behaviours, health behaviours and health outcomes of 600 female sex workers in Senegal in July and August 2017. We measure risk aversion of sex workers using an incentivised Gneezy and Potters task in addition to specific risk-taking scales in four domains (in general, finance, health and sex). Understanding of the experimental task was high despite low literacy level of participants. Using ordinary least squares, we find that risk aversion is an important predictor of sex workers’ sexual behaviours. We find that sex workers with higher level of risk aversion have less sex acts with clients, have less clients at risk of HIV, are more likely to engage in protected sex acts and as a result earn less money per sex act. Furthermore, we find that sex workers exhibiting higher level of risk aversion are less likely to be infected with sexually transmitted infections. Results highlight that some associations between risk preferences and sexual and health behaviours are domain specific. To conclude, our results confirm the role of risk preferences in the spread of HIV/AIDS epidemic and suggest the importance of collecting information on self-reported risk aversion to identify individuals who are at a greater risk of HIV/AIDS. Finally, our results provide some rationale in using lottery-based financial incentives to prevent sexually transmitted infections and HIV/AIDS among high-risk populations. We study the role of risk preferences on HIV/AIDS among sex workers in Senegal. Risk preferences were elicited in a lab-in- the-field experiment and self-reported. Risk aversion is a main predictor of sexual behaviours. The relationship between risk aversion and behaviours is domain-specific.
Collapse
Affiliation(s)
- Aurélia Lépine
- University College London, Institute for Global Health, London, UK.
| | - Carole Treibich
- University Grenoble Alpes, CNRS, INRAE, Grenoble INP, GAEL, 38000, Grenoble, France
| |
Collapse
|
14
|
Tahlil KM, Ong JJ, Rosenberg NE, Tang W, Conserve DF, Nkengasong S, Muessig KE, Iwelunmor J, Ezechi O, Gbaja-biamila T, Aliyu SH, Obiezu-Umeh C, Kapogiannis B, Tucker JD. Verification of HIV Self-Testing Use and Results: A Global Systematic Review. AIDS Patient Care STDS 2020; 34:147-156. [PMID: 32324482 PMCID: PMC7194324 DOI: 10.1089/apc.2019.0283] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
HIV self-testing (HIVST) allows individuals to interpret and report their own test results, thus decentralizing testing. Yet, this decentralization can make it difficult to verify self-testing results, which is important for linkage to care and surveillance. The aim of this systematic review is to summarize methods for verifying HIVST use and results. We followed guidance from the Cochrane Handbook 5.1 on systematic reviews. We searched four journal databases (PubMed, Embase, Scopus, and Cochrane Library), one clinical trials database (ClinicalTrials.gov), two conference abstract databases (International AIDS Society and Conference on Retroviruses and Opportunistic Infections) and one gray literature database (OpenGrey). We included studies that verified opening of kits or test results. Two researchers independently screened articles and extracted data regarding HIVST location, method of verification, who performed verification, proportion of results verified, and primary or secondary kit distribution. The search yielded 3853 unique citations, of which 40 contained information on HIVST verification and were included. Among these 40 studies, 13 were in high-income countries, 16 were in middle-income countries, and 11 were in low-income countries. Seventeen studies included key populations and two focused on youth. Three methods verified results: supervision by a health provider, returning used test kits, and electronic transmission of photographs. One method verified opening of kits using Bluetooth sensors. Although HIVST has increased worldwide, strategies to verify self-testing results remain limited. These findings suggest a need for additional innovative strategies for verifying HIVST use and results and linkage of self-testing results to surveillance and care systems.
Collapse
Affiliation(s)
- Kadija M. Tahlil
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jason J. Ong
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Central Clinical School, Monash University, Melbourne, Australia
| | - Nora E. Rosenberg
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Weiming Tang
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Susan Nkengasong
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kathryn E. Muessig
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Juliet Iwelunmor
- College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri, USA
| | - Oliver Ezechi
- The Nigerian Institute of Medical Research, Lagos, Nigeria
| | | | - Sani H. Aliyu
- National Agency for the Control of AIDS, Abuja, Nigeria
| | - Chisom Obiezu-Umeh
- College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri, USA
| | - Bill Kapogiannis
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Joseph D. Tucker
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| |
Collapse
|
15
|
Indravudh PP, Fielding K, Kumwenda MK, Nzawa R, Chilongosi R, Desmond N, Nyirenda R, Johnson CC, Baggaley RC, Hatzold K, Terris-Prestholt F, Corbett EL. Community-led delivery of HIV self-testing to improve HIV testing, ART initiation and broader social outcomes in rural Malawi: study protocol for a cluster-randomised trial. BMC Infect Dis 2019; 19:814. [PMID: 31533646 PMCID: PMC6751650 DOI: 10.1186/s12879-019-4430-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 08/30/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Prevention of new HIV infections is a critical public health issue. The highest HIV testing gaps are in men, adolescents 15-19 years old, and adults 40 years and older. Community-based HIV testing services (HTS) can contribute to increased testing coverage and early HIV diagnosis, with HIV self-testing (HIVST) strategies showing promise. Community-based strategies, however, are resource intensive, costly and not widely implemented. A community-led approach to health interventions involves supporting communities to plan and implement solutions to improve their health. This trial aims to determine if community-led delivery of HIVST can improve HIV testing uptake, ART initiation, and broader social outcomes in rural Malawi. METHODS The trial uses a parallel arm, cluster-randomised design with group village heads (GVH) and their defined catchment areas randomised (1:1) to community-led HIVST or continue with the standard of the care (SOC). As part of the intervention, informal community health cadres are supported to plan and implement a seven-day HIVST campaign linked to HIV treatment and prevention. Approximately 12 months after the initial campaign, intervention GVHs are randomised to lead a repeat HIVST campaign. The primary outcome includes the proportion of adolescents 15-19 years old who have tested for HIV in their lifetime. Secondary outcomes include recent testing in adults 40 years and older and men; ART initiation; knowledge of HIV prevention; and HIV testing stigma. Outcomes will be measured through cross-sectional surveys and clinic registers. Economic evaluation will determine the cost per person tested, cost per person diagnosed, and incremental cost effectiveness ratio. DISCUSSION To the best of our knowledge, this is the first trial to assess the effectiveness of community-led HTS, which has only recently been enabled by the introduction of HIVST. Community-led delivery of HIVST is a promising new strategy for providing periodic HIV testing to support HIV prevention in rural communities. Further, introduction of HIVST through a community-led framework seems particularly apt, with control over healthcare concurrently devolved to individuals and communities. TRIAL REGISTRATION Clinicaltrials.gov registry ( NCT03541382 ) registered 30 May 2018.
Collapse
Affiliation(s)
- Pitchaya P. Indravudh
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Moses K. Kumwenda
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Rebecca Nzawa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Nicola Desmond
- Clinical Sciences Department, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Rose Nyirenda
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Cheryl C. Johnson
- Department of HIV/AIDS, World Health Organisation, Geneva, Switzerland
| | | | - Karin Hatzold
- Population Services International, Johannesburg, South Africa
| | - Fern Terris-Prestholt
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth L. Corbett
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
16
|
van Lettow M, Cataldo F, Landes M, Kasende F, Nkhoma P, van Oosterhout JJ, Kim E, Schouten E, Nkhoma E, Nyirenda R, Tippett Barr BA. Impact of inter-partner HIV disclosure patterns in Malawi's PMTCT program: A mixed-method study. PLoS One 2019; 14:e0219967. [PMID: 31348782 PMCID: PMC6660128 DOI: 10.1371/journal.pone.0219967] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 07/06/2019] [Indexed: 11/19/2022] Open
Abstract
Background Evidence suggests that disclosure of HIV status between partners may influence prevention of maternal-to-child transmission of HIV (PMTCT) outcomes. We report partner disclosure in relation to maternal antiretroviral therapy (ART) uptake and adherence, and MTCT among postpartum HIV-infected Malawian women. Methods A cross-sectional mixed-method study was conducted as part of a nationally representative longitudinal cohort study. Between 2014–2016, all (34,637) mothers attending 54 under-5 clinics with their 4–26 week-old infants were approached, of which 98% (33,980) were screened for HIV; infants received HIV-1 DNA testing. HIV-exposure was confirmed in 3,566/33,980 (10.5%). Baseline data from mothers who were known to be HIV-infected at time of screening were included in the current analysis. Guardians (n = 17), newly diagnosed HIV-infected mothers (n = 256) and mothers or infants with undetermined HIV status (n = 30) were excluded. Data collected included socio-demographics, partner disclosure, maternal ART uptake, and adherence. Between 2016–2017, in-depth interviews and focus group discussions were conducted with adult mothers (n = 53) and their spouse/cohabiting partners (n = 19), adolescent mothers (n = 13), lost-to-follow up (LTFU) mothers (n = 22), community leaders (n = 23) and healthcare workers (n = 154). Results Of 3153 known HIV-infected mothers, 2882 (91.4%) reported having a spouse/cohabiting partner. Among 2882 couples, both partners, one partner, and neither partner disclosed to each other in 2090 (72.5%), 622 (21.6%), and 169 (5.9%), respectively. In multivariable models, neither partner disclosing was associated with no maternal ART (aOR 4.7; 95%CI 2.5–8.8), suboptimal treatment adherence (aOR 1.8; 95%CI 1.1–2.8) and MTCT (aOR 2.1; 95%CI 1.1–4.1). Women’s fear of blame by partners was central to decisions not to disclose within couples and when starting new relationships. LTFU mothers struggled to accept and disclose their status, hindering treatment initiation; some were unable to hide ART and feared involuntary disclosure. Conclusion Partner disclosure seems to play an important role in women’s decisions regarding ART initiation and adherence. Inter-partner non-disclosure was associated with no ART uptake, suboptimal treatment adherence and MTCT.
Collapse
Affiliation(s)
- Monique van Lettow
- Medical and Research Department, Dignitas International, Zomba, Malawi
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- * E-mail: ,
| | - Fabian Cataldo
- Medical and Research Department, Dignitas International, Zomba, Malawi
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Megan Landes
- Medical and Research Department, Dignitas International, Zomba, Malawi
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Florence Kasende
- Medical and Research Department, Dignitas International, Zomba, Malawi
| | - Pearson Nkhoma
- Medical and Research Department, Dignitas International, Zomba, Malawi
| | - Joep J. van Oosterhout
- Medical and Research Department, Dignitas International, Zomba, Malawi
- Department of Medicine, College of Medicine University of Malawi, Blantyre, Malawi
| | - Evelyn Kim
- United States Centers for Disease Control and Prevention, Lilongwe, Malawi
| | | | | | | | - Beth A. Tippett Barr
- Department of Medicine, College of Medicine University of Malawi, Blantyre, Malawi
- United States Centers for Disease Control and Prevention, Kisumu, Kenya
| |
Collapse
|
17
|
Lebina L, Seatlholo N, Taruberekera N, Radebe M, Kinghorn A, Meyer T, Mhazo M, Otwombe K, Hlongwane K, Ringane A, Koloane N, Nkuta M, Nkhwashu N, Farirai T, Kweza P, Chidarikire T, Shamu S, Kufa T, Puren A, Martinson N, Milovanovic M. Feasibility of community-based HIV self-screening in South Africa: a demonstration project. BMC Public Health 2019; 19:898. [PMID: 31286953 PMCID: PMC6615295 DOI: 10.1186/s12889-019-7122-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 06/07/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND HIV diagnosis is a critical step in linking HIV-infected individuals to care and treatment and linking HIV-uninfected persons to prevention services. However, the uptake of HIV testing remains low in many countries. HIV self-screening (HIVSS) is acceptable to adults, but there is limited data on HIVSS feasibility in community programmes. This study aimed to evaluate the feasibility of HIVSS in South Africa. METHODS We conducted a prospective study that enrolled participants through mobile site, homebased, workplace and sex worker programmes in two townships from May to November 2017. Following an information session on HIVSS, interested participants were offered one of three methods of HIVSS testing: supervised, semi-supervised, and unsupervised. Participants who opted for unsupervised testing and those who tested HIV positive after semi- or supervised HIVSS were followed up telephonically or with a home visit one week after receipt of the test kit to confirm results and linkages to care. Follow-up visits were concluded when the participant indicated that they had used the kit or had accessed a confirmatory HIV test. RESULTS Of the 2061 people approached, 88.2% (1818/2061) received HIV testing information. Of this group, 89% (1618/1818) were enrolled in the study and 70.0% (1133/1618) were tested for HIV with the kit. The median age was 28 (IQR:23-33) years with an even gender distribution. Of those enrolled, 43.0% (696/1618) were identified through homebased outreach, 42.5% (687/1618) through mobile sites, 7.3% (118/1618) at their workplace and 7.2% (117/1618) from sex worker programmes. A total of 68.7% (1110/1616) selected unsupervised HIVSS, whereas 6.3% (101/1616) opted for semi-supervised and 25.0% ((405/1616) chose supervised HIVSS. Overall, the HIV prevalence using the HIVSS test was 8.2% (93/1129). Of those newly diagnosed with HIV, 16% (12/75) were initiated on ART. Almost half (48.0%; 543/1131) of those tested were linked to a primary HIV test as follows: supervised (85.2%; 336/394); semi-supervised (93.8%; 91/97) and unsupervised (18.1%; 116/640). CONCLUSION Unsupervised HIVSS was by far the most selected and utilised HIVSS method. Linkages to primary and confirmatory testing for the unsupervised HIVSS and further care were low, despite home visits and telephonic reminders.
Collapse
Affiliation(s)
- Limakatso Lebina
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Ntombexolo Seatlholo
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Mopo Radebe
- Society for Family Health, Johannesburg, South Africa
| | - Anthony Kinghorn
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tessa Meyer
- Society for Family Health, Johannesburg, South Africa
| | - Miriam Mhazo
- Society for Family Health, Johannesburg, South Africa
| | - Kennedy Otwombe
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Khuthadzo Hlongwane
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ashley Ringane
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nthabiseng Koloane
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mbali Nkuta
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Thato Farirai
- Foundation for Professional Development, Tshwane, South Africa
| | - Patience Kweza
- Foundation for Professional Development, Tshwane, South Africa
| | - Thato Chidarikire
- HIV and AIDS and STI Cluster, National Department of Health, Pretoria, South Africa
| | - Simukai Shamu
- Foundation for Professional Development, Tshwane, South Africa
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Tendesayi Kufa
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Adrian Puren
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg, South Africa
- Division of Virology, School of Pathology, University of the Witwatersrand, Johannesburg, South Africa
| | - Neil Martinson
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Center for TB Research, Johns Hopkins University, Baltimore, MD, USA
| | - Minja Milovanovic
- Perinatal HIV Research Unit (PHRU), SA MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
18
|
Wulandari LPL, Ruddick A, Guy R, Kaldor J. "Self-testing sounds more private, rather than going to the clinic and everybody will find out": Facilitators and barriers regarding HIV testing among men who purchase sex in Bali, Indonesia. PLoS One 2019; 14:e0214987. [PMID: 30958845 PMCID: PMC6453456 DOI: 10.1371/journal.pone.0214987] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 03/25/2019] [Indexed: 12/29/2022] Open
Abstract
In many Asian countries, men who purchase sex account for the largest single network of people which often face elevated HIV risk in relation to the general population. However, high proportions of these men have never undertaken HIV testing. We assessed barriers to and facilitators of HIV testing among men who purchase sex in Indonesia, including the acceptability of HIV self-testing. A qualitative study was conducted during December 2016-January 2017 at fourteen sex-work venues and one voluntary HIV counselling and testing (VCT) clinic in Bali. Interviews were conducted with men who purchase sex exploring the men's views on HIV testing. Data were examined using thematic analysis. Twenty-nine men participated in the study. The themes that emerged regarding the barriers to HIV testing included fear of potential shame, embarrassment, and confidentiality breach in accessing HIV testing; fear of social exclusion if the test result was positive; self-treatment and prevention; the distance to a clinic; time constraints; and fear of an invasive testing method. Factors that were seen as facilitating a test were the convenience of time and place; the provision of speedy results; and privacy. Participants expressed interest in HIV self-testing and preferred it to clinic-based testing due to the privacy and confidentiality of the results. The findings support the introduction of an HIV self-testing strategy among this group to improve access to HIV testing.
Collapse
Affiliation(s)
- Luh Putu Lila Wulandari
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
- Department of Public Health and Preventive Medicine, Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia
- * E-mail: ,
| | - Abby Ruddick
- Independent Consultant, Denpasar, Bali, Indonesia
| | - Rebecca Guy
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - John Kaldor
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| |
Collapse
|
19
|
Watson V, Dacombe RJ, Williams C, Edwards T, Adams ER, Johnson CC, Mutseta MN, Corbett EL, Cowan FM, Ayles H, Hatzold K, MacPherson P, Taegtmeyer M. Re-reading of OraQuick HIV-1/2 rapid antibody test results: quality assurance implications for HIV self-testing programmes. J Int AIDS Soc 2019; 22 Suppl 1:e25234. [PMID: 30907514 PMCID: PMC6432491 DOI: 10.1002/jia2.25234] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 12/19/2018] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Scale-up of HIV self-testing (HIVST) will play a key role in meeting the United Nation's 90-90-90 targets. Delayed re-reading of used HIVST devices has been used by early implementation studies to validate the performance of self-test kits and to estimate HIV positivity among self-testers. We investigated the stability of results on used devices under controlled conditions to assess its potential as a quality assurance approach for HIVST scale-up. METHODS 444 OraQuick® HIV-1/2 rapid antibody tests were conducted using commercial plasma from two HIV-positive donors and HIV-negative plasma (high-reactive n = 148, weak-reactive n = 148 and non-reactive n = 148) and incubated them for six months under four conditions (combinations of high and low temperatures and humidity). Devices were re-read daily for one week, weekly for one subsequent month and then once a month by independent readers unaware of the previous results. We used multistage transition models to investigate rates of change in device results, and between storage conditions. RESULTS AND DISCUSSION There was a high incidence of device instability. Forty-three (29%) of 148 initially non-reactive results became false weak-reactive results. These changes were observed across all incubation conditions, the earliest on Day 4 (n = 9 kits). No initially HIV-reactive results changed to a non-reactive result. There were no significant associations between storage conditions and hazard of results transition. We observed substantial statistical agreement between independent re-readers over time (agreement range: 0.74 to 0.96). CONCLUSIONS Delayed re-reading of used OraQuick® HIV-1/2 rapid antibody tests is not currently a valid methodological approach to quality assurance and monitoring as we observed a high incidence (29%) of true non-reactive tests changing to false weak-reactive and therefore its use may overestimate true HIV positivity.
Collapse
Affiliation(s)
- Victoria Watson
- Department of International Public HealthLiverpool School of Tropical MedicineLiverpoolUnited Kingdom
| | - Russell J Dacombe
- Department of International Public HealthLiverpool School of Tropical MedicineLiverpoolUnited Kingdom
| | - Christopher Williams
- Research Centre for Drugs and DiagnosticsLiverpool School of Tropical MedicineLiverpoolUnited Kingdom
| | - Thomas Edwards
- Research Centre for Drugs and DiagnosticsLiverpool School of Tropical MedicineLiverpoolUnited Kingdom
| | - Emily R Adams
- Research Centre for Drugs and DiagnosticsLiverpool School of Tropical MedicineLiverpoolUnited Kingdom
| | - Cheryl C Johnson
- HIV DepartmentWorld Health OrganisationGenevaSwitzerland
- Department of Clinical ResearchLondon School of Hygiene & Tropical MedicineLondonUnited Kingdom
| | | | - Elizabeth L Corbett
- Department of Clinical ResearchLondon School of Hygiene & Tropical MedicineLondonUnited Kingdom
- Malawi Liverpool Welcome TrustClinical Research ProgrammeBlantyreMalawi
| | - Frances M Cowan
- Department of International Public HealthLiverpool School of Tropical MedicineLiverpoolUnited Kingdom
- Centre for Sexual Health HIV and AIDS ResearchHarareZimbabwe
| | - Helen Ayles
- Department of Clinical ResearchLondon School of Hygiene & Tropical MedicineLondonUnited Kingdom
- ZambartLusakaZambia
| | | | - Peter MacPherson
- Malawi Liverpool Welcome TrustClinical Research ProgrammeBlantyreMalawi
- Department of Clinical SciencesLiverpool School of Tropical MedicineLiverpoolUnited Kingdom
| | - Miriam Taegtmeyer
- Department of International Public HealthLiverpool School of Tropical MedicineLiverpoolUnited Kingdom
| |
Collapse
|
20
|
Kumwenda MK, Johnson CC, Choko AT, Lora W, Sibande W, Sakala D, Indravudh P, Chilongosi R, Baggaley RC, Nyirenda R, Taegtmeyer M, Hatzold K, Desmond N, Corbett EL. Exploring social harms during distribution of HIV self-testing kits using mixed-methods approaches in Malawi. J Int AIDS Soc 2019; 22 Suppl 1:e25251. [PMID: 30907508 PMCID: PMC6432111 DOI: 10.1002/jia2.25251] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 01/24/2019] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION HIV self-testing (HIVST) provides couples and individuals with a discreet, convenient and empowering testing option. As with all HIV testing, potential harms must be anticipated and mitigated to optimize individual and public health benefits. Here, we describe social harms (SHs) reported during HIVST implementation in Malawi, and propose a framework for grading and responding to harms, according to their severity. METHODS We report findings from six HIVST implementation studies in Malawi (2011 to 2017) that included substudies investigating SH reports. Qualitative methods included focus group discussions, in-depth interviews and critical incident interviews. Earlier studies used intensive quantitative methods (post-test questionnaires for intimate partner violence, household surveys, investigation of all deaths in HIVST communities). Later studies used post-marketing reporting with/without community engagement. Pharmacovigilance methodology (whereby potentially life-threatening/changing events are defined as "serious") was used to grade SH severity, assuming more complete passive reporting for serious events. RESULTS During distribution of 175,683 HIVST kits, predominantly under passive SH reporting, 25 serious SHs were reported from 19 (0.011%) self-testers, including 15 partners in eight couples with newly identified HIV discordancy, and one perinatally infected adolescent. There were no deaths or suicides. Marriage break-up was the most commonly reported serious SH (sixteen individuals; eight couples), particularly among serodiscordant couples. Among new concordant HIV-positive couples, blame and frustration was common but rarely (one episode) led to serious SHs. Among concordant HIV-negative couples, increased trust and stronger relationships were reported. Coercion to test or disclose was generally considered "well-intentioned" within established couples. Women felt empowered and were assertive when offering HIVST test kits to their partners. Some women who persuaded their partner to test, however, did report SHs, including verbal or physical abuse and economic hardship. CONCLUSIONS After more than six years of large-scale HIVST implementation and in-depth investigation of SHs in Malawi, we identified approximately one serious reported SH per 10,000 HIVST kits distributed, predominantly break-up of married serodiscordant couples. Both "active" and "passive" reporting systems identified serious SH events, although with more complete capture by "active" systems. As HIVST is scaled-up, efforts to support and further optimize community-led SH monitoring should be prioritized alongside HIVST distribution.
Collapse
Affiliation(s)
- Moses K Kumwenda
- Malawi Liverpool Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
- Helse Nord TB InitiativeCollege of MedicineUniversity of MalawiBlantyreMalawi
| | - Cheryl C Johnson
- HIV and Global Hepatitis DepartmentWorld Health OrganizationGenevaSwitzerland
- Clinical Research DepartmentLondon School of Hygiene and Tropical MedicineLondonUK
| | - Augustine T Choko
- Malawi Liverpool Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
- Clinical Research DepartmentLondon School of Hygiene and Tropical MedicineLondonUK
| | - Wezzie Lora
- Malawi Liverpool Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
- Department of International Public HealthLiverpool School of Tropical MedicineLiverpoolUK
| | - Wakumanya Sibande
- Malawi Liverpool Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
| | - Doreen Sakala
- Malawi Liverpool Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
| | - Pitchaya Indravudh
- Malawi Liverpool Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
- Clinical Research DepartmentLondon School of Hygiene and Tropical MedicineLondonUK
| | | | - Rachael C Baggaley
- HIV and Global Hepatitis DepartmentWorld Health OrganizationGenevaSwitzerland
| | | | - Miriam Taegtmeyer
- Department of International Public HealthLiverpool School of Tropical MedicineLiverpoolUK
| | - Karin Hatzold
- Population Services InternationalJohannesburgSouth Africa
| | - Nicola Desmond
- Malawi Liverpool Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
- Department of International Public HealthLiverpool School of Tropical MedicineLiverpoolUK
| | - Elizabeth L Corbett
- Malawi Liverpool Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
- Clinical Research DepartmentLondon School of Hygiene and Tropical MedicineLondonUK
| |
Collapse
|
21
|
Choko AT, Corbett EL, Stallard N, Maheswaran H, Lepine A, Johnson CC, Sakala D, Kalua T, Kumwenda M, Hayes R, Fielding K. HIV self-testing alone or with additional interventions, including financial incentives, and linkage to care or prevention among male partners of antenatal care clinic attendees in Malawi: An adaptive multi-arm, multi-stage cluster randomised trial. PLoS Med 2019; 16:e1002719. [PMID: 30601823 PMCID: PMC6314606 DOI: 10.1371/journal.pmed.1002719] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 11/21/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Conventional HIV testing services have been less comprehensive in reaching men than in reaching women globally, but HIV self-testing (HIVST) appears to be an acceptable alternative. Measurement of linkage to post-test services following HIVST remains the biggest challenge, yet is the biggest driver of cost-effectiveness. We investigated the impact of HIVST alone or with additional interventions on the uptake of testing and linkage to care or prevention among male partners of antenatal care clinic attendees in a novel adaptive trial. METHODS AND FINDINGS An adaptive multi-arm, 2-stage cluster randomised trial was conducted between 8 August 2016 and 30 June 2017, with antenatal care clinic (ANC) days (i.e., clusters of women attending on a single day) as the unit of randomisation. Recruitment was from Ndirande, Bangwe, and Zingwangwa primary health clinics in urban Blantyre, Malawi. Women attending an ANC for the first time for their current pregnancy (regardless of trimester), 18 years and older, with a primary male partner not known to be on ART were enrolled in the trial after giving consent. Randomisation was to either the standard of care (SOC; with a clinic invitation letter to the male partner) or 1 of 5 intervention arms: the first arm provided women with 2 HIVST kits for their partners; the second and third arms provided 2 HIVST kits along with a conditional fixed financial incentive of $3 or $10; the fourth arm provided 2 HIVST kits and a 10% chance of receiving $30 in a lottery; and the fifth arm provided 2 HIVST kits and a phone call reminder for the women's partners. The primary outcome was the proportion of male partners who were reported to have tested for HIV and linked into care or prevention within 28 days, with referral for antiretroviral therapy (ART) or circumcision accordingly. Women were interviewed at 28 days about partner testing and adverse events. Cluster-level summaries compared each intervention versus SOC using eligible women as the denominator (intention-to-treat). Risk ratios were adjusted for male partner testing history and recruitment clinic. A total of 2,349/3,137 (74.9%) women participated (71 ANC days), with a mean age of 24.8 years (SD: 5.4). The majority (2,201/2,233; 98.6%) of women were married, 254/2,107 (12.3%) were unable to read and write, and 1,505/2,247 (67.0%) were not employed. The mean age for male partners was 29.6 years (SD: 7.5), only 88/2,200 (4.0%) were unemployed, and 966/2,210 (43.7%) had never tested for HIV before. Women in the SOC arm reported that 17.4% (71/408) of their partners tested for HIV, whereas a much higher proportion of partners were reported to have tested for HIV in all intervention arms (87.0%-95.4%, p < 0.001 in all 5 intervention arms). As compared with those who tested in the SOC arm (geometric mean 13.0%), higher proportions of partners met the primary endpoint in the HIVST + $3 (geometric mean 40.9%, adjusted risk ratio [aRR] 3.01 [95% CI 1.63-5.57], p < 0.001), HIVST + $10 (51.7%, aRR 3.72 [95% CI 1.85-7.48], p < 0.001), and phone reminder (22.3%, aRR 1.58 [95% CI 1.07-2.33], p = 0.021) arms. In contrast, there was no significant increase in partners meeting the primary endpoint in the HIVST alone (geometric mean 17.5%, aRR 1.45 [95% CI 0.99-2.13], p = 0.130) or lottery (18.6%, aRR 1.43 [95% CI 0.96-2.13], p = 0.211) arms. The lottery arm was dropped at interim analysis. Overall, 46 male partners were confirmed to be HIV positive, 42 (91.3%) of whom initiated ART within 28 days; 222 tested HIV negative and were not already circumcised, of whom 135 (60.8%) were circumcised as part of the trial. No serious adverse events were reported. Costs per male partner who attended the clinic with a confirmed HIV test result were $23.73 and $28.08 for the HIVST + $3 and HIVST + $10 arms, respectively. Notable limitations of the trial included the relatively small number of clusters randomised to each arm, proxy reporting of the male partner testing outcome, and being unable to evaluate retention in care. CONCLUSIONS In this study, the odds of men's linkage to care or prevention increased substantially using conditional fixed financial incentives plus partner-delivered HIVST; combinations were potentially affordable. TRIAL REGISTRATION ISRCTN 18421340.
Collapse
Affiliation(s)
- Augustine T. Choko
- TB/HIV Group, Malawi–Liverpool–Wellcome Clinical Research Programme, Blantyre, Malawi
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Elizabeth L. Corbett
- TB/HIV Group, Malawi–Liverpool–Wellcome Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Nigel Stallard
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | | | - Aurelia Lepine
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Cheryl C. Johnson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
- World Health Organization, Geneva, Switzerland
| | - Doreen Sakala
- TB/HIV Group, Malawi–Liverpool–Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Thokozani Kalua
- Department of HIV/AIDS, Ministry of Health, Lilongwe, Malawi
| | - Moses Kumwenda
- TB/HIV Group, Malawi–Liverpool–Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| |
Collapse
|
22
|
MacPherson P, Webb EL, Lalloo DG, Nliwasa M, Maheswaran H, Joekes E, Phiri D, Squire B, Pai M, Corbett EL. Design and protocol for a pragmatic randomised study to optimise screening, prevention and care for tuberculosis and HIV in Malawi (PROSPECT Study). Wellcome Open Res 2018; 3:61. [PMID: 30542662 PMCID: PMC6259593 DOI: 10.12688/wellcomeopenres.14598.3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2018] [Indexed: 01/20/2023] Open
Abstract
Background: Adults seeking diagnosis and treatment for tuberculosis (TB) and HIV in low-resource settings face considerable barriers and have high pre-treatment mortality. Efforts to improve access to prompt TB treatment have been hampered by limitations in TB diagnostics, with considerable uncertainty about how available and new tests can best be implemented. Design and methods: The PROSPECT Study is an open, three-arm pragmatic randomised study that will investigate the effectiveness and cost-effectiveness of optimised HIV and TB diagnosis and linkage to care interventions in reducing time to TB diagnosis and prevalence of undiagnosed TB and HIV in primary care in Blantyre, Malawi. Participants (≥ 18 years) attending a primary care clinic with TB symptoms (cough of any duration) will be randomly allocated to one of three groups: (i) standard of care; (ii) optimised HIV diagnosis and linkage; or (iii) optimised HIV and TB diagnosis and linkage. We will test two hypotheses: firstly, whether prompt linkage to HIV care should be prioritised for adults with TB symptoms; and secondly, whether an optimised TB triage testing algorithm comprised of digital chest x-ray evaluated by computer-aided diagnosis software and sputum GeneXpert MTB/Rif can outperform clinician-directed TB screening. The primary trial outcome will be time to TB treatment initiation by day 56, and secondary outcomes will include prevalence of undiagnosed TB and HIV, mortality, quality of life, and cost-effectiveness. Conclusions: The PROSPECT Study will provide urgently-needed evidence under "real-life" conditions to inform clinicians and policy makers on how best to improve TB/HIV diagnosis and treatment in Africa. Clinical trial registration: NCT03519425 (08/05/2018).
Collapse
Affiliation(s)
- Peter MacPherson
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre , Malawi
| | - Emily L Webb
- London School of Hygiene & Tropical Medicine, London, UK
| | - David G. Lalloo
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Marriott Nliwasa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre , Malawi
- Helse Nord TB Programme, Department of Microbiology, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Elizabeth Joekes
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Dama Phiri
- Radiology Department, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Bertie Squire
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre , Malawi
| | - Madhukar Pai
- McGill International TB Centre, McGill University, Montreal , Canada
| | | |
Collapse
|
23
|
MacPherson P, Webb EL, Lalloo DG, Nliwasa M, Maheswaran H, Joekes E, Phiri D, Squire B, Pai M, Corbett EL. Design and protocol for a pragmatic randomised study to optimise screening, prevention and care for tuberculosis and HIV in Malawi (PROSPECT Study). Wellcome Open Res 2018; 3:61. [PMID: 30542662 PMCID: PMC6259593 DOI: 10.12688/wellcomeopenres.14598.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2018] [Indexed: 11/20/2022] Open
Abstract
Background: Adults seeking diagnosis and treatment for tuberculosis (TB) and HIV in low-resource settings face considerable barriers and have high pre-treatment mortality. Efforts to improve access to prompt TB treatment have been hampered by limitations in TB diagnostics, with considerable uncertainty about how available and new tests can best be implemented. Design and methods: The PROSPECT Study is an open, three-arm pragmatic randomised study that will investigate the effectiveness and cost-effectiveness of optimised HIV and TB diagnosis and linkage to care interventions in reducing time to TB diagnosis and prevalence of undiagnosed TB and HIV in primary care in Blantyre, Malawi. Participants (≥ 18 years) attending a primary care clinic with TB symptoms (cough of any duration) will be randomly allocated to one of three groups: (i) standard of care; (ii) optimised HIV diagnosis and linkage; or (iii) optimised HIV and TB diagnosis and linkage. We will test two hypotheses: firstly, whether prompt linkage to HIV care should be prioritised for adults with TB symptoms; and secondly, whether an optimised TB triage testing algorithm comprised of digital chest x-ray evaluated by computer-aided diagnosis software and sputum GeneXpert MTB/Rif can outperform clinician-directed TB screening. The primary trial outcome will be time to TB treatment initiation by day 56, and secondary outcomes will include prevalence of undiagnosed TB and HIV, mortality, quality of life, and cost-effectiveness. Conclusions: The PROSPECT Study will provide urgently-needed evidence under "real-life" conditions to inform clinicians and policy makers on how best to improve TB/HIV diagnosis and treatment in Africa. Clinical trial registration: NCT03519425 (08/05/2018).
Collapse
Affiliation(s)
- Peter MacPherson
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre , Malawi
| | - Emily L Webb
- London School of Hygiene & Tropical Medicine, London, UK
| | - David G. Lalloo
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Marriott Nliwasa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre , Malawi
- Helse Nord TB Programme, Department of Microbiology, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Elizabeth Joekes
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Dama Phiri
- Radiology Department, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Bertie Squire
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre , Malawi
| | - Madhukar Pai
- McGill International TB Centre, McGill University, Montreal , Canada
| | | |
Collapse
|
24
|
MacPherson P, Webb EL, Lalloo DG, Nliwasa M, Maheswaran H, Joekes E, Phiri D, Squire B, Pai M, Corbett EL. Design and protocol for a pragmatic randomised study to optimise screening, prevention and care for tuberculosis and HIV in Malawi (PROSPECT Study). Wellcome Open Res 2018; 3:61. [PMID: 30542662 PMCID: PMC6259593 DOI: 10.12688/wellcomeopenres.14598.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2018] [Indexed: 11/20/2022] Open
Abstract
Background: Adults seeking diagnosis and treatment for tuberculosis (TB) and HIV in low-resource settings face considerable barriers and have high pre-treatment mortality. Efforts to improve access to prompt TB treatment have been hampered by limitations in TB diagnostics, with considerable uncertainty about how available and new tests can best be implemented. Design and methods: The PROSPECT Study is an open, three-arm pragmatic randomised study that will investigate the effectiveness and cost-effectiveness of optimised HIV and TB diagnosis and linkage to care interventions in reducing time to TB diagnosis and prevalence of undiagnosed TB and HIV in primary care in Blantyre, Malawi. Participants (≥ 18 years) attending a primary care clinic with TB symptoms (cough of any duration) will be randomly allocated to one of three groups: (i) standard of care; (ii) optimised HIV diagnosis and linkage; or (iii) optimised HIV and TB diagnosis and linkage. We will test two hypotheses: firstly, whether prompt linkage to HIV care should be prioritised for adults with TB symptoms; and secondly, whether an optimised TB triage testing algorithm comprised of digital chest x-ray evaluated by computer-aided diagnosis software and sputum GeneXpert MTB/Rif can outperform clinician-directed TB screening. The primary trial outcome will be time to TB treatment initiation by day 56, and secondary outcomes will include prevalence of undiagnosed TB and HIV, mortality, quality of life, and cost-effectiveness. Conclusions: The PROSPECT Study will provide urgently-needed evidence under "real-life" conditions to inform clinicians and policy makers on how best to improve TB/HIV diagnosis and treatment in Africa. Clinical trial registration: NCT03519425 (08/05/2018).
Collapse
Affiliation(s)
- Peter MacPherson
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre , Malawi
| | - Emily L Webb
- London School of Hygiene & Tropical Medicine, London, UK
| | - David G. Lalloo
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Marriott Nliwasa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre , Malawi
- Helse Nord TB Programme, Department of Microbiology, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Elizabeth Joekes
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Dama Phiri
- Radiology Department, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Bertie Squire
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre , Malawi
| | - Madhukar Pai
- McGill International TB Centre, McGill University, Montreal , Canada
| | | |
Collapse
|
25
|
Schatz E, Knight L. "I was referred from the other side": Gender and HIV testing among older South Africans living with HIV. PLoS One 2018; 13:e0196158. [PMID: 29684054 PMCID: PMC5912735 DOI: 10.1371/journal.pone.0196158] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 04/06/2018] [Indexed: 12/02/2022] Open
Abstract
South Africa has a Universal Test and Treat (UTT) policy in place to ensure that everyone tests for HIV and can access treatment if they test positive. The aim of this study is to document the pathways that older South Africans who are living with HIV take to access testing and treatment in this context. Despite the aging of the HIV epidemic in South Africa and clear evidence that testing older persons (over age 50) is necessary, very little is known about the circumstances under which older persons test for HIV or their motivations for doing so. In this study, we analyze 21 qualitative, in-depth interviews with women and men aged 50 and over who are living with HIV from two townships outside of Cape Town. Using grounded theory to specify emerging themes, we find similarities and differences between older men and women in their pathways to testing. Men primarily test for HIV when their spouse is diagnosed or in connection with TB testing and treatment. Older women, who are more likely to be widowed or divorced, often test for HIV only when they are symptomatic or not responding appropriately to care for non-communicable diseases. Most importantly, we find that older South Africans do not seek testing as a response to risk. Instead, older men and women test only once they are symptomatic and referred by a provider, or as a result of a partner's status. Our respondents, particularly the women, expressed "shock" and confusion at learning they were HIV-positive because they do not see themselves as at risk of acquiring HIV. Because the benefits of UTT are greatest with early detection and treatment, older persons' tendency to test at such a late stage of illness decreases the individual and population level advantages of UTT. More research is needed to understand older persons' risk and testing behavior so that policy and programs include HIV testing messages that reach this population.
Collapse
Affiliation(s)
- Enid Schatz
- Department of Health Sciences & Department of Women’s & Gender Studies, University of Missouri, Columbia, Missouri, United States of America
| | - Lucia Knight
- School of Public Health, University of Western Cape, Bellville, South Africa
| |
Collapse
|
26
|
Abstract
In a Perspective, Ruanne Barnabas and Connie Celum discuss the implications of the accompanying Link4Health and Engage4Health studies for HIV care in sub-Saharan Africa.
Collapse
Affiliation(s)
- Ruanne V. Barnabas
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, Washington, United States of America
- Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- * E-mail:
| | - Connie Celum
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, Washington, United States of America
| |
Collapse
|