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Chipungu J, Smith H, Mwamba C, Haambokoma M, Sharma A, Savory T, Musheke M, Pry J, Bolton C, Sikazwe I, Herce ME. An exploration of multi-level factors affecting routine linkage to HIV care in Zambia's PEPFAR-supported treatment program in the treat all era. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003094. [PMID: 38781275 PMCID: PMC11115257 DOI: 10.1371/journal.pgph.0003094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 04/24/2024] [Indexed: 05/25/2024]
Abstract
Multiple steps from HIV diagnosis to treatment initiation and confirmed engagement with the health system are required for people living with HIV to establish full linkage to care in the modern treat all era. We undertook a qualitative study to gain an in-depth understanding of the impeding and enabling factors at each step of this linkage pathway. In-depth interviews were conducted with fifty-eight people living with HIV recruited from ten routine HIV care settings supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) in Lusaka, Zambia. Using a semi-structured interview guide informed by an established conceptual framework for linkage to care, questions explored the reasons behind late, missed, and early linkage into HIV treatment, as well as factors influencing the decision to silently transfer to a different clinic after an HIV diagnosis. We identified previously established and intersecting barriers of internal and external HIV-related stigma, concerns about ART side effects, substance use, uncertainties for the future, and a perceived lack of partner and social support that impeded linkage to care at every step of the linkage pathway. However, we also uncovered newer themes specific to the current test and treat era related to the rapidity of ART initiation and insufficient patient-centered post-test counseling that appeared to exacerbate these well-known barriers, including callous health workers and limited time to process a new HIV diagnosis before treatment. Long travel distance to the clinic where they were diagnosed was the most common reason for silently transferring to another clinic for treatment. On the other hand, individual resilience, quality counseling, patient-centered health workers, and a supportive and empathetic social network mitigated these barriers. These findings highlight potential areas for strengthening linkage to care and addressing early treatment interruption and silent transfer in the test and treat era in Zambia.
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Affiliation(s)
- Jenala Chipungu
- Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Helene Smith
- Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Chanda Mwamba
- Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Mwiza Haambokoma
- Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Anjali Sharma
- Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Theodora Savory
- Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Maurice Musheke
- Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Jake Pry
- Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Carolyn Bolton
- Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Izukanji Sikazwe
- Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Michael E. Herce
- Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
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Wamuti B, Jamil MS, Siegfried N, Ford N, Baggaley R, Johnson CC, Cherutich P. Understanding effective post-test linkage strategies for HIV prevention and care: a scoping review. J Int AIDS Soc 2024; 27:e26229. [PMID: 38604993 PMCID: PMC11009370 DOI: 10.1002/jia2.26229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 02/20/2024] [Indexed: 04/13/2024] Open
Abstract
INTRODUCTION Following HIV testing services (HTS), the World Health Organization recommends prompt linkage to prevention and treatment. Scale-up of effective linkage strategies is essential to achieving the global 95-95-95 goals for maintaining low HIV incidence by 2030 and reducing HIV-related morbidity and mortality. Whereas linkage to care including same-day antiretroviral therapy (ART) initiation for all people with HIV is now routinely implemented in testing programmes, linkage to HIV prevention interventions including behavioural or biomedical strategies, for HIV-negative individuals remains sub-optimal. This review aims to evaluate effective post-HTS linkage strategies for HIV overall, and highlight gaps specifically in linkage to prevention. METHODS Using the five-step Arksey and O'Malley framework, we conducted a scoping review searching existing published and grey literature. We searched PubMed, Cochrane Library, CINAHL, Web of Science and EMBASE databases for English-language studies published between 1 January 2010 and 30 November 2023. Linkage interventions included as streamlined interventions-involving same-day HIV testing, ART initiation and point-of-care CD4 cell count/viral load, case management-involving linkage coordinators developing personalized HIV care and risk reduction plans, incentives-financial and non-financial, partner services-including contact tracing, virtual-like social media, quality improvement-like use of score cards, and peer-based interventions. Outcomes of interest were linkage to any form of HIV prevention and/or care including ART initiation. RESULTS Of 2358 articles screened, 66 research studies met the inclusion criteria. Only nine linkage to prevention studies were identified (n = 9/66, 14%)-involving pre-exposure prophylaxis, voluntary medical male circumcision, sexually transmitted infection and cervical cancer screening. Linkage to care studies (n = 57/66, 86%) focused on streamlined interventions in the general population and on case management among key populations. DISCUSSION Despite a wide range of HIV prevention interventions available, there was a dearth of literature on HIV prevention programmes and on the use of messaging on treatment as prevention strategy. Linkage to care studies were comparatively numerous except those evaluating virtual interventions, incentives and quality improvement. CONCLUSIONS The findings give insights into linkage strategies but more understanding of how to provide these effectively for maximum prevention impact is needed.
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Affiliation(s)
- Beatrice Wamuti
- Department of Global Health and PopulationHarvard UniversityCambridgeMassachusettsUSA
| | - Muhammad S. Jamil
- Global HIV, Hepatitis and STIs Programs, World Health OrganizationGenevaSwitzerland
- Regional Office to the Eastern Mediterranean, World Health OrganizationCairoEgypt
| | | | - Nathan Ford
- Global HIV, Hepatitis and STIs Programs, World Health OrganizationGenevaSwitzerland
| | - Rachel Baggaley
- Global HIV, Hepatitis and STIs Programs, World Health OrganizationGenevaSwitzerland
| | - Cheryl Case Johnson
- Global HIV, Hepatitis and STIs Programs, World Health OrganizationGenevaSwitzerland
| | - Peter Cherutich
- Global HIV, Hepatitis and STIs Programs, World Health OrganizationGenevaSwitzerland
- Department of Preventive and Promotive HealthMinistry of HealthNairobiKenya
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McClarty LM, Becker ML, García PJ, Garnett GP, Dallabetta GA, Ward H, Aral SO, Blanchard JF. Programme science: a route to effective coverage and population-level impact for HIV and sexually transmitted infection prevention. Lancet HIV 2023; 10:e825-e834. [PMID: 37944547 DOI: 10.1016/s2352-3018(23)00224-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/10/2023] [Accepted: 08/22/2023] [Indexed: 11/12/2023]
Abstract
Improvements in context-specific programming are essential to address HIV and other sexually transmitted and blood-borne infection epidemics globally. A programme science approach emphasises the need for context-specific evidence and knowledge, generated on an ongoing basis, to inform timely and appropriate programmatic decisions. We aim to accelerate and improve the use of embedded research, inquiry, and learning to optimise population-level impact of public health programmes and to introduce an effective programme coverage framework as one tool to facilitate this goal. The framework was developed in partnership with public health experts in HIV and sexually transmitted and blood-borne infections through several workshops and meetings. The framework is a practice-based tool that centres on the use of data from iterative cycles of programme-embedded research and learning, as well as routine programme monitoring, to refine the strategy and implementation of a programme. This programme science approach aims to reduce programme coverage gaps, to optimise impact at the population level, and to achieve effective coverage. This framework should facilitate the generation of programme-embedded research and learning agendas to inform resource allocation, optimise population-level impact, and achieve equitable and effective programme coverage.
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Affiliation(s)
- Leigh M McClarty
- Institute for Global Public Health, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
| | - Marissa L Becker
- Institute for Global Public Health, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Patricia J García
- School of Public Health, Universidad Peruana Cayetano Heredia, San Martin de Porres, Lima, Peru
| | | | | | - Helen Ward
- Faculty of Medicine, School of Public Health, Imperial College London, London, UK
| | - Sevgi O Aral
- Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - James F Blanchard
- Institute for Global Public Health, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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Akwara E, Pinchoff J, Abularrage T, White C, Ngo TD. The Urban Environment and Disparities in Sexual and Reproductive Health Outcomes in the Global South: a Scoping Review. J Urban Health 2023:10.1007/s11524-023-00724-z. [PMID: 37052774 PMCID: PMC10100607 DOI: 10.1007/s11524-023-00724-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 04/14/2023]
Abstract
By 2050, the Global South will contain three-quarters of the world's urban inhabitants, yet no standardized categorizations of urban areas exist. This makes it challenging to compare sub-groups within cities. Sexual and reproductive health and rights (SRHR) are a critical component of ensuring that populations are healthy and productive, yet SRHR outcomes within and across urban settings vary significantly. A scoping review of the literature (2010-2022) was conducted to describe the current body of evidence on SRHR in urban settings in the Global South, understand disparities, and highlight promising approaches to improving urban SRHR outcomes. A total of 115 studies were identified, most from Kenya (30 articles; 26%), Nigeria (15; 13%), and India (16; 14%), focusing on family planning (56; 49%) and HIV/STIs (43; 37%). Findings suggest significant variation in access to services, and challenges such as gender inequality, safety, and precarious circumstances in employment and housing. Many of the studies (n = 84; 80%) focus on individual-level risks and do not consider how neighborhood environments, concentrated poverty, and social exclusion shape behaviors and norms related to SRHR. Research gaps in uniformly categorizing urban areas and key aspects of the urban environment make it challenging to understand the heterogeneity of urban environments, populations, and SRHR outcomes and compare across studies. Findings from this review may inform the development of holistic programs and policies targeting structural barriers to SRHR in urban environments to ensure services are inclusive, equitably available and accessible, and direct future research to fill identified gaps.
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Affiliation(s)
| | - Jessie Pinchoff
- Population Council, One Dag Hammarskjold Plaza, New York, NY, 10017, USA.
| | - Tara Abularrage
- Population Council, One Dag Hammarskjold Plaza, New York, NY, 10017, USA
| | - Corinne White
- Population Council, One Dag Hammarskjold Plaza, New York, NY, 10017, USA
| | - Thoai D Ngo
- Population Council, One Dag Hammarskjold Plaza, New York, NY, 10017, USA
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Cordingley O, McCrimmon T, West BS, Darisheva M, Primbetova S, Terlikbaeva A, Gilbert L, El-Bassel N, Frye V. Preferences for an HIV Self-Testing Program Among Women who Engage in sex Work and use Drugs in Kazakhstan, Central Asia. RESEARCH ON SOCIAL WORK PRACTICE 2023; 33:296-304. [PMID: 37426726 PMCID: PMC10328443 DOI: 10.1177/10497315221128594] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Purpose Women engaged in sex work (WESW) who use drugs face barriers to HIV testing. HIV self-testing (HST) may empower sex workers to learn their HIV status; however, it is not scaled up among WESW in Kazakhstan. This study aimed to explore barriers and facilitators to traditional HIV testing and HST among this population. Method We conducted 30 in-depth interviews (IDIs) and four focus groups (FGs) with Kazakhstani WESW who use drugs. Pragmatic analysis was used to explore key themes from qualitative data. Results Participants welcomed HST due to its potential to overcome logistical challenges by accessing HIV testing, as well as the stigma that WESW faces in traditional HIV testing. Participants desired emotional and social support for HST, and for linkage to HIV care and other services. Discussion HST among women who exchange sex and use drugs can be successfully implemented to mitigate stigma and barriers to HIV testing.
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Affiliation(s)
- Olivia Cordingley
- School of Social Work, Columbia University School of Social Work, New York, NY, USA
| | - Tara McCrimmon
- Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Brooke S. West
- School of Social Work, Columbia University School of Social Work, New York, NY, USA
| | | | | | | | - Louisa Gilbert
- School of Social Work, Columbia University School of Social Work, New York, NY, USA
| | - Nabila El-Bassel
- School of Social Work, Columbia University School of Social Work, New York, NY, USA
| | - Victoria Frye
- Department of Community Health and Social Medicine, CUNY School of Medicine, New York, NY, USA
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Endalamaw A, Gilks CF, Ambaw F, Habtewold TD, Assefa Y. Universal Health Coverage for Antiretroviral Treatment: A Review. Infect Dis Rep 2022; 15:1-15. [PMID: 36648855 PMCID: PMC9844463 DOI: 10.3390/idr15010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/16/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Universal health coverage is essential for the progress to end threats of the acquired immunodeficiency syndrome epidemic. The current review assesses the publication rate, strategies and barriers for antiretroviral therapy (ART) coverage, equity, quality of care, and financial protection. We searched Web of Science, PubMed, and Google Scholar. Of the available articles, 43.13% were on ART coverage, 40.28% were on financial protection, 10.43% were on quality of care, and 6.16% were on equity. A lack of ART, fear of unwanted disclosure, lack of transportation, unaffordable health care costs, long waiting time to receive care, and poverty were barriers to ART coverage. Catastrophic health care costs were higher among individuals who were living in rural settings, walked greater distances to reach health care institutions, had a lower socioeconomic status, and were immunocompromised. There were challenges to the provision of quality of care, including health care providers' inadequate salary, high workload and inadequate health workforce, inappropriate infrastructure, lack of training opportunities, unclear division of responsibility, and the presence of strict auditing. In conclusion, ART coverage was below the global average, and key populations were disproportionally less covered with ART in most countries. Huge catastrophic health expenditures were observed. UHC contexts of ART will be improved by reaching people with poor socioeconomic status, delivering appropriate services, establishing a proper health workforce and service stewardship.
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Affiliation(s)
- Aklilu Endalamaw
- School of Public Health, The University of Queensland, Brisbane, QLD 4072, Australia
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar P.O. Box 79, Ethiopia
- Correspondence: ; Tel.: +61-424-690-121
| | - Charles F Gilks
- School of Public Health, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Fentie Ambaw
- School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar P.O. Box 79, Ethiopia
| | - Tesfa Dejenie Habtewold
- Branch of Epidemiology, Division of Population Health Research, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, 9712 CP Groningen, The Netherlands
| | - Yibeltal Assefa
- School of Public Health, The University of Queensland, Brisbane, QLD 4072, Australia
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7
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Shanaube K, Gachie T, Hoddinott G, Schaap A, Floyd S, Mainga T, Bond V, Hayes R, Fidler S, Ayles H. Depressive symptoms and HIV risk behaviours among adolescents enrolled in the HPTN071 (PopART) trial in Zambia and South Africa. PLoS One 2022; 17:e0278291. [PMID: 36454874 PMCID: PMC9714741 DOI: 10.1371/journal.pone.0278291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 11/14/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Mental health is a critical and neglected public health problem for adolescents in sub-Saharan Africa. In this paper we aim to determine the prevalence of depressive symptoms and the association with HIV risk behaviours in adolescents aged 15-19 years in Zambia and SA. METHODS We conducted a cross-sectional survey from August-November 2017 in seven control communities of HPTN 071 (PopART) trial (a community-randomised trial of universal HIV testing and treatment), enrolling approximately 1400 eligible adolescents. HIV-status was self-reported. Depressive symptoms were measured with the Short Mood and Feelings Questionnaire (SMFQ), with a positive screen if adolescents scored ≥12. We fitted a logistic regression model to identify correlates of depressive symptoms with subgroup analyses among those who self-reported ever having had sex, by gender and country. RESULTS Out of 6997 households approached, 6057 (86.6%) were enumerated. 2546 adolescents were enumerated of whom 2120 (83.3%) consented to participate and were administered the SMFQ. The prevalence of depressive symptoms was 584/2120 (27.6%) [95%CI: 25.7%-29.5%]. Adolescents in SA were less likely to experience depressive symptoms (Adjusted Odds Ratio [AOR] = 0.63 (95% CI: 0.50, 0.79), p-value<0.0001). Female adolescents (AOR = 1.46 (95% CI: 1.19, 1.81), p-value<0.0001); those who reported ever having sex and being forced into sex (AOR = 1.80 (95% CI: 1.45, 2.23), p-value<0.001) and AOR = 1.67 (95% CI: 0.99, 2.84); p-value = 0.057 respectively) were more likely to experience depressive symptoms. Among 850 (40.1%) adolescents who self-reported to ever having had sex; those who used alcohol/drugs during their last sexual encounter were more likely to experience depressive symptoms (AOR = 2.18 (95% CI: 1.37, 3.47); p-value = 0.001), whereas those who reported using a condom were less likely to experience depressive symptoms (AOR = 0.74 (95% CI: 0.55, 1.00); p-value = 0.053). CONCLUSION The prevalence of depressive symptoms among adolescents ranged from 25-30% and was associated with increased HIV-risk behaviour.
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Affiliation(s)
| | - Thomas Gachie
- Zambart, Lusaka, Zambia
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Albertus Schaap
- Zambart, Lusaka, Zambia
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sian Floyd
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Virginia Bond
- Zambart, Lusaka, Zambia
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Richard Hayes
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sarah Fidler
- Department of infectious disease, Imperial College, London, Imperial College NIHR BRC, United Kingdom
| | - Helen Ayles
- Zambart, Lusaka, Zambia
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Groves AK, Stankard P, Bowler SL, Jamil MS, Gebrekristos LT, Smith PD, Quinn C, Ba NS, Chidarikire T, Nguyen VTT, Baggaley R, Johnson C. A systematic review and meta-analysis of the evidence for community-based HIV testing on men's engagement in the HIV care cascade. Int J STD AIDS 2022; 33:1090-1105. [PMID: 35786140 PMCID: PMC9660288 DOI: 10.1177/09564624221111277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/29/2022] [Accepted: 06/13/2022] [Indexed: 12/04/2022]
Abstract
OBJECTIVE Men with HIV are less likely than women to know their status, be on antiretroviral therapy, and be virally suppressed. This review examined men's community-based HIV testing services (CB-HTS) outcomes. DESIGN Systematic review and meta-analysis. METHODS We searched seven databases and conference abstracts through July 2018. We estimated pooled proportions and/or risk ratios (for meta-analyses) for each outcome using random effects models. RESULTS 188 studies met inclusion criteria. Common testing models included targeted outreach (e.g. mobile testing), home-based testing, and testing at stand-alone community sites. Across 25 studies reporting uptake, 81% (CI: 75-86%) of men offered testing accepted it. Uptake was higher among men reached through CB-HTS than facility-based HTS (RR = 1.39; CI: 1.13-1.71). Over 69% (CI: 64-71%) of those tested through CB-HTS were men, across 184 studies. Across studies reporting new HIV-positivity among men (n = 18), 96% were newly diagnosed (CI: 77-100%). Across studies reporting linkage to HIV care (n = 8), 70% (CI: 36-103%) of men were linked to care. Across 57 studies reporting sex-disaggregated data for CB-HTS conducted among key populations, men's uptake was high (80%; CI: 70-88%) and nearly all were newly diagnosed and linked to care (95%; CI: 94-100%; and 94%; CI: 88-100%, respectively). CONCLUSION CB-HTS is an important strategy for reaching undiagnosed men with HIV from the general population and key population groups, particularly using targeted outreach models. When compared to facility-based HIV testing services, men tested through CB-HTS are more likely to uptake testing, and nearly all men who tested positive through CB-HTS were newly diagnosed. Linkage to care may be a challenge following CB-HTS, and greater efforts and research are needed to effectively implement testing strategies that facilitate rapid ART initiation and linkage to prevention services.
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Affiliation(s)
- Allison K Groves
- Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | | | - Sarah L Bowler
- Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Muhammad S Jamil
- Department of HIV/AIDS, World Health
Organization, Geneva, Switzerland
| | | | - Patrick D Smith
- Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Caitlin Quinn
- Department of HIV/AIDS, World Health
Organization, Geneva, Switzerland
| | - Ndoungou Salla Ba
- Department of HIV/AIDS, World Health
Organization, Geneva, Switzerland
| | - Thato Chidarikire
- HIV Prevention Programmes, National Department of
Health, Johannesburg, South Africa
| | | | - Rachel Baggaley
- Department of HIV/AIDS, World Health
Organization, Geneva, Switzerland
| | - Cheryl Johnson
- Department of HIV/AIDS, World Health
Organization, Geneva, Switzerland
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Edwards JK, Cole SR, Breger TL, Filiatreau LM, Zalla L, Mulholland GE, Horberg MA, Silverberg MJ, John Gill M, Rebeiro PF, Thorne JE, Kasaie P, Marconi VC, Sterling TR, Althoff KN, Moore RD, Eron JJ. Five-Year Mortality for Adults Entering Human Immunodeficiency Virus Care Under Universal Early Treatment Compared With the General US Population. Clin Infect Dis 2022; 75:867-874. [PMID: 34983066 PMCID: PMC9477443 DOI: 10.1093/cid/ciab1030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Mortality among adults with human immunodeficiency virus (HIV) remains elevated over those in the US general population, even in the years after entry into HIV care. We explore whether the elevation in 5-year mortality would have persisted if all adults with HIV had initiated antiretroviral therapy within 3 months of entering care. METHODS Among 82 766 adults entering HIV care at North American AIDS Cohort Collaboration clinical sites in the United States, we computed mortality over 5 years since entry into HIV care under observed treatment patterns. We then used inverse probability weights to estimate mortality under universal early treatment. To compare mortality with those for similar individuals in the general population, we used National Center for Health Statistics data to construct a cohort representing the subset of the US population matched to study participants on key characteristics. RESULTS For the entire study period (1999-2017), the 5-year mortality among adults with HIV was 7.9% (95% confidence interval [CI]: 7.6%-8.2%) higher than expected based on the US general population. Under universal early treatment, the elevation in mortality for people with HIV would have been 7.2% (95% CI: 5.8%-8.6%). In the most recent calendar period examined (2011-2017), the elevation in mortality for people with HIV was 2.6% (95% CI: 2.0%-3.3%) under observed treatment patterns and 2.1% (.0%-4.2%) under universal early treatment. CONCLUSIONS Expanding early treatment may modestly reduce, but not eliminate, the elevation in mortality for people with HIV.
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Affiliation(s)
- Jessie K Edwards
- Department of Epidemiology, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Stephen R Cole
- Department of Epidemiology, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Tiffany L Breger
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lindsey M Filiatreau
- Department of Epidemiology, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Lauren Zalla
- Department of Epidemiology, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Grace E Mulholland
- Department of Epidemiology, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Michael A Horberg
- Kaiser Permanent Mid-Atlantic Permanente Research Institute, Rockville, Maryland, USA
| | | | - M John Gill
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Peter F Rebeiro
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jennifer E Thorne
- School of Medicine, Johns Hopkins University, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Parastu Kasaie
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Vincent C Marconi
- School of Medicine, and Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Timothy R Sterling
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USAand
| | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Richard D Moore
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Joseph J Eron
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Nardell MF, Adeoti O, Peters C, Kakuhikire B, Govathson-Mandimika C, Long L, Pascoe S, Tsai AC, Katz IT. Men missing from the HIV care continuum in sub-Saharan Africa: a meta-analysis and meta-synthesis. J Int AIDS Soc 2022; 25:e25889. [PMID: 35324089 PMCID: PMC8944222 DOI: 10.1002/jia2.25889] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 02/01/2022] [Indexed: 02/03/2023] Open
Abstract
Introduction Men are missing along the HIV care continuum. However, the estimated proportions of men in sub‐Saharan Africa meeting the UNAIDS 95‐95‐95 goals vary substantially between studies. We sought to estimate proportions of men meeting each of the 95‐95‐95 goals across studies in sub‐Saharan Africa, describe heterogeneity, and summarize qualitative evidence on factors influencing care engagement. Methods We systematically searched PubMed and Embase for peer‐reviewed articles published between 1 January 2014 and 16 October 2020. We included studies involving men ≥15 years old, with data from 2009 onward, reporting on at least one 95‐95‐95 goal in sub‐Saharan Africa. We estimated pooled proportions of men meeting these goals using DerSimonion‐Laird random effects models, stratifying by study population (e.g. studies focusing exclusively on men who have sex with men vs. studies that did not), facility setting (healthcare vs. community site), region (eastern/southern Africa vs. western/central Africa), outcome measurement (e.g. threshold for viral load suppression), median year of data collection (before vs. during or after 2017) and quality criteria. Data from qualitative studies exploring barriers to men's HIV care engagement were summarized using meta‐synthesis. Results and discussion We screened 14,896 studies and included 129 studies in the meta‐analysis, compiling data over the data collection period. Forty‐seven studies reported data on knowledge of serostatus, 43 studies reported on antiretroviral therapy use and 74 studies reported on viral suppression. Approximately half of men with HIV reported not knowing their status (0.49 [95% CI, 0.41–0.58; range, 0.09–0.97]) or not being on treatment (0.58 [95% CI, 0.51–0.65; range, 0.07–0.97]), while over three‐quarters of men achieved viral suppression on treatment (0.79 [95% CI, 0.77–0.81; range, 0.39–0.97]. Heterogeneity was high, with variation in estimates across study populations, settings and outcomes. The meta‐synthesis of 40 studies identified three primary domains in which men described risks associated with engagement in HIV care: perceived social norms, health system challenges and poverty. Conclusions Psychosocial and systems‐level interventions that change men's perceptions of social norms, improve trust in and accessibility of the health system, and address costs of accessing care are needed to better engage men, especially in HIV testing and treatment.
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Affiliation(s)
- Maria F Nardell
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Oluwatomi Adeoti
- Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Carson Peters
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Bernard Kakuhikire
- Faculty of Business and Management Sciences, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Caroline Govathson-Mandimika
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Alexander C Tsai
- Harvard Medical School, Boston, Massachusetts, USA.,Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA.,Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Global Health Institute, Cambridge, Massachusetts, USA
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11
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MacKellar D, Hlophe T, Ujamaa D, Pals S, Dlamini M, Dube L, Suraratdecha C, Williams D, Byrd J, Tobias J, Mndzebele P, Behel S, Pathmanathan I, Mazibuko S, Tilahun E, Ryan C. Antiretroviral therapy initiation and retention among clients who received peer-delivered linkage case management and standard linkage services, Eswatini, 2016-2020: retrospective comparative cohort study. Arch Public Health 2022; 80:74. [PMID: 35260189 PMCID: PMC8905856 DOI: 10.1186/s13690-022-00810-9] [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] [Received: 08/06/2021] [Accepted: 01/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Persons living with HIV infection (PLHIV) who are diagnosed in community settings in sub-Saharan Africa are particularly vulnerable to barriers to care that prevent or delay many from obtaining antiretroviral therapy (ART). METHODS We conducted a retrospective cohort study to assess if a package of peer-delivered linkage case management and treatment navigation services (CommLink) was more effective than peer-delivered counseling, referral, and telephone follow-up (standard linkage services, SLS) in initiating and retaining PLHIV on ART after diagnosis in community settings in Eswatini. HIV-test records of 773 CommLink and 769 SLS clients aged ≥ 15 years diagnosed between March 2016 and March 2018, matched by urban and rural settings of diagnosis, were selected for the study. CommLink counselors recorded resolved and unresolved barriers to care (e.g., perceived wellbeing, fear of partner response, stigmatization) during a median of 52 days (interquartile range: 35-69) of case management. RESULTS Twice as many CommLink than SLS clients initiated ART by 90 days of diagnosis overall (88.4% vs. 37.9%, adjusted relative risk (aRR): 2.33, 95% confidence interval (CI): 1.97, 2.77) and during test and treat when all PLHIV were eligible for ART (96.2% vs. 37.1%, aRR: 2.59, 95% CI: 2.20, 3.04). By 18 months of diagnosis, 54% more CommLink than SLS clients were initiated and retained on ART (76.3% vs. 49.5%, aRR: 1.54, 95% CI: 1.33, 1.79). Peer counselors helped resolve 896 (65%) of 1372 identified barriers of CommLink clients. Compared with clients with ≥ 3 unresolved barriers to care, 42% (aRR: 1.42, 95% CI: 1.19, 1.68) more clients with 1-2 unresolved barriers, 44% (aRR: 1.44, 95% CI: 1.25, 1.66) more clients with all barriers resolved, and 54% (aRR: 1.54, 95% CI: 1.30, 1.81) more clients who had no identified barriers were initiated and retained on ART by 18 months of diagnosis. CONCLUSIONS To improve early ART initiation and retention among PLHIV diagnosed in community settings, HIV prevention programs should consider providing a package of peer-delivered linkage case management and treatment navigation services. Clients with multiple unresolved barriers to care measured as part of that package should be triaged for differentiated linkage and retention services.
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Affiliation(s)
- Duncan MacKellar
- Division of Global HIV and TB, Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | | | | | - Sherri Pals
- Division of Global HIV and TB, Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Lenhle Dube
- Eswatini Ministry of Health, Mbabane, Eswatini
| | - Chutima Suraratdecha
- Division of Global HIV and TB, Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Daniel Williams
- U.S. Centers for Disease Control and Prevention, Pretoria, South Africa
| | | | - James Tobias
- Division of Global HIV and TB, Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Stephanie Behel
- Division of Global HIV and TB, Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ishani Pathmanathan
- Division of Global HIV and TB, Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | - Caroline Ryan
- U.S. Centers for Disease Control and Prevention, Mbabane, Eswatini
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12
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Limbada M, Bwalya C, Macleod D, Shibwela O, Floyd S, Nzara D, Situmbeko V, Hayes R, Fidler S, Ayles H. Acceptability and Preferences of Two Different Community Models of ART Delivery in a High Prevalence Urban Setting in Zambia: Cluster-Randomized Trial, Nested in the HPTN 071 (PopART) Study. AIDS Behav 2022; 26:328-338. [PMID: 34304330 PMCID: PMC8813709 DOI: 10.1007/s10461-021-03385-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2021] [Indexed: 11/29/2022]
Abstract
Community delivery of Antiretroviral therapy (ART) is a novel innovation to increase sustainable ART coverage for People living with HIV (PLHIV) in resource limited settings. Within a nested cluster-randomised sub-study in two urban communities that participated in the HPTN 071 (PopART) trial in Zambia we investigated individual acceptability and preferences for ART delivery models. Stable PLHIV were enrolled in a cluster-randomized trial of three different models of ART: Facility-based delivery (SoC), Home-based delivery (HBD) and Adherence clubs (AC). Consenting individuals were asked to express their stated preference for ART delivery options. Those assigned to the community models of ART delivery arms could choose ("revealed preference") between the assigned arm and facility-based delivery. In total 2489 (99.6%) eligible individuals consented to the study and 95.6% chose community models of ART delivery rather than facility-based delivery when offered a choice. When asked to state their preference of model of ART delivery, 67.6% did not state a preference of one model over another, 22.8% stated a preference for HBD, 5.0% and 4.6% stated a preference for AC and SoC, respectively. Offering PLHIV choices of community models of ART delivery is feasible and acceptable with majority expressing HBD as their stated preferred option.
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Affiliation(s)
- Mohammed Limbada
- Zambart House, School of Medicine, University of Zambia, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - Chiti Bwalya
- Zambart House, School of Medicine, University of Zambia, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Osborn Shibwela
- Zambart House, School of Medicine, University of Zambia, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Diana Nzara
- Zambart House, School of Medicine, University of Zambia, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - Vasty Situmbeko
- Zambart House, School of Medicine, University of Zambia, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Sarah Fidler
- Imperial College, United Kingdom and Imperial College NIHR BRC, London, UK
| | - Helen Ayles
- Zambart House, School of Medicine, University of Zambia, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - the HPTN 071 (PopART) Study Team
- Zambart House, School of Medicine, University of Zambia, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
- Imperial College, United Kingdom and Imperial College NIHR BRC, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
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13
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Phiri MM, Schaap A, Simwinga M, Hensen B, Floyd S, Mulubwa C, Simuyaba M, Chiti B, Bond V, Shanaube K, Fidler S, Hayes R, Ayles H. Closing the gap: did delivery approaches complementary to home-based testing reach men with HIV testing services during and after the HPTN 071 (PopART) trial in Zambia? J Int AIDS Soc 2022; 25:e25855. [PMID: 35001530 PMCID: PMC8743361 DOI: 10.1002/jia2.25855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 11/26/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The HPTN 071 (PopART) trial demonstrated that universal HIV testing-and-treatment reduced community-level HIV incidence. Door-to-door delivery of HIV testing services (HTS) was one of the main components of the intervention. From an early stage, men were less likely to know their HIV status than women, primarily because they were not home during service delivery. To reach more men, different strategies were implemented during the trial. We present the relative contribution of these strategies to coverage of HTS and the impact of community hubs implemented after completion of the trial among men. METHODS Between 2013 and 2017, three intervention rounds (IRs) of door-to-door HTS delivery were conducted in eight PopART communities in Zambia. Additional strategies implemented in parallel, included: community-wide "Man-up" campaigns (IR1), smaller HTS campaigns at work/social places (IR2) and revisits to households with the option of HIV self-testing (HIVST) (IR3). In 2018, community "hubs" offering HTS were implemented for 7 months in all eight communities. Population enumeration data for each round of HTS provided the denominator, allowing for calculation of the proportion of men tested as a result of each strategy during different time periods. RESULTS By the end of the three IRs, 65-75% of men were reached with HTS, primarily through door-to-door service delivery. In IR1 and IR2, "Man-up" and work/social place campaigns accounted for ∼1 percentage point each and in IR3, revisits with the option of self-testing for ∼15 percentage points of this total coverage per IR. The yield of newly diagnosed HIV-positive men ranged from 2.2% for HIVST revisits to 9.9% in work/social places. At community hubs, the majority of visitors accepting services were men (62.8%). In total, we estimated that ∼36% (2.2% tested HIV positive) of men resident but not found at their household during IR3 of PopART accessed HTS provided at the hubs after trial completion. CONCLUSIONS Achieving high coverage of HTS among men requires universal, home-based service delivery combined with an option of HIVST and delivery of HTS through community-based hubs. When men are reached, they are willing to test for HIV. Reaching men thus requires implementers to adapt their HTS delivery strategies to meet men's needs. CLINICAL TRIAL NUMBER NCT01900977.
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Affiliation(s)
| | - Ab Schaap
- ZambartLusakaZambia
- Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | | | - Bernadette Hensen
- Clinical Research DepartmentLondon School of Hygiene and Tropical MedicineLondonUK
| | - Sian Floyd
- Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | | | | | | | - Virginia Bond
- ZambartLusakaZambia
- Department of Global HealthLondon School of Hygiene and Tropical MedicineLondonUK
| | | | - Sarah Fidler
- Imperial College and Imperial College NIHR BRCLondonUK
| | - Richard Hayes
- Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Helen Ayles
- ZambartLusakaZambia
- Clinical Research DepartmentLondon School of Hygiene and Tropical MedicineLondonUK
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14
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Simpson N, Kydd A, Phiri M, Mbewe M, Sigande L, Gachie T, Ngobeni M, Monese T, Figerova Z, Schlesinger H, Bond V, Belemu S, Simwinga M, Schaap A, Biriotti M, Fidler S, Ayles H. Insaka: mobile phone support groups for adolescent pregnant women living with HIV. BMC Pregnancy Childbirth 2021; 21:663. [PMID: 34592959 PMCID: PMC8482634 DOI: 10.1186/s12884-021-04140-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 09/22/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Mobile phone-based interventions have been demonstrated in different settings to overcome barriers to accessing critical psychosocial support. In this study, we aimed to assess the acceptability and feasibility of a phone-based, peer-to-peer support group intervention for adolescent pregnant women aged 15-24 years living with HIV in Zambia. METHODS Sixty-one consenting participants were recruited from Antenatal Clinics of two large urban communities in Lusaka. They were invited to participate in the mobile phone-based intervention that allowed them to anonymously communicate in a small group led by a facilitator for 4 months. A mixed methods approach was used to assess acceptability and feasibility, including a focus group discussion, pre- and post-intervention interview and analysis of the content of the text message data generated. RESULTS Participants reported finding the platform "not hard to use" and enjoyed the anonymity of the groups. Seventy-one percent of participants (n = 43) participated in the groups, meaning they sent text messages to their groups. Approximately 12,000 text messages were sent by participants (an average of 169 messages/user and 6 mentors in 6 groups. Topics discussed were related to social support and relationships, stigma, HIV knowledge and medication adherence. CONCLUSION The study showed that the intervention was acceptable and feasible, and highlighted the potential of the model for overcoming existing barriers to provision of psychosocial support to this population.
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Affiliation(s)
- Nikita Simpson
- Department of Anthropology, London School of Economics and Political Science, London, UK.
- SHM Foundation, 20-22 Bedford Row, London, UK.
| | - Anna Kydd
- SHM Foundation, 20-22 Bedford Row, London, UK
| | | | | | | | | | | | | | | | | | - Virginia Bond
- Zambart, Lusaka, Zambia
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | | | - Sarah Fidler
- Department of Infectious Diseases, Imperial College, London, UK
| | - Helen Ayles
- Zambart, Lusaka, Zambia
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
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15
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Hensen B, Phiri M, Schaap A, Floyd S, Simuyaba M, Mwenge L, Sigande L, Belemu S, Shanaube K, Simwinga M, Fidler S, Hayes R, Ayles H. Yathu Yathu ("For us, by us"): Design of a cluster-randomised trial of the impact of community-based, peer-led comprehensive sexual and reproductive health services for adolescents and young people aged 15 to 24 in Lusaka, Zambia. Contemp Clin Trials 2021; 110:106568. [PMID: 34543725 DOI: 10.1016/j.cct.2021.106568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 08/16/2021] [Accepted: 09/13/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND In sub-Saharan Africa, the growing population of adolescents and young people aged 15 to 24 face a high burden of HIV, and other preventable and treatable sexually transmitted infections. Despite this burden, adolescents and young people are the population least served by available sexual and reproductive (SRH) services. This trial aims to evaluate the impact of community-based peer-led SRH services, combined with a novel incentivised "loyalty card" system, on knowledge of HIV status and coverage of SRH services. METHODS A cluster-randomised trial (CRT) with embedded process and economic evaluation. DISCUSSION With little available evidence of the impact of community-based, peer-led services on coverage of SRH services, our study will provide evidence critical to expanding our knowledge of how to reach adolescents and young people. The "loyalty card" system is also a novel approach to providing SRH services. The delivery of community-based services supported by incentives in the form of loyalty cards is innovative, and may prove a simple strategy to improve access to SRH services. Adolescents and young people remain underserved by available SRH services; there remains a critical need to identify ways to provide adolescents and young people with access to SRH services. Rigorous evidence of whether this innovative strategy, with strong links to the local health facility, increases coverage of critical SRH services would add to the evidence-base of how to reach adolescents and young people.
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Affiliation(s)
- B Hensen
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom.
| | | | - A Schaap
- Zambart, Lusaka, Zambia; Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - S Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | | | | | | | - S Fidler
- Imperial College and Imperial College NIHR BRC, London, United Kingdom
| | - R Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - H Ayles
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom; Zambart, Lusaka, Zambia
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16
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Rosen JG, Kayeyi N, Chibuye M, Phiri L, Namukonda ES, Mbizvo MT. Sexual debut and risk behaviors among orphaned and vulnerable children in Zambia: which protective deficits shape HIV risk? VULNERABLE CHILDREN AND YOUTH STUDIES 2021; 17:130-146. [PMID: 36159210 PMCID: PMC9496638 DOI: 10.1080/17450128.2021.1975858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 08/25/2021] [Indexed: 06/02/2023]
Abstract
Orphaned and vulnerable children (OVC) are not only affected by, but also rendered at-risk of, HIV due to overlapping deficits in protective assets, from school to household financial security. Drawing from a protective deficit framework, this study examines correlates of sexual risk - including multiple sexual partnerships, unprotected sex, and age at sexual debut - among OVC aged 13-17 years in Zambia. In May-October 2016, a two-stage stratified random sampling design was used to recruit OVC and their adult caregivers (N = 2,034) in four provinces. OVC-caregiver dyads completed a structured interview addressing household characteristics, protective assets (i.e. finances, schooling, and nutrition), and general health and wellbeing. Associations of factors derived from the multi-component protective deficits framework were examined using multivariable ordered logistic regression, comparing sexually inexperienced OVC to those with a sexual debut and reporting ≥1 sexual behavior(s). A sub-analysis of older (ages 15-17) OVC identified correlates of early (before age 15) and later (at or after age 15) sexual debut using multinomial logistic regression. Among 735 OVC aged 13-17, 14% reported a sexual debut, among whom 14% and 22% reported 2+ past-year partners and non-condom last sex, respectively. Older age (Adjusted Odds Ratio [aOR] = 2.08, 95% Confidence Interval [CI] 1.32-3.27), male sex (aOR = 1.90, CI 1.22-2.96), not having a birth certificate (aOR = 2.05, CI 1.03-4.09), out-of-school status (aOR = 2.63, CI 1.66-4.16), and non-household labor (aOR = 1.84, CI 1.01-3.38) were significantly associated with higher sexual risk. Male sex was the only factor significantly associated with early sexual debut in multivariable analysis. Sexual risk-reduction strategies require age- and sex-specific differentiation and should be prioritized for OVC in financially distressed households.
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Affiliation(s)
- Joseph G Rosen
- Reproductive Health Programme, Population Council, Lusaka, Zambia
| | - Nkomba Kayeyi
- Reproductive Health Programme, Population Council, Lusaka, Zambia
| | - Mwelwa Chibuye
- Reproductive Health Programme, Population Council, Lusaka, Zambia
| | - Lyson Phiri
- Reproductive Health Programme, Population Council, Lusaka, Zambia
| | | | - Michael T Mbizvo
- Reproductive Health Programme, Population Council, Lusaka, Zambia
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17
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Simuyaba M, Hensen B, Phiri M, Mwansa C, Mwenge L, Kabumbu M, Belemu S, Shanaube K, Schaap A, Floyd S, Fidler S, Hayes R, Ayles H, Simwinga M. Engaging young people in the design of a sexual reproductive health intervention: Lessons learnt from the Yathu Yathu ("For us, by us") formative study in Zambia. BMC Health Serv Res 2021; 21:753. [PMID: 34325696 PMCID: PMC8320161 DOI: 10.1186/s12913-021-06696-7] [Citation(s) in RCA: 9] [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: 02/18/2021] [Accepted: 06/24/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Meeting the sexual and reproductive health (SRH) needs of adolescents and young people (AYP) requires their meaningful engagement in intervention design. We describe an iterative process of engaging AYP to finalise the design of a community-based, peer-led and incentivised SRH intervention for AYP aged 15-24 in Lusaka and the lessons learnt. METHODS Between November 2018 and March 2019, 18 focus group discussions, eight in-depth interviews and six observations were conducted to assess AYP's knowledge of HIV/SRH services, factors influencing AYP's sexual behaviour and elicit views on core elements of a proposed intervention, including: community-based spaces (hubs) for service delivery, type of service providers and incentivising service use through prevention points cards (PPC; "loyalty" cards to gain points for accessing services and redeem these for rewards). A total of 230 AYP (15 participated twice in different research activities) and 21 adults (only participated in the community mapping discussions) participated in the research. Participants were purposively selected based on age, sex, where they lived and their roles in the study communities. Data were analysed thematically. RESULTS Alcohol and drug abuse, peer pressure, poverty, unemployment and limited recreation facilities influenced AYP's sexual behaviours. Adolescent boys and young men lacked knowledge of contraceptive services and all AYP of pre and post exposure prophylaxis for HIV prevention. AYP stated a preference for accessing services at "hubs" located in the community rather than the health facility. AYP considered the age, sex and training of the providers when choosing whom they were comfortable accessing services from. PPCs were acceptable among AYP despite the loyalty card concept being new to them. AYP suggested financial and school support, electronic devices, clothing and food supplies as rewards. CONCLUSIONS Engaging AYP in the design of an SRH intervention was feasible, informative and considered responsive to their needs. Although AYP's suggestions were diverse, the iterative process of AYP engagement facilitated the design of an intervention that is informed by AYP and implementable. TRIAL REGISTRATION This formative study informed the design of this trial: ClinicalTrials.gov, NCT04060420. Registered 19 August, 2019.
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Affiliation(s)
| | - Bernadette Hensen
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | | | | | | | - Ab Schaap
- Zambart, Lusaka, Zambia
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Sarah Fidler
- Department of Infectious Disease, Imperial College NIHR BRC, Imperial College, London, UK
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Helen Ayles
- Zambart, Lusaka, Zambia
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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18
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Amstutz A, Matsela L, Lejone TI, Kopo M, Glass TR, Labhardt ND. Reaching Absent and Refusing Individuals During Home-Based HIV Testing Through Self-Testing-at What Cost? Front Med (Lausanne) 2021; 8:653677. [PMID: 34268321 PMCID: PMC8276095 DOI: 10.3389/fmed.2021.653677] [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] [Received: 01/15/2021] [Accepted: 05/18/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction: In the HOSENG trial (NCT03598686), the secondary distribution of oral self-tests for persons absent or refusing to test during a home-based HIV testing campaign in rural Lesotho resulted in an increase in testing coverage of 21% compared to a testing campaign without secondary distribution. This study aims to determine the per patient costs of both HOSENG trial arms. Method: We conducted a micro-costing study to estimate the cost of home-based HIV testing with (HOSENG intervention arm) and without (HOSENG control arm) secondary self-test distribution from a provider's perspective. A mixture of top-down and bottom-up costing was used. We estimated both the financial and economic per patient costs of each possible testing cascade scenario. The costs were adjusted to 2018 US$. Results: The overall provider cost for delivering the home-based HIV testing with secondary distribution was US$36,481 among the 4,174 persons enumerated and 3,094 eligible for testing in the intervention villages compared to US$28,620 for 3,642 persons enumerated and 2,727 eligible for testing in the control. The cost per person eligible for testing was US$11.79 in the intervention vs. US$10.50 in the control. This difference was mainly driven by the cost of distributed oral self-tests. The cost per person tested was, however, lower in intervention villages (US$15.70 vs. US$22.15) due to the higher testing coverage achieved through self-test distribution. The cost per person confirmed new HIV+ was US$889.79 in the intervention and US$753.17 in the control. Conclusion: During home-based HIV testing in Lesotho, the secondary distribution of self-tests for persons absent or refusing to test during the visit reduced the costs per person tested and thus presents a promising add-on for such campaigns. Trial Registration:https://ClinicalTrials.gov/, identifier: NCT03598686
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Affiliation(s)
- Alain Amstutz
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Lineo Matsela
- Health Economics Unit, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Mathebe Kopo
- SolidarMed, Partnerships for Health, Butha-Buthe, Lesotho
| | - Tracy Renée Glass
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Niklaus Daniel Labhardt
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
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Suryana K. The Impact of Universal Test and Treat Program on Highly Active Anti Retroviral Therapy Outcomes (Coverage, Adherence and Lost to Follow Up) at Wangaya Hospital in Denpasar, Bali-Indonesia: A Retrospective Cohort Study. Open AIDS J 2021. [DOI: 10.2174/1874613602115010028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background:
World Health Organization (WHO) (2015) recommended that all people diagnosed with human immunodeficiency virus (HIV)-positive initiate Highly Active Anti Retroviral Therapy (HAART) immediately (less than a week), irrespective of CD4 count (Universal Test and Treat / UTT) Program.
Objective:
To evaluate the impact of UTT as a current therapeutic program on HIV treatment outcomes, coverage, adherence, and lost to follow-up (LTFU) at Wangaya Hospital in Denpasar, Bali, Indonesia.
Methods:
A Retrospective cohort study was conducted during July 2017 - June 2018 (Pre-UTT) and September 2018 – August 2019 (Post-UTT). Around 402 medical records were selected, reviewed, and enrolled. Data were analyzed using SPSS software for windows version 24.0. Bivariate analysis (Chi-square test) was performed on all variables with a statistically significant t level of 0.05.
Results:
Among 4,322 new visitors; 3,585 (82.95%) agreed to take HIV test and 402(11.21%) were confirmed HIV reactive. Most participants confirmed HIV reactive occured at age 25-34 years old and 230 (57.21%) were male. The majority education level were primary (Junior high school) 302(75.12%), 379(94.28%) were employed and 281 (69.90%) stayed in Denpasar. About 350 (87.06%) received HAART, 298 (85.14%) with high adherence and 52 (14.86%) LTFU. Pre-UTT, HAART coverage; 83.03% (181), were statistically significant increased to 91.85% (169) post UTT (p=0.000). High adherence pre-UTT; 79.56% (144) was significantly increased to 91.12% (154) post UTT (p=0.006) and LTFU were significantly decreased; 20.44% (37) to 8.87% (15) (p=0.006).
Conclusion:
UTT program significantly improve the HIV treatment outcome (increased coverage, adherence, and decreased LTFU).
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20
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MacKellar D, Williams D, Dlamini M, Byrd J, Dube L, Mndzebele P, Mazibuko S, Pathmanathan I, Tilahun E, Ryan C. Overcoming Barriers to HIV Care: Findings from a Peer-Delivered, Community-Based, Linkage Case Management Program (CommLink), Eswatini, 2015-2018. AIDS Behav 2021; 25:1518-1531. [PMID: 32780187 PMCID: PMC7876149 DOI: 10.1007/s10461-020-02991-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
To help persons living with HIV (PLHIV) in Eswatini initiate antiretroviral therapy (ART), the CommLink case-management program provided a comprehensive package of linkage services delivered by HIV-positive, peer counselors. Of 1250 PLHIV participants aged ≥ 15 years diagnosed in community settings, 75% reported one or more barriers to care (e.g., fearing stigmatization). Peer counselors helped resolve 1405 (65%) of 2166 identified barriers. During Test and Treat (October 2016-September 2018), the percentage of participants who initiated ART and returned for ≥ 1 antiretroviral refills was 92% overall (759/824); 99% (155/156) among participants without any identified barriers; 96% (544/564) among participants whose counselors helped resolve all or all but one barrier; and 58% (59/102) among participants who had ≥ 2 unresolved barriers to care. The success of CommLink is attributed, at least in part, to peer counselors who helped their clients avoid or at least temporarily resolve many well-known barriers to HIV care.
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Affiliation(s)
- Duncan MacKellar
- Division of Global HIV and TB, Center for Global Health, U.S. Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA, 30329, USA.
| | - Daniel Williams
- Division of Global HIV and TB, Center for Global Health, U.S. Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA, 30329, USA
| | | | | | - Lenhle Dube
- Eswatini National AIDS Programme, Eswatini Ministry of Health, Mbabane, Eswatini
| | | | | | - Ishani Pathmanathan
- Division of Global HIV and TB, Center for Global Health, U.S. Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA, 30329, USA
| | | | - Caroline Ryan
- U.S. Centers for Disease Control and Prevention, Mbabane, Eswatini
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21
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Tarigan YN, Woodman RJ, Miller ER, Wisaksana R, Ward PR. Impact of strategic use of antiretroviral therapy intervention to the HIV continuum of care in 13 cities in Indonesia: an interrupted time series analysis. AIDS Res Ther 2021; 18:22. [PMID: 33902631 PMCID: PMC8074419 DOI: 10.1186/s12981-021-00340-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/08/2021] [Indexed: 12/01/2022] Open
Abstract
Background In 2013 the Indonesian government introduced the strategic use of antiretroviral therapy (SUFA) initiative of expanding access to HIV test and treatment, to help achieve the UNAIDS 90–90–90 targets. However, there has been no comprehensive evaluation of the impact of this intervention in Indonesia. We conducted an interrupted time series (ITS) analysis across 6-years to assess its immediate and medium-term impact. Methods Monthly aggregated HIV data from all HIV care clinics for persons aged ≥ 15 years were collected from 13 pilot cities. The data period encompassed 3-years prior to SUFA (26 Dec 2010–25 Dec 2013) and 3-years post-SUFA (26 Dec 2013–25 Dec 2016). The ITS was performed using a multilevel negative binomial regression model to assess the immediate and trend changes in each stage of the HIV continuum of care. Results In the pre-SUFA period, the overall coverage in the respective risk populations for HIV tests, cases, enrolments, eligible cases and ARV initiation were 1.0%, 8.6%, 98.9%, 76.9% and 75.8% respectively. In the post-SUFA period coverage was 3%, 3.8%, 98.6%, 90.3% and 81.2% respectively—with a significant increase in the median number of HIV tests, HIV cases, those eligible for ARV treatment and treatment initiation (p < 0.05 for each). The ITS analysis demonstrated immediate increases in HIV tests (IRR = 1.41, 95% CI 1.25, 1.59; p < 0.001) and an immediate decrease in detected HIV cases per person tested (IRR = 0.77, 95% CI 0.69–0.86; p < 0.001) in the month following commencement of SUFA. There was also a 3% decline in the monthly trend for HIV tests performed (IRR = 0.97; 95% CI 0.97–0.98, p < 0.001), a 1% increase for detected cases (IRR = 1.01, 95% CI 1.0–1.02, p < 0.001), and a 1% decline for treatment initiation (IRR = 0.99,95% CI 0.99–1.0 p < 0.05). Conclusions SUFA was associated with an immediate and sustained increase in the absolute number of HIV tests performed, detected HIV cases, and close to complete coverage of detected cases that were enrolled to care and defined as eligible for treatment. However, treatment initiation remained sub-optimal. The findings of this study provide valuable information on the real-world effect of accelerating ARV utilizing Treatment as Prevention for the full HIV continuum of care in limited resource countries. Supplementary Information The online version contains supplementary material available at 10.1186/s12981-021-00340-4.
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22
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Chen L, Luo M, Xu Y, Xia Y, Zhou X, Chen W, Wang H, Jiang T, Chen W, Luo Y, Ma Q, Jiang J, Pan X. The first 90: Progress in HIV detection in Zhejiang Province, 2008-2018. PLoS One 2021; 16:e0249517. [PMID: 33831067 PMCID: PMC8031385 DOI: 10.1371/journal.pone.0249517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 03/19/2021] [Indexed: 11/20/2022] Open
Abstract
To analyze the results of HIV screening and the HIV-positive rate based on different HIV detection strategies in Zhejiang Province, China. Data were downloaded from the AIDS Prevention and Control Information System on May 1, 2019. HIV screening, prevalence, and incidence data were analyzed from 2008 to 2018. The incidence of HIV was calculated from the results of BED testing. SPSS software (ver. 19.0) was used for the analysis. The number of people screened for HIV increased by 229.7% from 2008 to 2018, while the incidence of HIV increased from 1.14‱ (2010) to 1.67‱ (2018), peak by 2015 (2.28‱). The proportion of people screened for HIV in medical institutions increased from 62.0% in 2008 to 67.1% in 2018, while of all positive tests, 47.9% were conducted at medical institutions in 2008, which increased to 63.2% in 2018. VCT and STD clinic attendees, who had only 4.5% of all those undergoing HIV tests, accounted for 23.7% of all HIV positive in 2018. The rate of HIV-positive people and incidence of HIV both increased in Zhejiang Province between 2008 and 2015. The most effective strategy for detecting HIV new cases is screening visitors to VCT and STD clinics.
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Affiliation(s)
- Lin Chen
- Department of AIDS/STD Control and Prevention, Zhejiang Provincial Center for Disease Control, Hangzhou, Zhejiang, People’s Republic of China
| | - Mingyu Luo
- Department of AIDS/STD Control and Prevention, Zhejiang Provincial Center for Disease Control, Hangzhou, Zhejiang, People’s Republic of China
| | - Yun Xu
- Department of AIDS/STD Control and Prevention, Zhejiang Provincial Center for Disease Control, Hangzhou, Zhejiang, People’s Republic of China
| | - Yan Xia
- Department of AIDS/STD Control and Prevention, Zhejiang Provincial Center for Disease Control, Hangzhou, Zhejiang, People’s Republic of China
| | - Xin Zhou
- Department of AIDS/STD Control and Prevention, Zhejiang Provincial Center for Disease Control, Hangzhou, Zhejiang, People’s Republic of China
| | - Wanjun Chen
- Department of AIDS/STD Control and Prevention, Zhejiang Provincial Center for Disease Control, Hangzhou, Zhejiang, People’s Republic of China
| | - Hui Wang
- Department of AIDS/STD Control and Prevention, Zhejiang Provincial Center for Disease Control, Hangzhou, Zhejiang, People’s Republic of China
| | - Tingting Jiang
- Department of AIDS/STD Control and Prevention, Zhejiang Provincial Center for Disease Control, Hangzhou, Zhejiang, People’s Republic of China
| | - Weiyong Chen
- Department of AIDS/STD Control and Prevention, Zhejiang Provincial Center for Disease Control, Hangzhou, Zhejiang, People’s Republic of China
| | - Yan Luo
- Department of AIDS/STD Control and Prevention, Hangzhou Center for Disease Control and Prevention, Hangzhou, Zhejiang, People’s Republic of China
| | - Qiaoqin Ma
- Department of AIDS/STD Control and Prevention, Zhejiang Provincial Center for Disease Control, Hangzhou, Zhejiang, People’s Republic of China
| | - Jianmin Jiang
- Department of AIDS/STD Control and Prevention, Zhejiang Provincial Center for Disease Control, Hangzhou, Zhejiang, People’s Republic of China
| | - Xiaohong Pan
- Department of AIDS/STD Control and Prevention, Zhejiang Provincial Center for Disease Control, Hangzhou, Zhejiang, People’s Republic of China
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Grabowski MK, Patel EU, Nakigozi G, Ssempijja V, Ssekubugu R, Ssekasanvu J, Ndyanabo A, Kigozi G, Nalugoda F, Gray RH, Kalibbala S, Serwadda DM, Laeyendecker O, Wawer MJ, Chang LW, Quinn TC, Kagaayi J, Tobian AAR, Reynolds SJ. Prevalence and Predictors of Persistent Human Immunodeficiency Virus Viremia and Viral Rebound After Universal Test and Treat: A Population-Based Study. J Infect Dis 2021; 223:1150-1160. [PMID: 33471100 PMCID: PMC8030722 DOI: 10.1093/infdis/jiab021] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 01/13/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND There are limited data on individual human immunodeficiency virus (HIV) viral load (VL) trajectories at the population-level after the introduction of universal test and treat (UTT) in sub-Saharan Africa. METHODS Human immunodeficiency virus VLs were assessed among HIV-positive participants through 3 population-based surveys in 4 Ugandan fishing communities surveyed between November 2011 and August 2017. The unit of analysis was a visit-pair (2 consecutive person-visits), which were categorized as exhibiting durable VL suppression, new/renewed VL suppression, viral rebound, or persistent viremia. Adjusted relative risks (adjRRs) and 95% confidence intervals (CIs) of persistent viremia were estimated using multivariate Poisson regression. RESULTS There were 1346 HIV-positive participants (n = 1883 visit-pairs). The population-level prevalence of durable VL suppression increased from 29.7% to 67.9% during UTT rollout, viral rebound declined from 4.4% to 2.7%, and persistent viremia declined from 20.8% to 13.3%. Younger age (15-29 vs 40-49 years; adjRR = 1.80; 95% CI = 1.19-2.71), male sex (adjRR = 2.09, 95% CI = 1.47-2.95), never being married (vs currently married; adjRR = 1.88, 95% CI = 1.34-2.62), and recent migration to the community (vs long-term resident; adjRR = 1.91, 95% CI = 1.34-2.73) were factors associated with persistent viremia. CONCLUSIONS Despite increases in durable VL suppression during roll out of UTT in hyperendemic communities, a substantial fraction of the population, whose risk profile tended to be younger, male, and mobile, remained persistently viremic.
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Affiliation(s)
- M Kate Grabowski
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Eshan U Patel
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Victor Ssempijja
- Rakai Health Sciences Program, Entebbe, Uganda
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Sponsored by the National Cancer Institute, Bethesda, Maryland, USA
| | | | - Joseph Ssekasanvu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
| | | | | | | | - Ronald H Gray
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
| | | | - David M Serwadda
- Rakai Health Sciences Program, Entebbe, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | - Oliver Laeyendecker
- Makerere University School of Public Health, Kampala, Uganda
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Maria J Wawer
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Larry W Chang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Thomas C Quinn
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, Bethesda, Maryland, USA
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Steven J Reynolds
- Rakai Health Sciences Program, Entebbe, Uganda
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, Bethesda, Maryland, USA
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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24
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Shanaube K, Macleod D, Chaila MJ, Mackworth-Young C, Hoddinott G, Schaap A, Floyd S, Bock P, Hayes R, Fidler S, Ayles H. HIV Care Cascade Among Adolescents in a "Test and Treat" Community-Based Intervention: HPTN 071 (PopART) for Youth Study. J Adolesc Health 2021; 68:719-727. [PMID: 33059959 PMCID: PMC8022105 DOI: 10.1016/j.jadohealth.2020.07.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 07/20/2020] [Accepted: 07/20/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE The PopART for Youth (P-ART-Y) study was nested within the HPTN 071 (PopART) trial, a three-arm community randomized trial in 21 communities in Zambia and South Africa. The P-ART-Y study evaluated the acceptability and uptake of a combination HIV prevention package among young people. We report on the HIV care cascade for adolescents aged 10-19 years from 14 communities receiving the full HIV prevention package in Zambia and South Africa. METHODS Adolescents were offered participation in the PopART intervention, which included universal home-based HIV testing, linkage to care, antiretroviral therapy (ART) adherence, and other services. Data were collected from September 2016 to December 2017, covering the third round (R3) of the intervention. RESULTS We enumerated (listed) 128,241 adolescents (Zambia: 95,295 and South Africa: 32,946). Of the adolescents offered HIV testing, 81.9% accepted in Zambia and 70.3% in South Africa. Knowledge of HIV status was higher among older adolescents and increased from 31.4% before R3 to 88.3% at the end of R3 in Zambia and from 28.3% to 79.5% in South Africa. Overall, there were 1,710 (1.9%) adolescents identified as living with HIV by the end of R3 (515 new diagnoses and 1,195 self-reported). Of the new diagnoses, 335 (65.0%) were girls aged 15-19 years. The median time to initiate ART was 5 months. ART coverage before and after R3 increased from 61.3% to 78.7% in Zambia and from 65.6% to 87.8% in South Africa, with boys having higher uptake than girls in both countries. CONCLUSIONS The PopART intervention substantially increased coverage toward the first and second UNAIDS 90-90-90 targets in adolescents.
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Affiliation(s)
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Constance Mackworth-Young
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Ab Schaap
- Zambart, Lusaka, Zambia,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sarah Fidler
- Faculty of Medicine, Department of Infectious Disease, Imperial College, London, United Kingdom
| | - Helen Ayles
- Zambart, Lusaka, Zambia,Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Pathmanathan I, Nelson R, de Louvado A, Thompson R, Pals S, Casavant I, Cardoso MJA, Ujamaa D, Bonzela J, Mikusova S, Chivurre V, Tamele S, Sleeman K, Zhang G, Zeh C, Dobbs T, Vubil A, Auld A, Briggs-Hagen M, Vergara A, Couto A, MacKellar D. High Coverage of Antiretroviral Treatment With Annual Home-Based HIV Testing, Follow-up Linkage Services, and Implementation of Test and Start: Findings From the Chókwè Health Demographic Surveillance System, Mozambique, 2014-2019. J Acquir Immune Defic Syndr 2021; 86:e97-e105. [PMID: 33252546 PMCID: PMC7970427 DOI: 10.1097/qai.0000000000002583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 10/20/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Early antiretroviral therapy (ART) is necessary for HIV epidemic control and depends on early diagnosis and successful linkage to care. Since 2014, annual household-based HIV testing and counseling and linkage services have been provided through the Chókwè Health and Demographic Surveillance System for residents testing HIV positive in this high HIV-burden district. METHODS District-wide Test and Start [T&S, ART for all people living with HIV (PLHIV)] began in August 2016, supported by systematic interventions to improve linkage to care and treatment. Annual rounds (R) of random household surveys were conducted to assess trends in population prevalence of ART use and viral load suppression (<1000 viral RNA copies/mL). RESULTS Between R1 (April 2014-April 2015) and R5 (April 2018-Mar 2019), 46,090 (67.2%) of 68,620 residents aged 15-59 years were tested for HIV at home at least once, and 3711 were newly diagnosed with HIV and provided linkage services. Population prevalence of current ART use among PLHIV increased from 65.0% to 87.5% between R1 and R5. ART population prevalence was lowest among men aged 25-34 years (67.8%) and women aged 15-24 (78.0%), and highest among women aged 35-44 years (93.6%) and 45-59 years (93.7%) in R5. Viral load suppression prevalence increased among all PLHIV aged 15-59 years from 52.0% in R1 to 78.3% in R5. DISCUSSION Between 2014 and 2019, Chókwè Health and Demographic Surveillance System residents surpassed the UNAIDS targets of ≥81% of PLHIV on ART and ≥73% virally suppressed. This achievement supports the combination of efforts from household-based HIV testing and counseling, support for linkage to care and treatment, and continued investments in T&S implementation.
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Affiliation(s)
| | - Robert Nelson
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Ricardo Thompson
- Chókwè Health Research and Training Center, National Institute of Health, Maputo, Mozambique
| | - Sherri Pals
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | | | - Dawud Ujamaa
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Juvêncio Bonzela
- Chókwè Health Research and Training Center, National Institute of Health, Maputo, Mozambique
| | - Silvia Mikusova
- Elizabeth Glaser Pediatric AIDS Foundation, Maputo, Mozambique
| | - Victor Chivurre
- Provincial Directorate of Public Health, Xai-Xai, Gaza, Mozambique
| | - Stelio Tamele
- District Directorate of Public Health, Chókwè, Gaza, Mozambique
| | - Katrina Sleeman
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Guoqing Zhang
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Clement Zeh
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Trudy Dobbs
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Adolfo Vubil
- National Institute of Health, Maputo, Mozambique
| | - Andrew Auld
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Alfredo Vergara
- Centers for Disease Control and Prevention, Maputo, Mozambique
| | - Aleny Couto
- Mozambique Ministry of Health (MISAU), Maputo, Mozambique
| | - Duncan MacKellar
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Abstract
BACKGROUND Population-level estimates of disease prevalence and control are needed to assess prevention and treatment strategies. However, available data often suffer from differential missingness. For example, population-level HIV viral suppression is the proportion of all HIV-positive persons with suppressed viral replication. Individuals with measured HIV status, and among HIV-positive individuals those with measured viral suppression, likely differ from those without such measurements. METHODS We discuss three sets of assumptions to identify population-level suppression in the intervention arm of the SEARCH Study (NCT01864603), a community randomized trial in rural Kenya and Uganda (2013-2017). Using data on nearly 100,000 participants, we compare estimates from (1) an unadjusted approach assuming data are missing-completely-at-random (MCAR); (2) stratification on age group, sex, and community; and (3) targeted maximum likelihood estimation to adjust for a larger set of baseline and time-updated variables. RESULTS Despite high measurement coverage, estimates of population-level viral suppression varied by identification assumption. Unadjusted estimates were most optimistic: 50% (95% confidence interval [CI] = 46%, 54%) of HIV-positive persons suppressed at baseline, 80% (95% CI = 78%, 82%) at year 1, 85% (95% CI = 83%, 86%) at year 2, and 85% (95% CI = 83%, 87%) at year 3. Stratifying on baseline predictors yielded slightly lower estimates, and full adjustment reduced estimates meaningfully: 42% (95% CI = 37%, 46%) of HIV-positive persons suppressed at baseline, 71% (95% CI = 69%, 73%) at year 1, 76% (95% CI = 74%, 78%) at year 2, and 79% (95% CI = 77%, 81%) at year 3. CONCLUSIONS Estimation of population-level disease burden and control requires appropriate adjustment for missing data. Even in large studies with limited missingness, estimates relying on the MCAR assumption or baseline stratification should be interpreted cautiously.
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Shanaube K, Schaap A, Hoddinott G, Mubekapi-Musadaidzwa C, Floyd S, Bock P, Hayes R, Fidler S, Ayles H. Impact of a community-wide combination HIV prevention intervention on knowledge of HIV status among adolescents. AIDS 2021; 35:275-285. [PMID: 33048875 PMCID: PMC7810414 DOI: 10.1097/qad.0000000000002722] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/10/2020] [Accepted: 09/14/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the impact of a community-wide combination HIV-prevention package (PopART Intervention) that includes universal testing and treatment (UTT) on knowledge of HIV status, among adolescents aged 15--19 years. DESIGN The HPTN 071 (PopART) for Youth (P-ART-Y) study was nested within HPTN 071 (PopART), a three-arm, cluster-randomized trial conducted from 2013 through 2018 in 21 communities in Zambia and South Africa. Communities were randomly assigned to arm A (combination prevention intervention with universal ART), arm B (prevention intervention with ART provided according to local guidelines), or arm C (standard-of-care). METHODS Knowledge of HIV status was measured using data collected during the third round of the PopART intervention in arms A and B (October 2016 to December 2017) and by conducting a cross-sectional survey (August to November 2017) in arm C communities to provide comparative data. The survey was conducted among ∼200 randomly selected adolescents in each community. We used linear regression of the 21 community-level values to make comparisons among trial arms. RESULTS Knowledge of HIV status was 78.2% (23 544/30 089) in arm A and 76.0% (24 417/32 148) in arm B communities, compared with 32.9% (698/2120) in arm C communities. Knowledge of HIV status varied by country, triplet, sex, and age. The adjusted mean difference was 42.3% between arm A with arm C, 95% CI 28.1-56.6, P less than 0.001 and 40.4% between arm B with arm C, 95% CI 24.6-56.2, P < 0.001). CONCLUSION Implementation of a community-wide combination HIV-prevention package that includes UTT substantially enhanced knowledge of HIV status among adolescents.
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Affiliation(s)
| | - Ab Schaap
- Zambart, Lusaka, Zambia
- London School of Hygiene and Tropical Medicine
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Pediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | | | - Sian Floyd
- London School of Hygiene and Tropical Medicine
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Pediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | | | - Sarah Fidler
- Imperial College, London, UK & Imperial College NIHR BRC, London, UK
| | - Helen Ayles
- Zambart, Lusaka, Zambia
- London School of Hygiene and Tropical Medicine
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Mapangisana T, Machekano R, Kouamou V, Maposhere C, McCarty K, Mudzana M, Munyati S, Mutsvangwa J, Manasa J, Shamu T, Bogoshi M, Israelski D, Katzenstein D. Viral load care of HIV-1 infected children and adolescents: A longitudinal study in rural Zimbabwe. PLoS One 2021; 16:e0245085. [PMID: 33444325 PMCID: PMC7808638 DOI: 10.1371/journal.pone.0245085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 12/22/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Maintaining virologic suppression of children and adolescents on ART in rural communities in sub-Saharan Africa is challenging. We explored switching drug regimens to protease inhibitor (PI) based treatment and reducing nevirapine and zidovudine use in a differentiated community service delivery model in rural Zimbabwe. METHODS From 2016 through 2018, we followed 306 children and adolescents on ART in Hurungwe, Zimbabwe at Chidamoyo Christian Hospital, which provides compact ART regimens at 8 dispersed rural community outreach sites. Viral load testing was performed (2016) by Roche and at follow-up (2018) by a point of care viral load assay. Virologic failure was defined as viral load ≥1,000 copies/ml. A logistic regression model which included demographics, treatment regimens and caregiver's characteristics was used to assess risks for virologic failure and loss to follow-up (LTFU). RESULTS At baseline in 2016, 296 of 306 children and adolescents (97%) were on first-line ART, and only 10 were receiving a PI-based regimen. The median age was 12 years (IQR 8-15) and 55% were female. Two hundred and nine (68%) had viral load suppression (<1,000 copies/ml) and 97(32%) were unsuppressed (viral load ≥1000). At follow-up in 2018, 42/306 (14%) were either transferred 23 (7%) or LTFU 17 (6%) and 2 had died. In 2018, of the 264 retained in care, 107/264 (41%), had been switched to second-line, ritonavir-boosted PI with abacavir as a new nucleotide analog reverse transcriptase inhibitor (NRTI). Overall viral load suppression increased from 68% in 2016 to 81% in 2018 (P<0.001). CONCLUSION Viral load testing, and switching to second-line, ritonavir-boosted PI with abacavir significantly increased virologic suppression among HIV-infected children and adolescents in rural Zimbabwe.
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Affiliation(s)
- Tichaona Mapangisana
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
| | - Rhoderick Machekano
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America
| | - Vinie Kouamou
- Department of Medicine, University of Zimbabwe, Harare, Zimbabwe
| | | | | | | | - Shungu Munyati
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | | | - Justen Manasa
- Department of Medical Microbiology, University of Zimbabwe, Harare, Zimbabwe
- African Institute for Biomedical Sciences and Technology, Harare, Zimbabwe
| | - Tinei Shamu
- Newlands Clinic, Harare, Zimbabwe
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mampedi Bogoshi
- Gilead Sciences Inc., Foster City, California, United States of America
| | - Dennis Israelski
- Gilead Sciences Inc., Foster City, California, United States of America
| | - David Katzenstein
- Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
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Truong HHM, Mocello AR, Ouma D, Bushman D, Kadede K, Ating'a E, Obunge D, Bukusi EA, Odhiambo F, Cohen CR. Community-based HIV testing services in an urban setting in western Kenya: a programme implementation study. Lancet HIV 2021; 8:e16-e23. [PMID: 33166505 PMCID: PMC10880946 DOI: 10.1016/s2352-3018(20)30253-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 08/12/2020] [Accepted: 08/24/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Some countries are struggling to reach the UNAIDS target of 90% of all individuals with HIV knowing their HIV status, especially among men and youth. To identify individuals who are unaware of their HIV-positive status and achieve testing saturation, we implemented a hybrid HIV testing approach in an urban informal settlement in western Kenya. In this study, we aimed to describe the uptake of HIV testing and linkage to care and treatment during this programme. METHODS The Community Health Initiative involved community mapping, household census, multidisease community health campaigns, and home-based tracking in the informal settlement of Obunga in Kisumu, Kenya. 52 multidisease community health campaigns were held throughout the programme coverage area, at which HIV testing by certified testing service counsellors was one of the health services available. Individuals aged 15 years or older who were not previously identified as HIV-positive, children younger than 15 years who reported being sexually active or for whom testing was requested by a parent or guardian, and individuals who tested HIV-negative within the past 3 months but who reported a recent risk were all eligible for testing. Health and counselling services were tailored for men and youth to encourage their participation. Individuals identified during the census who did not attend a community health campaign were tracked using global positioning system data and offered home-based HIV testing services. We calculated the previously unidentified fraction, defined as the number of individuals who were newly identified as HIV-positive as a proportion of all individuals previously identified and newly identified as HIV-positive. FINDINGS Between Jan 11 and Aug 29, 2018, the Community Health Initiative programme reached 23 584 individuals, of whom 11 526 (48·9%) were men and boys and 5635 (23·9%) were aged 15-24 years. Of 12 769 individuals who were eligible for HIV testing, 12 407 (97·2%) accepted testing, including 3917 (31·6%) first-time testers. 101 individuals were newly identified as HIV-positive out of 1248 total individuals who were HIV-positive, representing an 8·1% previously unidentified fraction. The previously unidentified fraction was highest among men (9·8%) and among people aged 15-24 years (15·3%). INTERPRETATION Community-based hybrid HIV testing was successfully implemented in an urban setting. Innovative approaches that make HIV testing more accessible and acceptable, particularly to men and young people, are crucial for achieving testing and treatment saturation. Focusing on identifying individuals who are unaware of their HIV-positive status in combination with monitoring the previously unidentified fraction has the potential to achieve the UNAIDS Fast Track commitment to end AIDS by 2030. FUNDING US President's Emergency Plan for AIDS Relief through the US Centers for Disease Control and Prevention.
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Affiliation(s)
- Hong-Ha M Truong
- Department of Medicine, University of California, San Francisco, CA, USA.
| | - A Rain Mocello
- Department of Obstetrics, Gynecology, and Reproductive Services, University of California, San Francisco, CA, USA
| | - David Ouma
- Kenya Medical Research Institute, Kisumu, Kenya
| | - Dena Bushman
- Department of Medicine, University of California, San Francisco, CA, USA
| | | | | | | | | | | | - Craig R Cohen
- Department of Obstetrics, Gynecology, and Reproductive Services, University of California, San Francisco, CA, USA
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Brault MA, Spiegelman D, Abdool Karim SS, Vermund SH. Integrating and Interpreting Findings from the Latest Treatment as Prevention Trials. Curr HIV/AIDS Rep 2020; 17:249-258. [PMID: 32297219 DOI: 10.1007/s11904-020-00492-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW In 2018-2019, studies were published assessing the effectiveness of reducing HIV incidence by expanding HIV testing, linkage to HIV treatment, and assistance to persons living with HIV to adhere to their medications (the "90-90-90" strategy). These tests of "treatment as prevention" (TasP) had complex results. RECENT FINDINGS The TasP/ANRS 12249 study in South Africa, the SEARCH study in Kenya and Uganda, and one comparison (arms A to C) of the HPTN 071 (PopART) study in South Africa and Zambia did not demonstrate a community impact on HIV incidence. In contrast, the Botswana Ya Tsie study and the second comparison (arms B to C) of PopART indicated significant ≈ 30% reductions in HIV incidence in the intervention communities where TasP was expanded. We discuss the results of these trials and outline future research and challenges. These include the efficient expansion of widespread HIV testing, better linkage to care, and viral suppression among all persons living with HIV. A top implementation science priority for the next decade is to determine what strategies to use in specific local contexts.
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Affiliation(s)
- Marie A Brault
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA.
| | - Donna Spiegelman
- Department of Biostatistics; Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Salim S Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Sten H Vermund
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
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Amstutz A, Lejone TI, Khesa L, Muhairwe J, Bresser M, Vanobberghen F, Kopo M, Kao M, Nsakala BL, Tlali K, Klimkait T, Battegay M, Labhardt ND, Glass TR. Home-based oral self-testing for absent and declining individuals during a door-to-door HIV testing campaign in rural Lesotho (HOSENG): a cluster-randomised trial. Lancet HIV 2020; 7:e752-e761. [PMID: 33045193 DOI: 10.1016/s2352-3018(20)30233-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND In sub-Saharan Africa, home-based HIV testing is validated and accepted, but coverage is low because household members are often absent during home-based testing campaigns. We aimed to measure the effect of a secondary distribution of oral-fluid HIV self-tests on coverage during home-based testing in rural Lesotho. METHODS The Home-Based Self-Testing (HOSENG) trial was a cluster-randomised, non-blinded superiority trial in rural villages in the catchment area of 20 health facilities of two districts in Lesotho (Butha-Buthe and Mokhotlong). Eligible villages had a consenting village chief and at least one registered village health worker; eligible households had a consenting representative aged 18 years or older. The HOSENG trial provided a recruitment platform for the interlinked Village-Based Refill of Antiretroviral Therapy (VIBRA) trial. Villages were randomly assigned 1:1:1:1 with block sizes of four to one of four groups: VIBRA control and HOSENG control; VIBRA control and HOSENG intervention; VIBRA intervention and HOSENG control; and VIBRA intervention and HOSENG intervention. Randomisation was stratified by district, village size, and access to the nearest health facility. An independent statistician was responsible for the computer-generated randomisation list. In the intervention group, oral-fluid HIV self-tests were left for absent or declining household members (aged ≥12 years) during a home visit from the HIV testing campaign team. One present household member was trained on self-test use. Distributed self-tests were followed up by village health workers. In control village clusters, absent or declining household members were referred to the clinic for HIV testing. The primary outcome was HIV testing coverage among all household members aged 12 years or older within 120 days, defined as a confirmed HIV test result or known status, reported in testing registers at the health facilities or on the follow-up forms of the village health worker. Adjusted random-effects logistic regression with individuals as the unit of analysis was used. This trial is registered with ClinicalTrials.gov, NCT03598686. FINDINGS Between July 26, 2018, and Dec 12, 2018, 3091 consenting households with 7816 household members aged 12 years or older were enrolled and randomly assigned (intervention: 57 village clusters, 1620 households, 4174 household members; control: 49 village clusters, 1471 households, 3642 household members). In the control group, 38 (3%) of 1455 initially absent or declining household members tested at a clinic within 120 days. In the intervention group, 841 (53%) of 1601 initially absent or declining household members had a confirmed status within 120 days; 12 (1%) of 841 tested at the clinic and 829 (99%) used their self-test kit. This resulted in a testing coverage of 2201 (60%) of 3642 in the control group versus 3386 (81%) of 4174 in the intervention group (odds ratio 3·00 [95% CI 2·52-3·59]; p<0·0001). INTERPRETATION Secondary distribution of oral-fluid HIV self-tests during home-based testing increases testing coverage substantially and thus presents a promising add-on during testing campaigns. FUNDING Swiss National Science Foundation.
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Affiliation(s)
- Alain Amstutz
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland; Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | | | - Lefu Khesa
- SolidarMed, Partnerships for Health, Maseru, Lesotho
| | | | - Moniek Bresser
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Fiona Vanobberghen
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Mathebe Kopo
- SolidarMed, Partnerships for Health, Maseru, Lesotho
| | - Mpho Kao
- SolidarMed, Partnerships for Health, Maseru, Lesotho
| | | | - Katleho Tlali
- SolidarMed, Partnerships for Health, Maseru, Lesotho
| | - Thomas Klimkait
- University of Basel, Basel, Switzerland; Molecular Virology, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Manuel Battegay
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Niklaus Daniel Labhardt
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland; Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
| | - Tracy Renée Glass
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
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Iwuji C, Chimukuche RS, Zuma T, Plazy M, Larmarange J, Orne-Gliemann J, Siedner M, Shahmanesh M, Seeley J. Test but not treat: Community members' experiences with barriers and facilitators to universal antiretroviral therapy uptake in rural KwaZulu-Natal, South Africa. PLoS One 2020; 15:e0239513. [PMID: 32970730 PMCID: PMC7514038 DOI: 10.1371/journal.pone.0239513] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 09/08/2020] [Indexed: 01/20/2023] Open
Abstract
Introduction Antiretroviral therapy (ART) has revolutionised the care of HIV-positive individuals resulting in marked decreases in morbidity and mortality, and markedly reduced transmission to sexual partners. However, these benefits can only be realised if individuals are aware of their HIV-positive status, initiated and retained on suppressive lifelong ART. Framed using the socio-ecological model, the present study explores factors contributing to poor ART uptake among community members despite high acceptance of HIV-testing within a Treatment as Prevention (TasP) trial. In this paper we identify barriers and facilitators to treatment across different levels of the socio-ecological framework covering individual, community and health system components. Methods This research was embedded within a cluster-randomised trial (ClinicalTrials.gov, number NCT01509508) of HIV treatment as Prevention in rural KwaZulu-Natal, South Africa. Data were collected between January 2013 and July 2014 from resident community members. Ten participants contributed to repeat in-depth interviews whilst 42 participants took part in repeat focus group discussions. Data from individual interviews and focus group discussions were triangulated using community walks to give insights into community members’ perception of the barriers and facilitators of ART uptake. We used thematic analysis guided by a socio-ecological framework to analyse participants’ narratives from both individual interviews and focus group discussions. Results Barriers and facilitators operating at the individual, community and health system levels influence ART uptake. Stigma was an over-arching barrier, across all three levels and expressed variably as fear of HIV disclosure, concerns about segregated HIV clinical services and negative community religious perceptions. Other barriers were individual (substance misuse, fear of ART side effects), community (alternative health beliefs). Facilitators cited by participants included individual (expectations of improved health and longer life expectancy following ART, single tablet regimens), community (availability of ART in the community through mobile trial facilities) and health system factors (fast and efficient service provided by friendly staff). Discussion We identified multiple barriers to achieving universal ART uptake. To enhance uptake in HIV care services, and achieve the full benefits of ART requires interventions that tackle persistent HIV stigma, and offer people with HIV respectful, convenient and efficient services. These interventions require evaluation in appropriately designed studies.
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Affiliation(s)
- Collins Iwuji
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, United Kingdom
- Africa Health Research Institute, Berea, KwaZulu-Natal, South Africa
- * E-mail:
| | | | - Thembelihle Zuma
- Africa Health Research Institute, Berea, KwaZulu-Natal, South Africa
| | - Melanie Plazy
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Bordeaux, France
| | - Joseph Larmarange
- Institut de Recherche pour le Développement(IRD), Centre Population et Développement (Ceped), Paris, France
| | - Joanna Orne-Gliemann
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Bordeaux, France
| | - Mark Siedner
- Africa Health Research Institute, Berea, KwaZulu-Natal, South Africa
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Maryam Shahmanesh
- Africa Health Research Institute, Berea, KwaZulu-Natal, South Africa
- Institute for Global Health, University College London, London, United Kingdom
| | - Janet Seeley
- Africa Health Research Institute, Berea, KwaZulu-Natal, South Africa
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Changes in the HIV continuum of care following expanded access to HIV testing and treatment in Indonesia: A retrospective population-based cohort study. PLoS One 2020; 15:e0239041. [PMID: 32915923 PMCID: PMC7485792 DOI: 10.1371/journal.pone.0239041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/30/2020] [Indexed: 11/19/2022] Open
Abstract
Background In 2013, the Indonesian government launched the strategic use of antiretroviral therapy (SUFA) initiative with an aim to move closer to achieving the UNAIDS 90-90-90 target. This study assessed the impact of SUFA on the cascade of HIV care. Methods We performed a two-year retrospective population-based cohort study of all HIV positive individuals aged ≥ 18 years residing in two cities where SUFA was operational using data from HIV clinics. We analysed data for one-year pre- and one-year post-SUFA implementation. We assessed the rates of enrolment in care, assessment for eligibility for antiretroviral therapy (ART), treatment initiation, loss to follow-up (LTFU) and mortality. Multivariate Cox regression was used to determine the pre-to-post-SUFA hazard ratio. Results A total of 2,292 HIV positive individuals (1,085 and 1,207 pre and post-SUFA respectively) were followed through their cascade of care. In the pre-SUFA period, 811 (74.6%) were enrolled in care, 702 (86.6%) were found eligible for ART, 485 (69.1%) initiated treatment, 102 (21%) were LTFU and 117 (10.8%) died. In the post-SUFA period, 930 (77%) were enrolled in care, 896 (96.3%) were found eligible for ART, 627 (70%) initiated treatment, 100 (16%) were LTFU and 148 (12.3%) dead. There was an 11% increase in the rate of HIV linkage to care (HR = 1.11; 95% CI 1.001, 1.22 p<0.05), a 13% increase in the rate of eligibility for ART (HR = 1.13, 95% CI 1.02,1.25, p<0.01) and a 27% reduction in LTFU (HR = 0.73, 95%CI 0.55, 0.97, p<0.05). Rates of ART initiation and mortality did not change. Conclusion SUFA was effective in improving HIV care in relation to linkage to care, eligibility and ART retention. Therefore, the scale up across the whole of Indonesia of the SUFA currently in the form of a test and treat policy, with improvement in testing and treatment strategies is justified.
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Marinda E, Simbayi L, Zuma K, Zungu N, Moyo S, Kondlo L, Jooste S, Nadol P, Igumbor E, Dietrich C, Briggs-Hagen M. Towards achieving the 90-90-90 HIV targets: results from the south African 2017 national HIV survey. BMC Public Health 2020; 20:1375. [PMID: 32907565 PMCID: PMC7487872 DOI: 10.1186/s12889-020-09457-z] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 08/27/2020] [Indexed: 12/27/2022] Open
Abstract
Background Measuring progress towards the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90–90–90 treatment targets is key to assessing progress towards turning the HIV epidemic tide. In 2017, the UNAIDS model estimated that 75% of people living with HIV (PLHIV) globally knew their HIV positive status, 79% of those who knew their status were on antiretroviral therapy (ART), and 81% of those who knew their HIV status and were on ART had a suppressed viral load. The fifth South African national HIV sero-behavioural survey collected nationally representative data that enabled the empirical estimation of these 90–90–90 targets for the country stratified by a variety of key factors. Methods To evaluate progress towards achievement of the 90–90–90 targets for South Africa, data obtained from a national, representative, cross-sectional population-based multi-stage stratified cluster random survey conducted in 2017 were analysed. The Fifth South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (SABSSM V), collected behavioural and biomarker data from individuals residing in households from 1000 randomly selected Small Area Layers (SALs), across all nine provinces of the country. Structured questionnaires were used to collect socio-demographic data, knowledge and perceptions about HIV, and related risk behaviours. Blood samples were collected to test for HIV infection, antiretroviral use, and viral suppression (defined as < 1000 copies/ml). Weighted proportions of study participants aged 15 years and older who tested HIV positive were computed for those who reported awareness of their status (1st 90), and among these, those who were currently on ART (2nd 90) and of these, those who were virally suppressed (3rd 90). Results Among persons 15 years and older who were HIV positive, 84.8% were aware of their HIV positive status, of whom 70.7% were currently on ART, with 87.4% of these estimated to have suppressed viral load at the time of the survey. These estimates varied by sex, age, and geo-location type. Relatively higher percentages across all three indicators for women compared to men were observed: 88.7% versus 78.2% for those aware of their status, 72.3% versus 67.7% for on ART, and 89.8% versus 82.3% for viral suppression. Knowing one’s positive HIV status increased with age: 74.0, 85.8, and 88.1% for age groups 15–24 years old, 25–49 years old and 50–64 years old, although for those 65 years and older, 78.7% knew their HIV positive status. A similar pattern was observed for the 2nd 90, among those who knew their HIV positive status, 51.7% of 15 to 24 year olds, 70.5% of those aged 25–49 years old, 82.9% of those aged 50–64 years old and 82.4% of those aged 65 years or older were currently on ART. Viral suppression for the above mentioned aged groups, among those who were on ART was 85.2, 87.2, 89.5, and 84.6% respectively. The 90–90–90 indicators for urban areas were 87.7, 66.5, and 87.2%, for rural settings was 85.8, 79.8, and 88.4%, while in commercial farming communities it was 56.2, 67.6 and 81.4%. Conclusions South Africa appears to be on track to achieve the first 90 indicator by 2020. However, it is behind on the second 90 indicator with ART coverage that was ~ 20-percentage points below the target among people who knew their HIV status, this indicates deficiencies around linkage to and retention on ART. Overall viral suppression among those on ART is approaching the target at 87.4%, but this must be interpreted in the context of low reported ART coverage as well as with variation by age and sex. Targeted diagnosis, awareness, and treatment programs for men, young people aged 15–24 years old, people who reside in farming communities, and in specific provinces are needed. More nuanced 90–90–90 estimates within provinces, specifically looking at more granular sub-national level (e.g. districts), are needed to identify gaps in specific regions and to inform provincial interventions.
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Affiliation(s)
- Edmore Marinda
- Human Sciences Research Council, Pretoria, South Africa. .,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
| | - Leickness Simbayi
- Human Sciences Research Council, Pretoria, South Africa.,Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Khangelani Zuma
- Human Sciences Research Council, Pretoria, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Sizulu Moyo
- Human Sciences Research Council, Pretoria, South Africa.,School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Lwando Kondlo
- Human Sciences Research Council, Pretoria, South Africa
| | - Sean Jooste
- Human Sciences Research Council, Pretoria, South Africa
| | - Patrick Nadol
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Atlanta, Pretoria, GA, South Africa
| | - Ehimario Igumbor
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Atlanta, Pretoria, GA, South Africa.,School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Cheryl Dietrich
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Atlanta, Pretoria, GA, South Africa
| | - Melissa Briggs-Hagen
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Atlanta, Pretoria, GA, South Africa
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Steiner C, MacKellar D, Cham HJ, Rwabiyago OE, Maruyama H, Msumi O, Pals S, Weber R, Kundi G, Byrd J, Kazaura K, Madevu-Matson C, Morales F, Justman J, Rutachunzibwa T, Rwebembera A. Community-wide HIV testing, linkage case management, and defaulter tracing in Bukoba, Tanzania: pre-intervention and post-intervention, population-based survey evaluation. Lancet HIV 2020; 7:e699-e710. [PMID: 32888413 DOI: 10.1016/s2352-3018(20)30199-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 05/03/2020] [Accepted: 05/13/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Community randomised trials have had mixed success in implementing combination prevention strategies that diagnose 90% of people living with HIV, initiate and retain on antiretroviral therapy (ART) 90% of those diagnosed, and achieve viral load suppression in 90% of those on ART (90-90-90). The Bukoba Combination Prevention Evaluation (BCPE) aimed to achieve 90-90-90 in Bukoba Municipal Council, Tanzania, by scaling up new HIV testing, linkage, and retention interventions. METHOD We did population-based, cross-sectional surveys before and after our community-wide intervention in Bukoba-a mixed urban and rural council of approximately 150 000 residents located on the western shore of Lake Victoria in Tanzania. BCPE interventions were implemented in 11 government-supported health-care facilities throughout Bukoba from Oct 1, 2014, to March 31, 2017, when national ART-eligibility guidelines expanded from CD4 counts of less than 350 cells per μL (Oct 1, 2014-Dec 31, 2015) and 500 or less cells per μL (Jan 1, 2016-Sept 30, 2016) to any CD4 cell count (test and treat, Oct 1, 2016-March 31, 2017). We used pre-intervention (Nov 4, 2013-Jan 25, 2014) and post-intervention (June 21, 2017-Sept 20, 2017) population-based household surveys to assess population prevalence of undiagnosed HIV infection and ART coverage, and progress towards 90-90-90, among residents aged 18-49 years. FINDINGS During the 2·5-year intervention, BCPE did 133 695 HIV tests, diagnosed and linked 3918 people living with HIV to HIV care at 11 Bukoba facilities, and returned to HIV care 604 patients who had stopped care. 4795 and 5067 residents aged 18-49 years participated in pre-intervention and post-intervention surveys. HIV prevalence before and after the intervention was similar: pre-intervention 8·9% (95% CI 7·5-10·4); post-intervention 8·4% (6·9-9·9). Prevalence of undiagnosed HIV infection decreased from 4·7% to 2·0% (prevalence ratio 0·42, 95% CI 0·31-0·57), and current ART use among all people living with HIV increased from 32·2% to 70·9% (2·20, 1·82-2·66) overall, 23·0% to 62·1% among men (2·70, 1·84-3·96), and 16·7% to 64·4% among people aged 18-29 years (3·87, 2·54-5·89). Of 436 and 435 people living with HIV aged 18-49 years who participated in pre-intervention and post-intervention surveys, previous HIV diagnosis increased from 47·4% (41·3-53·4) to 76·2% (71·8-80·6), ART use among diagnosed people living with HIV increased from 68·0% (60·9-75·2) to 93·1% (90·2-96·0), and viral load suppression of those on ART increased from 88·7% (83·6-93·8) to 91·3% (88·6-94·1). INTERPRETATION BCPE findings suggest scaling up recommended HIV testing, linkage, and retention interventions can help reduce prevalence of undiagnosed HIV infection, increase ART use among all people living with HIV, and make substantial progress towards achieving 90-90-90 in a relatively short period. BCPE facility-based testing and linkage interventions are undergoing national scale up to help achieve 90-90-90 in Tanzania. FUNDING US Presidents' Emergency Plan for AIDS Relief.
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Affiliation(s)
| | - Duncan MacKellar
- Division of Global HIV and TB, National Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Haddi Jatou Cham
- Division of Global HIV and TB, National Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | - Omari Msumi
- ICAP at Columbia University, Maseru, Lesotho
| | - Sherri Pals
- Division of Global HIV and TB, National Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Rachel Weber
- US Centers for Disease Control and Prevention, Harare, Zimbabwe
| | | | | | | | | | | | | | - Thomas Rutachunzibwa
- Ministry of Health, Community Development, Gender, Elderly and Children, Bukoba, Tanzania
| | - Anath Rwebembera
- National AIDS Control Program, Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
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Hensen B, Schaap AJ, Mulubwa C, Floyd S, Shanaube K, Phiri MM, Bond V, Bwalya C, Simwinga M, Fidler S, Hayes R, Mwinga A, Ayles H. Who Accepts and Who Uses Community-Based Secondary Distribution HIV Self-Testing (HIVST) Kits? Findings From the Intervention Arm of a Cluster-Randomized Trial of HIVST Distribution Nested in Four HPTN 071 (PopART) Communities in Zambia. J Acquir Immune Defic Syndr 2020; 84:355-364. [PMID: 32195749 PMCID: PMC7340225 DOI: 10.1097/qai.0000000000002344] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/21/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND HPTN 071 (PopART) was a community-randomized trial of a universal testing-and-treatment intervention on HIV incidence at population level in Zambia and South Africa. In Zambia, a trial of community-based distribution of HIV self-testing (HIVST) kits, including secondary distribution, as an option for HIV-testing was nested within 4 PopART intervention communities. We used data from the intervention arm of the nested trial to measure levels of and factors associated with acceptance and use of secondary distribution HIVST kits. METHODS Community HIV care providers offered the PopART combination HIV-prevention intervention door-to-door, systematically visiting all households and enumerating all household members. From 1 February to 30 April 2017, individuals aged 16 years and older consenting to PopART were offered the option to HIV self-test, if eligible for HIV-testing services. Individuals aged 18 years and older who reported a partner absent during household visits were offered an HIVST kit for secondary distribution to this partner. We used two data sources to measure acceptance and use of secondary distribution HIVST kits. RESULTS Among 9105 individuals aged 18 years and older consenting to PopART, 9.1% (n = 825) accepted an HIVST kit for secondary distribution. Approximately 55.8% reported that the kit had been used. Women were more likely to accept, and men more likely to use, secondary distribution HIVST kits. Kits were more likely to be used by individuals aged 30+ and who had not participated in a previous round of PopART. Approximately 6.8% had a reactive result. CONCLUSIONS Community-based secondary distribution of HIVST kits reached men absent during community HIV care provider household visits and is a complement to facility- and community-based HIV-testing services, which often miss men.
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Affiliation(s)
- Bernadette Hensen
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Albertus J Schaap
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Zambart, Lusaka, Zambia
| | | | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - Virginia Bond
- Zambart, Lusaka, Zambia
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom; and
| | | | | | - Sarah Fidler
- Imperial College, London, United Kingdom and Imperial College NIHR BRC
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Helen Ayles
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Zambart, Lusaka, Zambia
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Pry J, Chipungu J, Smith HJ, Bolton Moore C, Mutale J, Duran‐Frigola M, Savory T, Herce ME. Patient-reported reasons for declining same-day antiretroviral therapy initiation in routine HIV care settings in Lusaka, Zambia: results from a mixed-effects regression analysis. J Int AIDS Soc 2020; 23:e25560. [PMID: 32618137 PMCID: PMC7333172 DOI: 10.1002/jia2.25560] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 05/14/2020] [Accepted: 06/04/2020] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION In the current "test and treat" era, HIV programmes are increasingly focusing resources on linkage to care and same-day antiretroviral therapy (ART) initiation to meet UNAIDS 95-95-95 targets. After observing sub-optimal treatment indicators in health facilities supported by the Centre for Infectious Disease Research in Zambia (CIDRZ), we piloted a "linkage assessment" tool in facility-based HIV testing settings to uncover barriers to same-day linkage to care and ART initiation among newly identified people living with HIV (PLHIV) and to guide HIV programme quality improvement efforts. METHODS The one-page, structured linkage assessment tool was developed to capture patient-reported barriers to same-day linkage and ART initiation using three empirically supported categories of barriers: social, personal and structural. The tool was implemented in three health facilities, two urban and one rural, in Lusaka, Zambia from 1 November 2017 to 31 January 2018, and administered to all newly identified PLHIV declining same-day linkage and ART. Individuals selected as many reasons as relevant. We used mixed-effects logistic regression modelling to evaluate predictors of citing specific barriers to same-day linkage and ART, and Fisher's Exact tests to assess differences in barrier citation by socio-demographics and HIV testing entry point. RESULTS A total of 1278 people tested HIV positive, of whom 126 (9.9%) declined same-day linkage and ART, reporting a median of three barriers per respondent. Of these 126, 71.4% were female. Females declining same-day ART were younger, on average, (median 28.5 years, interquartile range (IQR): 21 to 37 years) than males (median 34.5 years, IQR: 26 to 44 years). The most commonly reported barrier category was structural, "clinics were too crowded" (n = 33), followed by a social reason, "friends and family will condemn me" (n = 30). The frequency of citing personal barriers differed significantly across HIV testing point (χ2 p = 0.03). Significant predictors for citing ≥1 barrier to same-day ART were >50 years of age (OR: 12.59, 95% CI: 6.00 to 26.41) and testing at a rural facility (OR: 9.92, 95% CI: 4.98 to 19.79). CONCLUSIONS Given differences observed in barriers to same-day ART initiation reported across sex, age, testing point, and facility type, new, tailored counselling and linkage to care approaches are needed, which should be rigorously evaluated in routine programme settings.
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Affiliation(s)
- Jake Pry
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
- Division of Infectious DiseasesSchool of MedicineWashington UniversitySt. LouisMOUSA
| | - Jenala Chipungu
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
| | - Helene J Smith
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
| | - Carolyn Bolton Moore
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
- School of MedicineUniversity of AlabamaBirminghamALUSA
| | - Jacob Mutale
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
| | - Miquel Duran‐Frigola
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
- Joint IRB‐BSC‐CRG Program in Computational BiologyInstitute for Research in Biomedicine (IRB Barcelona)The Barcelona Institute of Science and TechnologyBarcelonaCataloniaSpain
| | - Theodora Savory
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
| | - Michael E Herce
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
- Institute for Global Health & Infectious DiseasesSchool of MedicineUniversity of North CarolinaChapel HillNCUSA
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Abstract
Four of the largest HIV prevention trials have been conducted in sub-Saharan Africa, enrolling hundreds of thousands of participants in catchment areas of millions of people. The trials have focused on community-level interventions to increase diagnosis and initiation of antiretroviral therapy (ART) to improve health and reduce HIV transmission. Universal test-and-treat strategies are deployed to achieve viral suppression thereby reducing risk to uninfected persons, known as treatment as prevention (TasP).
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Bwalya C, Simwinga M, Hensen B, Gwanu L, Hang’andu A, Mulubwa C, Phiri M, Hayes R, Fidler S, Mwinga A, Ayles H, Bond V. Social response to the delivery of HIV self-testing in households: experiences from four Zambian HPTN 071 (PopART) urban communities. AIDS Res Ther 2020; 17:32. [PMID: 32527261 PMCID: PMC7288417 DOI: 10.1186/s12981-020-00287-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 05/27/2020] [Indexed: 12/22/2022] Open
Abstract
Background Door-to-door distribution of HIV self-testing kits (HIVST) has the potential to increase uptake of HIV testing services (HTS). However, very few studies have explored the social response to and implications of door-to-door including secondary distribution of HIVST on household relations and the ability of individuals to self-test with or without supervision within households. Methods A CRT of HIVST distribution was nested within the HPTN 071 (PopART) trial, in four Zambian communities randomised to receive the PopART intervention. The nested HIVST trial aimed to increase knowledge of HIV status at population level. Between February 1 and April 30, 2017, 66 zones (clusters) within these four communities were randomly allocated to either the PopART standard of care door-to-door HTS (33 clusters) or PopART standard of care door-to-door HTS plus oral HIVST (33 clusters). In clusters randomised to HIVST, trained Community HIV care provider (CHiPs) visited households and offered individuals aged ≥ 16 and eligible for an offer of HTS the choice of HIV testing using HIVST or routine door-to-door HTS (finger-prick RDT). To document participants’ experiences with HIVST, Interviews (n = 40), observations (n = 22) and group discussions (n = 91) with household members and CHiPs were conducted. Data were coded using Atlas.ti 7 and analysed thematically. Results The usage and storage of HIVST kits was facilitated by familiarity with and trust in CHiPs, the novelty of HIVST, and demonstrations and supervision provided by CHiPs. Door-to-door distribution of HIVST kits was appreciated for being novel, convenient, private, empowering, autonomous and easy-to-use. Literacy and age influenced accurate usage of HIVST kits. The novelty of using oral fluids to test for HIV raised questions, some anxiety and doubts about the accuracy of HIVST. Although HIVST protected participants from experiencing clinic-based stigma, it did not address self-stigma. Within households, HIVST usually strengthened relationships but, amongst couples, there were a few reports of social harms. Conclusion Door-to-door distribution of HIVST as a choice for how to HIV test is appreciated at community level and provides an important testing option in the sub-Saharan context. However, it should be accompanied by counselling to manage social harms and by supporting those testing HIV-positive to link to care.
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Integrating Economic Evaluation and Implementation Science to Advance the Global HIV Response. J Acquir Immune Defic Syndr 2020; 82 Suppl 3:S314-S321. [PMID: 31764269 DOI: 10.1097/qai.0000000000002219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Numerous cost-effectiveness analyses have indicated good value for money from a wide array of interventions for treatment and prevention of HIV/AIDS. There is limited evidence, however, regarding how cost-effectiveness information contributes to better decision-making around investment and action in the global HIV response. METHODS We review challenges for economic evaluation relevant to the global HIV response and consider how the practice of cost-effectiveness analysis could integrate approaches and insights from implementation science to enhance the impact and efficiency of HIV investments. RESULTS In light of signals that cost-effectiveness analyses may be vulnerable to systematic bias toward overly optimistic conclusions, we emphasize two priorities for advancing the field of economic evaluation in HIV/AIDS and more broadly in global health: (1) systematic reevaluation of the cost-effectiveness literature with reference to ex-post empirical evidence on costs and effects in real-world programs and (2) development and adoption of good-practice guidelines for incorporating implementation and delivery aspects into economic evaluations. Toward the latter aim, we propose an integrative approach that focuses on comparative evaluation of strategies, which specify both technologies/interventions as well as the delivery platforms, complementary interventions, and actions needed to increase coverage, quality, and uptake of those technologies/interventions. Specific recommendations draw on several existing implementation science models that provide systematic frameworks for understanding implementation barriers and enablers, designing and choosing specific implementation and policy actions, and evaluating outcomes. DISCUSSION These preliminary steps aimed at bridging the divide between economic evaluation and implementation science can help to advance the practice of economic evaluation toward a science of comparative strategy evaluation.
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Topp SM, Carbone NB, Tseka J, Kamtsendero L, Banda G, Herce ME. " Most of what they do, we cannot do!" How lay health workers respond to barriers to uptake and retention in HIV care among pregnant and breastfeeding mothers in Malawi. BMJ Glob Health 2020; 5:e002220. [PMID: 32561513 PMCID: PMC7304641 DOI: 10.1136/bmjgh-2019-002220] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 05/06/2020] [Accepted: 05/09/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND In the era of Option B+ and 'treat all' policies for HIV, challenges to retention in care are well documented. In Malawi, several large community-facility linkage (CFL) models have emerged to address these challenges, training lay health workers (LHW) to support the national prevention of mother-to-child transmission (PMTCT) programme. This qualitative study sought to examine how PMTCT LHW deployed by Malawi's three most prevalent CFL models respond to known barriers to access and retention to antiretroviral therapy (ART) and PMTCT. METHODS We conducted a qualitative study, including 43 semi-structured interviews with PMTCT clients; 30 focus group discussions with Ministry of Health (MOH)-employed lay and professional providers and PMTCT LHWs; a facility CFL survey and 2-4 hours of onsite observation at each of 8 sites and in-depth interviews with 13 programme coordinators and MOH officials. Thematic analysis was used, combining inductive and deductive approaches. RESULTS Across all three models, PMTCT LHWs carried out a number of 'targeted' activities that respond directly to a range of known barriers to ART uptake and retention. These include: (i) fulfilling counselling and educational functions that responded to women's fears and uncertainties; (ii) enhancing women's social connectedness and participation in their own care and (iii) strengthening service function by helping clinic-based providers carry out duties more efficiently and effectively. Beyond absorbing workload or improving efficiency, however, PMTCT LHWs supported uptake and retention through foundational but often intangible work to strengthen CFL, including via efforts to strengthen facility-side responsiveness, and build community members' recognition of and trust in services. CONCLUSION PMTCT LHWs in each of the CFL models examined, addressed social, cultural and health system factors influencing client access to, and engagement with, HIV care and treatment. Findings underscore the importance of person-centred design in the 'treat-all' era and the contribution LHWs can make to this, but foreground the challenges of achieving person-centredness in the context of an under-resourced health system. Further work to understand the governance and sustainability of these project-funded CFL models and LHW cadres is now urgently required.
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Affiliation(s)
- Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | | | | | | | - Godfrey Banda
- University of North Carolina Project, Lilongwe, Malawi
| | - Michael E Herce
- Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel HIll, North Carolina, USA
- Implementation Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
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Floyd S, Shanaube K, Yang B, Schaap A, Griffith S, Phiri M, Macleod D, Sloot R, Sabapathy K, Bond V, Bock P, Ayles H, Fidler S, Hayes R. HIV testing and treatment coverage achieved after 4 years across 14 urban and peri-urban communities in Zambia and South Africa: An analysis of findings from the HPTN 071 (PopART) trial. PLoS Med 2020; 17:e1003067. [PMID: 32240156 PMCID: PMC7117659 DOI: 10.1371/journal.pmed.1003067] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 02/26/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) set the 90-90-90 targets: that 90% of people living with HIV know their HIV status, that 90% of those who know their HIV-positive status are on antiretroviral therapy (ART), and that 90% of those on treatment are virally suppressed. The aim was to reach these targets by 2020. We assessed the feasibility of achieving the first two targets, and the corresponding 81% ART coverage target, as part of the HIV Prevention Trials Network (HPTN) 071 Population Effects of Antiretroviral Therapy to Reduce HIV Transmission (PopART) community-randomized trial. METHODS AND FINDINGS The study population was individuals aged ≥15 years living in 14 urban and peri-urban "PopART intervention" communities in Zambia and South Africa (SA), with a total population of approximately 600,000 and approximately 15% adult HIV prevalence. Community HIV care providers (CHiPs) delivered the PopART intervention during 2014-2017. This was a combination HIV prevention package including universal home-based HIV testing, referral of HIV-positive individuals to government HIV clinic services that offered universal ART (Arm A) or ART according to national guidelines (Arm B), and revisits to HIV-positive individuals to support linkage to HIV care and retention on ART. The intervention was delivered in 3 "rounds," each about 15 months long, during which CHiPs visited all households and aimed to contact all individuals aged ≥15 years at least once. In Arm A in Round 3 (R3), 67% (41,332/61,402) of men and 86% (56,345/65,896) of women in Zambia and 56% (17,813/32,095) of men and 71% (24,461/34,514) of women in SA participated in the intervention, among 193,907 residents aged ≥15 years. Following participation, HIV status was known by 90% of men and women in Zambia and by 78% of men and 85% of women in SA. The median time from CHiP referral of HIV-positive individuals to ART initiation was approximately 3 months. By the end of R3, an estimated 95% of HIV-positive women and 85% of HIV-positive men knew their HIV status, and among these individuals, approximately 90% of women and approximately 85% of men were on ART. ART coverage among all HIV-positive individuals was approximately 85% in women and approximately 75% in men, up from about 45% at the start of the study. ART coverage was lowest among men aged 18 to 34 and women aged 15 to 24 years, and among mobile individuals/in-migrants. Findings from Arm B were similar. The main limitations to our study were that estimates of testing and treatment coverage among men relied on considerable extrapolation because, in each round, approximately one-third of men did not participate in the PopART intervention; that our findings are for a service delivery model that was relatively intensive; and that we did not have comparable data from the 7 "standard-of-care" (Arm C) communities. CONCLUSIONS Our study showed that very high HIV testing and treatment coverage can be achieved through persistent delivery of universal testing, facilitated linkage to HIV care, and universal treatment services. The ART coverage target of 81% was achieved overall, after 4 years of delivery of the PopART intervention, though important gaps remained among men and young people. Our findings are consistent with previously reported findings from southern and east Africa, extending their generalisability to urban settings with high rates of in-migration and mobility and to Zambia and SA. TRIAL REGISTRATION ClinicalTrials.gov NCT01900977.
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Affiliation(s)
- Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kwame Shanaube
- Zambart, University of Zambia School of Medicine, Lusaka, Zambia
| | - Blia Yang
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Ab Schaap
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Zambart, University of Zambia School of Medicine, Lusaka, Zambia
| | - Sam Griffith
- FHI 360, HIV Prevention Trials Network, Durham, North Carolina, United States of America
| | - Mwelwa Phiri
- Zambart, University of Zambia School of Medicine, Lusaka, Zambia
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Rosa Sloot
- Department of Global Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kalpana Sabapathy
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Virginia Bond
- Department of Global Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Helen Ayles
- Zambart, University of Zambia School of Medicine, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sarah Fidler
- HIV Clinical Trials Unit, Imperial College London, London, United Kingdom
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Crabtree‐Ramírez B, Belaunzarán‐Zamudio PF, Cortes CP, Morales M, Sued O, Sierra‐Madero J, Cahn P, Pozniak A, Grinsztejn B. The HIV epidemic in Latin America: a time to reflect on the history of success and the challenges ahead. J Int AIDS Soc 2020; 23:e25468. [PMID: 32115884 PMCID: PMC7049674 DOI: 10.1002/jia2.25468] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 02/02/2020] [Indexed: 11/21/2022] Open
Affiliation(s)
- Brenda Crabtree‐Ramírez
- Departamento de InfectologíaInstituto Nacional de Ciencias Médicas y Nutrición, Salvador ZubiránTlalpanMexico
| | - Pablo F Belaunzarán‐Zamudio
- Departamento de InfectologíaInstituto Nacional de Ciencias Médicas y Nutrición, Salvador ZubiránTlalpanMexico
| | | | | | - Omar Sued
- Fundación HuéspedInvestigaciones ClínicasBuenos AiresArgentina
| | - Juan Sierra‐Madero
- Departamento de InfectologíaInstituto Nacional de Ciencias Médicas y Nutrición, Salvador ZubiránTlalpanMexico
| | - Pedro Cahn
- Fundación HuéspedInvestigaciones ClínicasBuenos AiresArgentina
| | - Anton Pozniak
- Chelsea and Westminster Hospital NHS Foundation Trust and Imperial College LondonLondonUK
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro ChagasFundacao Oswaldo CruzRio de JaneiroBrazil
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Edwards JK, Arimi P, Ssengooba F, Mulholland G, Markiewicz M, Bukusi EA, Orikiiriza JT, Virkud A, Weir S. The HIV care continuum among resident and non-resident populations found in venues in East Africa cross-border areas. J Int AIDS Soc 2020; 22:e25226. [PMID: 30675984 PMCID: PMC6344908 DOI: 10.1002/jia2.25226] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 12/17/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction HIV care and treatment in cross‐border areas in East Africa face challenges perhaps not seen to the same extent in other geographic areas, particularly for mobile and migrant populations. Here, we estimate the proportion of people with HIV found in these cross‐border areas in each stage of the HIV care and treatment cascade, including the proportion who knows their status, the proportion on treatment and the proportion virally suppressed. Methods Participants (n = 11,410) working or socializing in public places in selected East Africa cross border areas were recruited between June 2016 and February 2017 using the Priorities for Local AIDS Control Efforts method and administered a behavioural survey and rapid HIV test. This approach was designed to recruit a stratified random sample of people found in public spaces or venues in each cross border area. For participants testing positive for HIV, viral load was measured from dried blood spots. The proportion in each step of the cascade was estimated using inverse probability weights to account for the sampling design and informative HIV test refusals. Estimates are reported separately for residents of the cross border areas and non‐residents found in those areas. Results Overall, 43% of participants with HIV found in cross‐border areas knew their status, 87% of those participants were on antiretroviral therapy (ART), and 80% of participants on ART were virally suppressed. About 20% of people with HIV found in cross border areas were sampled outside their subdistrict or subcounty of residence. While both resident and non‐resident individuals who knew their status were likely to be on ART (85% and 96% respectively), people on ART recruited outside their area of residence were less likely to be suppressed (64% suppressed; 95% CI: 43, 81) compared to residents (84% suppressed; 95% CI: 75, 93). Conclusions People living in or travelling through cross‐border areas may face barriers in learning their HIV status. Moreover, while non‐residents were more likely to be on treatment than residents, they were less likely to be suppressed, suggesting gaps in continuity of care for people in East Africa travelling outside their area of residence despite timely initiation of treatment.
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Affiliation(s)
- Jessie K Edwards
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Peter Arimi
- U.S. Agency for International Development, Kenya/East Africa Regional Mission, Nairobi, Kenya
| | | | - Grace Mulholland
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Milissa Markiewicz
- MEASURE Evaluation, Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Judy T Orikiiriza
- Rwanda Military Hospital, Kigali, Rwanda.,Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Arti Virkud
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Sharon Weir
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,MEASURE Evaluation, Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Akullian A, Morrison M, Garnett GP, Mnisi Z, Lukhele N, Bridenbecker D, Bershteyn A. The effect of 90-90-90 on HIV-1 incidence and mortality in eSwatini: a mathematical modelling study. Lancet HIV 2020; 7:e348-e358. [PMID: 32061317 PMCID: PMC7221345 DOI: 10.1016/s2352-3018(19)30436-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 12/12/2019] [Accepted: 12/20/2019] [Indexed: 12/26/2022]
Abstract
Background The rapid scale-up of antiretroviral therapy (ART) towards the UNAIDS 90-90-90 goals over the last decade has sparked considerable debate as to whether universal test and treat can end the HIV-1 epidemic in sub-Saharan Africa. We aimed to develop a network transmission model, calibrated to capture age-specific and sex-specific gaps in the scale-up of ART, to estimate the historical and future effect of attaining and surpassing the UNAIDS 90-90-90 treatment targets on HIV-1 incidence and mortality, and to assess whether these interventions will be enough to achieve epidemic control (incidence of 1 infection per 1000 person-years) by 2030. Methods We used eSwatini (formerly Swaziland) as a case study to develop our model. We used data on HIV prevalence by 5-year age bins, sex, and year from the 2007 Swaziland Demographic Health Survey (SDHS), the 2011 Swaziland HIV Incidence Measurement Survey, and the 2016 Swaziland Population Health Impact Assessment (PHIA) survey. We estimated the point prevalence of ART coverage among all HIV-infected individuals by age, sex, and year. Age-specific data on the prevalence of male circumcision from the SDHS and PHIA surveys were used as model inputs for traditional male circumcision and scale-up of voluntary medical male circumcision (VMMC). We calibrated our model using publicly available data on demographics; HIV prevalence by 5-year age bins, sex, and year; and ART coverage by age, sex, and year. We modelled the effects of five scenarios (historical scale-up of ART and VMMC [status quo], no ART or VMMC, no ART, age-targeted 90-90-90, and 100% ART initiation) to quantify the contribution of ART scale-up to declines in HIV incidence and mortality in individuals aged 15–49 by 2016, 2030, and 2050. Findings Between 2010 and 2016, status-quo ART scale-up among adults (aged 15–49 years) in eSwatini (from 34·0% in 2010 to 74·1% in 2016) reduced HIV incidence by 43·57% (95% credible interval 39·71 to 46·36) and HIV mortality by 56·17% (54·06 to 58·92) among individuals aged 15–49 years, with larger reductions in incidence among men and mortality among women. Holding 2016 ART coverage levels by age and sex into the future, by 2030 adult HIV incidence would fall to 1·09 (0·87 to 1·29) per 100 person-years, 1·42 (1·13 to 1·71) per 100 person-years among women and 0·79 (0·63 to 0·94) per 100 person-years among men. Achieving the 90-90-90 targets evenly by age and sex would further reduce incidence beyond status-quo ART, primarily among individuals aged 15–24 years (an additional 17·37% [7·33 to 26·12] reduction between 2016 and 2030), with only modest additional incidence reductions in adults aged 35–49 years (1·99% [–5·09 to 7·74]). Achieving 100% ART initiation among all people living with HIV within an average of 6 months from infection—an upper bound of plausible treatment effect—would reduce adult HIV incidence to 0·73 infections (0·55 to 0·92) per 100 person-years by 2030 and 0·46 (0·33 to 0·59) per 100 person-years by 2050. Interpretation Scale-up of ART over the last decade has already contributed to substantial reductions in HIV-1 incidence and mortality in eSwatini. Focused ART targeting would further reduce incidence, especially in younger individuals, but even the most aggressive treatment campaigns would be insufficient to end the epidemic in high-burden settings without a renewed focus on expanding preventive measures. Funding Global Good Fund and the Bill & Melinda Gates Foundation.
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Affiliation(s)
- Adam Akullian
- Institute for Disease Modeling, Bellevue, WA, USA; Department of Global Health, University of Washington, Seattle, WA, USA.
| | | | | | - Zandile Mnisi
- Ministry of Health, Kingdom of eSwatini, Mbabane, eSwatini
| | | | | | - Anna Bershteyn
- Institute for Disease Modeling, Bellevue, WA, USA; Department of Population Health, New York University School of Medicine, New York, NY, USA
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46
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Fatti G, Grimwood A, Nachega JB, Nelson JA, LaSorda K, van Zyl G, Grobbelaar N, Ayles H, Hayes R, Beyers N, Fidler S, Bock P. Better Virological Outcomes Among People Living With Human Immunodeficiency Virus (HIV) Initiating Early Antiretroviral Treatment (CD4 Counts ≥500 Cells/µL) in the HIV Prevention Trials Network 071 (PopART) Trial in South Africa. Clin Infect Dis 2020; 70:395-403. [PMID: 30877753 PMCID: PMC7768744 DOI: 10.1093/cid/ciz214] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 03/13/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND There have been concerns about reduced adherence and human immunodeficiency virus (HIV) virological suppression (VS) among clinically well people initiating antiretroviral therapy (ART) with high pre-ART CD4 cell counts. We compared virological outcomes by pre-ART CD4 count, where universal ART initiation was provided in the HIV Prevention Trials Network 071 (PopART) trial in South Africa prior to routine national and international implementation. METHODS This prospective cohort study included adults initiating ART at facilities providing universal ART since January 2014. VS (<400 copies/mL), confirmed virological failure (VF) (2 consecutive viral loads >1000 copies/mL), and viral rebound were compared between participants in strata of baseline CD4 cell count. RESULTS The sample included 1901 participants. VS was ≥94% among participants with baseline CD4 count ≥500 cells/µL at all 6-month intervals to 30 months. The risk of an elevated viral load (≥400 copies/mL) was independently lower among participants with baseline CD4 count ≥500 cells/µL (3.3%) compared to those with CD4 count 200-499 cells/µL (9.2%) between months 18 and 30 (adjusted relative risk, 0.30 [95% confidence interval, .12-.74]; P = .010). The incidence rate of VF was 7.0, 2.0, and 0.5 per 100 person-years among participants with baseline CD4 count <200, 200-499, and ≥500 cells/µL, respectively (P < .0001). VF was independently lower among participants with baseline CD4 count ≥500 cells/µL (adjusted hazard ratio [aHR], 0.23; P = .045) and 3-fold higher among those with baseline CD4 count <200 cells/µL (aHR, 3.49; P < .0001). CONCLUSIONS Despite previous concerns, participants initiating ART with CD4 counts ≥500 cells/µL had very good virological outcomes, being better than those with CD4 counts 200-499 cells/µL. CLINICAL TRIALS REGISTRATION NCT01900977.
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Affiliation(s)
- Geoffrey Fatti
- Kheth’Impilo AIDS Free Living, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Jean B Nachega
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pennsylvania
- Department of Infectious Diseases and Microbiology, University of Pittsburgh Graduate School of Public Health, Pennsylvania
- Department of Epidemiology and International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
- Department of Medicine and Centre for Infectious Diseases, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town
| | - Jenna A Nelson
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pennsylvania
| | - Kelsea LaSorda
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pennsylvania
| | - Gert van Zyl
- Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University and National Health Laboratory Service, Tygerberg, South Africa
| | | | - Helen Ayles
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, United Kingdom
- Zambart, Ridgeway Campus University of Zambia, Lusaka
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Nulda Beyers
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Sarah Fidler
- Department of Medicine, Imperial College London and Imperial College National Institute for Health Research Biomedical Research Centre, United Kingdom
| | - Peter Bock
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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47
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Arinze F, Gong W, Green AF, De Schacht C, Carlucci JG, Silva W, Claquin G, Tique JA, Stefanutto M, Graves E, Van Rompaey S, Alvim MFS, Tomo S, Moon TD, Wester CW. Immunodeficiency at Antiretroviral Therapy Start: Five-Year Adult Data (2012-2017) Based on Evolving National Policies in Rural Mozambique. AIDS Res Hum Retroviruses 2020; 36:39-47. [PMID: 31359762 PMCID: PMC9836686 DOI: 10.1089/aid.2019.0043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Before the 2015 implementation of "Test and Start," the initiation of combination antiretroviral therapy (ART) was guided by specific CD4 cell count thresholds. As scale-up efforts progress, the prevalence of advanced HIV disease at ART initiation is expected to decline. We analyzed the temporal trends in the median CD4 cell counts among adults initiating ART and described factors associated with initiating ART with severe immunodeficiency in Zambézia Province, Mozambique. We included all HIV-positive, treatment-naive adults (age ≥ 15 years) who initiated ART at a Friends in Global Health (FGH)-supported health facility between September 2012 and September 2017. Quantile regression and multivariable logistic regression models were applied to ascertain the median change in CD4 cell count and odds of initiating ART with severe immunodeficiency, respectively. A total of 68,332 patients were included in the analyses. The median change in CD4 cell count under "Test and Start" was higher at +68 cells/mm3 (95% CI: 57.5-78.4) compared with older policies. Younger age and female sex (particularly those pregnant/lactating) were associated with higher median CD4 cell counts at ART initiation. Male sex, advanced age, WHO Stage 4 disease, and referrals to the health facility through inpatient provider-initiated testing and counseling (PITC) were associated with higher odds of initiating ART with severe immunodeficiency. Although there were reassuring trends in increasing median CD4 cell counts with ART initiation, ongoing efforts are needed that target universal HIV testing to ensure the early initiation of ART in men and older patients.
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Affiliation(s)
- Folasade Arinze
- Department of Internal Medicine, WellStar Health System, Marietta, Georgia.,Department of Medicine, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee
| | - Wu Gong
- Department of Biostatistics, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee
| | - Ann F. Green
- Vanderbilt Institute for Global Health (VIGH), Nashville, Tennessee
| | | | - James G. Carlucci
- Vanderbilt Institute for Global Health (VIGH), Nashville, Tennessee.,Department of Pediatrics, Microbiology, and Immunology, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee
| | - Wilson Silva
- Friends in Global Health (FGH), Maputo, Mozambique.,Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee
| | - Gael Claquin
- Friends in Global Health (FGH), Maputo, Mozambique
| | | | | | - Erin Graves
- Vanderbilt Institute for Global Health (VIGH), Nashville, Tennessee
| | | | | | - Simão Tomo
- Direcção Provincial de Saúde Zambézia (DPS-Z), Quelimane, Mozambique
| | - Troy D. Moon
- Vanderbilt Institute for Global Health (VIGH), Nashville, Tennessee.,Department of Pediatrics, Microbiology, and Immunology, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee
| | - C. William Wester
- Department of Medicine, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee.,Vanderbilt Institute for Global Health (VIGH), Nashville, Tennessee.,Address correspondence to: C. William Wester, MD, MPH, Vanderbilt Institute for Global Health (VIGH), 2525 West End Avenue, Suite 750, Nashville, TN 37203
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48
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Nuwagaba-Biribonwoha H, Wu Y, Gachuhi AB, McNairy ML, Madau V, Lamb M, Mazibuko S, Mnisi Z, Burke S, Philip N, Sahabo R, El Sadr WM. Low rates of prior HIV testing among HIV-positive adults accessing outpatient services in Eswatini. AIDS Res Ther 2019; 16:38. [PMID: 31806036 PMCID: PMC6896727 DOI: 10.1186/s12981-019-0254-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 11/20/2019] [Indexed: 11/24/2022] Open
Abstract
Prior HIV testing and awareness of HIV-positive status were assessed among HIV-positive adults at 20 clinics in Eswatini. Of 2196 HIV-positive adults, 1183 (53.8%) reported no prior HIV testing, and 1948 (88.7%) were unaware of their HIV-positive status. Males [adjusted odds ratio, AOR, (95% confidence interval): 0.7 (0.5–0.9)], youth 18–25 years [AOR 0.6 (0.4–0.95)], adults ≥ 50 years [AOR 0.5 (0.3–0.9)], those needing family support [AOR 0.6 (0.5–0.8)], and those living ≥ 45 min from clinic [AOR 0.5 (0.4–0.8)] were less likely to know their HIV-positive status. More HIV testing is needed to achieve 95-95-95 targets, with targeted strategies for those less likely to test for HIV.
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49
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Truong HHM, Akama E, Guzé MA, Otieno F, Obunge D, Wandera E, Nsengiyumva NP, Obabo S, Bushman D, Kadede K, Bukusi EA, Oyaro P, Cohen CR. Implementation of a Community-Based Hybrid HIV Testing Services Program as a Strategy to Saturate Testing Coverage in Western Kenya. J Acquir Immune Defic Syndr 2019; 82:362-367. [PMID: 31658179 PMCID: PMC7148116 DOI: 10.1097/qai.0000000000002160] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Knowledge of HIV status is the entry point for linkage to prevention, care, and treatment, and the first step toward achieving the UNAIDS 90-90-90 targets. Most countries rely on proxies for estimating testing saturation, including periodic population-based sampling and yield (number positive among those tested). We conducted a community-based "Hybrid" HIV testing services (HTS) program to identify persons unaware of their HIV-positive status. SETTING Homa Bay County, Kenya; July-September, 2016. METHODS We conducted community mapping, household census, multi-disease community health campaigns (CHCs), and home-based tracking. HIV testing eligibility was based on 2015 national guidelines. The previously unidentified fraction (PUF) was defined as the proportion of newly identified persons living with HIV (PLWH) out of all previously identified and newly identified PLWH. RESULTS The Hybrid HTS program reached 28,885 persons in total: 25,340 residents and 3545 nonresidents. There were 19,288 persons reached through CHCs and tracking. Of 11,316 individuals eligible for HIV testing, 9463 (83%) accepted testing, including 1230 (13%) first-time testers. There were 115 newly identified PLWH of 1589 total HIV-positive persons, representing a 7.2% PUF. Of 93 newly identified PLWH at the CHCs, 68% initiated same-day antiretroviral therapy. CONCLUSION The Hybrid HTS program identified persons previously unaware of their HIV-positive status, thereby enabling linkage to care and same-day treatment and reducing onward transmission risk. An approach focused on identifying persons unaware of their HIV-positive status in combination with ascertaining the PUF has the potential to better target testing strategies to identify >90% of PLWH in a community.
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Affiliation(s)
- Hong-Ha M. Truong
- Departments of Medicine, University of California, San Francisco, CA, USA
| | - Eliud Akama
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Mary A. Guzé
- Obstetrics, Gynecology & Reproductive Services, University of California, San Francisco, CA, USA
| | - Frankline Otieno
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Duncan Obunge
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Esther Wandera
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Sammy Obabo
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Dena Bushman
- Departments of Medicine, University of California, San Francisco, CA, USA
| | - Kevin Kadede
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Elizabeth A. Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Craig R. Cohen
- Obstetrics, Gynecology & Reproductive Services, University of California, San Francisco, CA, USA
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50
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Alwano MG, Bachanas P, Block L, Roland M, Sento B, Behel S, Lebelonyane R, Wirth K, Ussery F, Bapati W, Motswere-Chirwa C, Abrams W, Ussery G, Miller JA, Bile E, Fonjungo P, Kgwadu A, Holme MP, Del Castillo L, Gaolathe T, Leme K, Majingo N, Lockman S, Makhema J, Bock N, Moore J. Increasing knowledge of HIV status in a country with high HIV testing coverage: Results from the Botswana Combination Prevention Project. PLoS One 2019; 14:e0225076. [PMID: 31765394 PMCID: PMC6876886 DOI: 10.1371/journal.pone.0225076] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 10/27/2019] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Achieving widespread knowledge of HIV-positive status is a crucial step to reaching universal ART coverage, population level viral suppression, and ultimately epidemic control. We implemented a multi-modality HIV testing approach to identify 90% or greater of HIV-positive persons in the Botswana Combination Prevention Project (BCPP) intervention communities. METHODS BCPP is a cluster-randomized trial designed to evaluate the impact of combination prevention interventions on HIV incidence in 30 communities in Botswana. Community case finding and HIV testing that included home and targeted mobile testing were implemented in the 15 intervention communities. We described processes for identifying HIV-positive persons, uptake of HIV testing by age, gender and venue, characteristics of persons newly diagnosed through BCPP, and coverage of knowledge of status reached at the end of study. RESULTS Of the 61,655 eligible adults assessed in home or mobile settings, 13,328 HIV-positive individuals, or 93% of the estimated 14,270 positive people in the communities were identified through BCPP. Knowledge of status increased by 25% over the course of the study with the greatest increases seen among men (37%) as compared to women (19%) and among youth aged 16-24 (77%) as compared to older age groups (21%). Although more men were tested through mobile than through home-based testing, higher rates of newly diagnosed HIV-positive men were found through home than mobile testing. CONCLUSIONS Even when HIV testing coverage is high, additional gains can be made using a multi-modality HIV testing strategy to reach different sub-populations who are being missed by non-targeted program activities. Men and youth can be reached and will engage in community testing when services are brought to places they access routinely.
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Affiliation(s)
- Mary Grace Alwano
- U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Gaborone, Botswana
| | - Pamela Bachanas
- U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Atlanta, Georgia, United States of America
| | - Lisa Block
- Northrop Grumman, Atlanta, Georgia, United States of America
| | - Michelle Roland
- U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Gaborone, Botswana
| | - Baraedi Sento
- Tebelopele HIV Counseling and Testing Center, Gaborone, Botswana
| | - Stephanie Behel
- U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Atlanta, Georgia, United States of America
| | | | - Kathleen Wirth
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Faith Ussery
- U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Atlanta, Georgia, United States of America
| | - William Bapati
- Tebelopele HIV Counseling and Testing Center, Gaborone, Botswana
| | | | - William Abrams
- U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Gaborone, Botswana
| | - Gene Ussery
- Northrop Grumman, Atlanta, Georgia, United States of America
| | - James A. Miller
- Northrop Grumman, Atlanta, Georgia, United States of America
| | - Ebi Bile
- U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Gaborone, Botswana
| | - Peter Fonjungo
- U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Atlanta, Georgia, United States of America
| | - Agisanag Kgwadu
- Tebelopele HIV Counseling and Testing Center, Gaborone, Botswana
| | - Molly Pretorius Holme
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Lisetta Del Castillo
- U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Gaborone, Botswana
| | | | - Kelebemang Leme
- Tebelopele HIV Counseling and Testing Center, Gaborone, Botswana
| | | | - Shahin Lockman
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Joseph Makhema
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Naomi Bock
- U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Atlanta, Georgia, United States of America
| | - Janet Moore
- U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Atlanta, Georgia, United States of America
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