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Metz M, Among VH, Dzinamarira T, Ussery F, Nkurunziza P, Bahizi J, Biraro S, Ogollah FM, Musinguzi J, Kirungi W, Naluguza M, Mwangi C, Birhanu S, Nelson LJ, Longwe H, Winterhalter FS, Voetsch AC, Parekh BS, Patel HK, Duong YT, Bray R, Farley SM. People Who Self-Reported Testing HIV-Positive but Tested HIV-Negative: A Multi-Country Puzzle of Data, Serology, and Ethics, 2015-2021. Trop Med Infect Dis 2024; 9:220. [PMID: 39330909 PMCID: PMC11435972 DOI: 10.3390/tropicalmed9090220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Revised: 08/30/2024] [Accepted: 09/10/2024] [Indexed: 09/28/2024] Open
Abstract
During population-based HIV impact assessments (PHIAs), some participants who self-reported testing HIV-positive (PSRP) tested negative in one or more subsequent survey HIV tests. These unexpected discrepancies between their self-reported results and the survey results draw into question the validity of either the self-reported status or the test results. We analyzed PSRP with negative test results aged 15-59 years old using data collected from 2015 to 2021 in 13 countries, assessing prevalence, self-report status, survey HIV status, viral load, rapid tests and confirmatory tests, and answers to follow-up questions (such as years on treatment). Across these surveys, 19,026 participants were PSRP, and 256 (1.3%) of these were concluded to be HIV-negative after additional survey-based testing and review. PSRP determined to be HIV-negative trended higher in countries with a higher HIV prevalence, but their number was small enough that accepting self-reported HIV-positive status without testing would not have significantly affected the prevalence estimates for HIV or viral load suppression. Additionally, using more detailed information for Uganda, we examined 107 PSRP with any negative test results and found no significant correlation with years on treatment or age. Using these details, we examined support for the possible reasons for these discrepancies beyond misdiagnosis and false reporting. These findings suggest that those conducting surveys would benefit from a nuanced understanding of HIV testing among PSRP to conduct surveys ethically and produce high-quality results.
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Affiliation(s)
- Melissa Metz
- ICAP at Columbia University, New York, NY 10032, USA; (F.S.W.); (S.M.F.)
| | | | | | - Faith Ussery
- Division of Global HIV and TB, Global Health Center, US Centers for Disease Control and Prevention (CDC), Atlanta, GA 30329, USA; (F.U.); (S.B.); (A.C.V.); (B.S.P.); (H.K.P.)
| | - Peter Nkurunziza
- ICAP Uganda, Plot 1 Lourdel Rd, 5th Floor Lourdel Towers, Kampala, Uganda; (P.N.); (J.B.); (S.B.)
| | - Janet Bahizi
- ICAP Uganda, Plot 1 Lourdel Rd, 5th Floor Lourdel Towers, Kampala, Uganda; (P.N.); (J.B.); (S.B.)
| | - Samuel Biraro
- ICAP Uganda, Plot 1 Lourdel Rd, 5th Floor Lourdel Towers, Kampala, Uganda; (P.N.); (J.B.); (S.B.)
| | | | | | - Wilford Kirungi
- Uganda Ministry of Health, Kampala P.O. Box 7272, Uganda (W.K.)
| | - Mary Naluguza
- Division of Global HIV and TB, Global Health Center, US Centers for Disease Control and Prevention (CDC), Kampala P.O. Box 7007, Uganda; (M.N.); (L.J.N.)
| | - Christina Mwangi
- Division of Global HIV and TB, Global Health Center, US Centers for Disease Control and Prevention (CDC), Kampala P.O. Box 7007, Uganda; (M.N.); (L.J.N.)
| | - Sehin Birhanu
- Division of Global HIV and TB, Global Health Center, US Centers for Disease Control and Prevention (CDC), Atlanta, GA 30329, USA; (F.U.); (S.B.); (A.C.V.); (B.S.P.); (H.K.P.)
| | - Lisa J. Nelson
- Division of Global HIV and TB, Global Health Center, US Centers for Disease Control and Prevention (CDC), Kampala P.O. Box 7007, Uganda; (M.N.); (L.J.N.)
| | - Herbert Longwe
- ICAP South Africa, Erasmuskloof, Pretoria P.O Box 11203, South Africa;
| | | | - Andrew C. Voetsch
- Division of Global HIV and TB, Global Health Center, US Centers for Disease Control and Prevention (CDC), Atlanta, GA 30329, USA; (F.U.); (S.B.); (A.C.V.); (B.S.P.); (H.K.P.)
| | - Bharat S. Parekh
- Division of Global HIV and TB, Global Health Center, US Centers for Disease Control and Prevention (CDC), Atlanta, GA 30329, USA; (F.U.); (S.B.); (A.C.V.); (B.S.P.); (H.K.P.)
| | - Hetal K. Patel
- Division of Global HIV and TB, Global Health Center, US Centers for Disease Control and Prevention (CDC), Atlanta, GA 30329, USA; (F.U.); (S.B.); (A.C.V.); (B.S.P.); (H.K.P.)
| | - Yen T. Duong
- ICAP at Columbia University, New York, NY 10032, USA; (F.S.W.); (S.M.F.)
| | - Rachel Bray
- ICAP at Columbia University, New York, NY 10032, USA; (F.S.W.); (S.M.F.)
| | - Shannon M. Farley
- ICAP at Columbia University, New York, NY 10032, USA; (F.S.W.); (S.M.F.)
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Joseph RH, Obeng-Aduasare Y, Achia T, Agedew A, Jonnalagadda S, Katana A, Odoyo EJ, Appolonia A, Raizes E, Dubois A, Blandford J, Nganga L. Beyond the 95s: What happens when uniform program targets are applied across a heterogenous HIV epidemic in Eastern and Southern Africa? PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003723. [PMID: 39298413 DOI: 10.1371/journal.pgph.0003723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 08/26/2024] [Indexed: 09/21/2024]
Abstract
The UNAIDS 95-95-95 targets are an important metric for guiding national HIV programs and measuring progress towards ending the HIV epidemic as a public health threat by 2030. Nevertheless, as proportional targets, the outcome of reaching the 95-95-95 targets will vary greatly across, and within, countries owing to the geographic diversity of the HIV epidemic. Countries and subnational units with a higher initial prevalence and number of people living with HIV (PLHIV) will remain with a larger number and higher prevalence of virally unsuppressed PLHIV-persons who may experience excess morbidity and mortality and can transmit the virus to others. Reliance on achievement of uniform proportional targets as a measure of program success can potentially mislead resource allocation and progress towards equitable epidemic control. More granular surveillance information on the HIV epidemic is required to effectively calibrate strategies and intensity of HIV programs across geographies and address current and projected health disparities that may undermine efforts to reach and sustain HIV epidemic control even after the 95 targets are achieved.
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Affiliation(s)
- Rachael H Joseph
- Division of Global HIV & TB, Global Health Center, U.S. Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Yaa Obeng-Aduasare
- Division of Global HIV & TB, Global Health Center, U.S. Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Thomas Achia
- Division of Global HIV & TB, Global Health Center, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Abraham Agedew
- Division of Global HIV & TB, Global Health Center, U.S. Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Sasi Jonnalagadda
- Division of Global HIV & TB, Global Health Center, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Abraham Katana
- Division of Global HIV & TB, Global Health Center, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Elijah J Odoyo
- Division of Global HIV & TB, Global Health Center, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Aoko Appolonia
- Division of Global HIV & TB, Global Health Center, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Elliot Raizes
- Division of Global HIV & TB, Global Health Center, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Amy Dubois
- Division of Global HIV & TB, Global Health Center, U.S. Centers for Disease Control and Prevention, Pretoria, South Africa
| | - John Blandford
- Division of Global HIV & TB, Global Health Center, U.S. Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Lucy Nganga
- Division of Global HIV & TB, Global Health Center, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
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Zuniga JM, Prachniak C, Policek N, Magula N, Gandhi A, Anderson J, Diallo DD, Lima VD, Ravishankar S, Acharya S, Achrekar A, Adeleke M, Aïna É, Baptiste S, Barrow G, Begovac J, Bukusi E, Castel A, Castellanos E, Cestou J, Chirambo G, Crowley J, Dedes N, Ditiu L, Doherty M, Duncombe C, Durán A, Futterman D, Hader S, Kounkeu C, Lawless F, Lazarus JV, Lex S, Lobos C, Mayer K, Mejia M, Moheno HR, d'Arminio Monforte A, Morán-Arribas M, Nagel D, Ndugwa R, Ngunu C, Poonkasetwattana M, Prins M, Quesada A, Rudnieva O, Ruth S, Saavedra J, Toma L, Wanjiku Njenga L, Williams B. IAPAC-Lancet HIV Commission on the future of urban HIV responses. Lancet HIV 2024; 11:e607-e648. [PMID: 39043198 DOI: 10.1016/s2352-3018(24)00124-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 04/26/2024] [Accepted: 05/02/2024] [Indexed: 07/25/2024]
Affiliation(s)
- José M Zuniga
- International Association of Providers of AIDS Care, Washington, DC, USA; Fast-Track Cities Institute, Washington, DC, USA.
| | | | | | | | - Anisha Gandhi
- New York City Department of Health and Mental Hygiene, New York, NY, USA
| | | | | | | | | | | | | | | | | | - Solange Baptiste
- International Treatment Preparedness Coalition, Johannesburg, South Africa
| | | | | | - Elizabeth Bukusi
- Kenya Medical Research Institute, Nairobi, Kenya; University of Nairobi, Nairobi, Kenya
| | | | | | - Jorge Cestou
- Chicago Department of Public Health, Chicago, IL, USA
| | | | | | | | | | - Meg Doherty
- World Health Organization, Geneva, Switzerland
| | - Chris Duncombe
- International Association of Providers of AIDS Care, Washington, DC, USA
| | - Adriana Durán
- Ministry of Health, City of Buenos Aires, Buenos Aires, Argentina
| | | | | | - Chyrol Kounkeu
- Cameroonian Association for the Development and Empowerment of Vulnerable People, Yaoundé, Cameroon
| | - Fran Lawless
- Mayor's Office of Health Policy, New Orleans, LA, USA
| | - Jeffrey V Lazarus
- University of Barcelona, Barcelona, Spain; CUNY Graduate School of Public Health and Policy, New York, NY, USA
| | | | | | - Kenneth Mayer
- Fenway Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | | | | | | | | | | | | | - Carol Ngunu
- Nairobi City County Department of Health, Nairobi, Kenya
| | | | - Maria Prins
- Academic Medical Center, Amsterdam, Netherlands
| | - Amara Quesada
- Action for Health Initiatives, Quezon City, Philippines
| | | | - Simon Ruth
- Thorne Harbour Health, Melbourne, VIC, Australia
| | | | - Lance Toma
- San Francisco Community Health Center, San Francisco, CA, USA
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Loeb T, Willis K, Velishavo F, Lee D, Rao A, Baral S, Rucinski K. Leveraging Routinely Collected Program Data to Inform Extrapolated Size Estimates for Key Populations in Namibia: Small Area Estimation Study. JMIR Public Health Surveill 2024; 10:e48963. [PMID: 38573760 PMCID: PMC11027056 DOI: 10.2196/48963] [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: 05/12/2023] [Revised: 09/07/2023] [Accepted: 12/13/2023] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Estimating the size of key populations, including female sex workers (FSW) and men who have sex with men (MSM), can inform planning and resource allocation for HIV programs at local and national levels. In geographic areas where direct population size estimates (PSEs) for key populations have not been collected, small area estimation (SAE) can help fill in gaps using supplemental data sources known as auxiliary data. However, routinely collected program data have not historically been used as auxiliary data to generate subnational estimates for key populations, including in Namibia. OBJECTIVE To systematically generate regional size estimates for FSW and MSM in Namibia, we used a consensus-informed estimation approach with local stakeholders that included the integration of routinely collected HIV program data provided by key populations' HIV service providers. METHODS We used quarterly program data reported by key population implementing partners, including counts of the number of individuals accessing HIV services over time, to weight existing PSEs collected through bio-behavioral surveys using a Bayesian triangulation approach. SAEs were generated through simple imputation, stratified imputation, and multivariable Poisson regression models. We selected final estimates using an iterative qualitative ranking process with local key population implementing partners. RESULTS Extrapolated national estimates for FSW ranged from 4777 to 13,148 across Namibia, comprising 1.5% to 3.6% of female individuals aged between 15 and 49 years. For MSM, estimates ranged from 4611 to 10,171, comprising 0.7% to 1.5% of male individuals aged between 15 and 49 years. After the inclusion of program data as priors, the estimated proportion of FSW derived from simple imputation increased from 1.9% to 2.8%, and the proportion of MSM decreased from 1.5% to 0.75%. When stratified imputation was implemented using HIV prevalence to inform strata, the inclusion of program data increased the proportion of FSW from 2.6% to 4.0% in regions with high prevalence and decreased the proportion from 1.4% to 1.2% in regions with low prevalence. When population density was used to inform strata, the inclusion of program data also increased the proportion of FSW in high-density regions (from 1.1% to 3.4%) and decreased the proportion of MSM in all regions. CONCLUSIONS Using SAE approaches, we combined epidemiologic and program data to generate subnational size estimates for key populations in Namibia. Overall, estimates were highly sensitive to the inclusion of program data. Program data represent a supplemental source of information that can be used to align PSEs with real-world HIV programs, particularly in regions where population-based data collection methods are challenging to implement. Future work is needed to determine how best to include and validate program data in target settings and in key population size estimation studies, ultimately bridging research with practice to support a more comprehensive HIV response.
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Affiliation(s)
- Talia Loeb
- Data for Implementation (Data.FI), Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Kalai Willis
- Data for Implementation (Data.FI), Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | | | - Daniel Lee
- United States Agency for International Development Dominican Republic, Santo Domingo, Dominican Republic
| | - Amrita Rao
- Data for Implementation (Data.FI), Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Stefan Baral
- Data for Implementation (Data.FI), Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Katherine Rucinski
- Data for Implementation (Data.FI), Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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Rosen JG, Ssekubugu R, Chang LW, Ssempijja V, Galiwango RM, Ssekasanvu J, Ndyanabo A, Kisakye A, Nakigozi G, Rucinski KB, Patel EU, Kennedy CE, Nalugoda F, Kigozi G, Ratmann O, Nelson LJ, Mills LA, Kabatesi D, Tobian AAR, Quinn TC, Kagaayi J, Reynolds SJ, Grabowski MK. Temporal dynamics and drivers of durable HIV viral load suppression and persistent high- and low-level viraemia during Universal Test and Treat scale-up in Uganda: a population-based study. J Int AIDS Soc 2024; 27:e26200. [PMID: 38332519 PMCID: PMC10853573 DOI: 10.1002/jia2.26200] [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: 06/16/2023] [Accepted: 12/04/2023] [Indexed: 02/10/2024] Open
Abstract
INTRODUCTION Population-level data on durable HIV viral load suppression (VLS) following the implementation of Universal Test and Treat (UTT) in Africa are limited. We assessed trends in durable VLS and viraemia among persons living with HIV in 40 Ugandan communities during the UTT scale-up. METHODS In 2015-2020, we measured VLS (<200 RNA copies/ml) among participants in the Rakai Community Cohort Study, a longitudinal population-based HIV surveillance cohort in southern Uganda. Persons with unsuppressed viral loads were characterized as having low-level (200-999 copies/ml) or high-level (≥1000 copies/ml) viraemia. Individual virologic outcomes were assessed over two consecutive RCCS survey visits (i.e. visit-pairs; ∼18-month visit intervals) and classified as durable VLS (<200 copies/ml at both visits), new/renewed VLS (<200 copies/ml at follow-up only), viral rebound (<200 copies/ml at initial visit only) or persistent viraemia (≥200 copies/ml at both visits). Population prevalence of each outcome was assessed over calendar time. Community-level prevalence and individual-level predictors of persistent high-level viraemia were also assessed using multivariable Poisson regression with generalized estimating equations. RESULTS Overall, 3080 participants contributed 4604 visit-pairs over three survey rounds. Most visit-pairs (72.4%) exhibited durable VLS, with few (2.5%) experiencing viral rebound. Among those with any viraemia at the initial visit (23.5%, n = 1083), 46.9% remained viraemic through follow-up, 91.3% of which was high-level viraemia. One-fifth (20.8%) of visit-pairs exhibiting persistent high-level viraemia self-reported antiretroviral therapy (ART) use for ≥12 months. Prevalence of persistent high-level viraemia varied substantially across communities and was significantly elevated among young persons aged 15-29 years (vs. 40- to 49-year-olds; adjusted risk ratio [adjRR] = 2.96; 95% confidence interval [95% CI]: 2.21-3.96), males (vs. females; adjRR = 2.40, 95% CI: 1.87-3.07), persons reporting inconsistent condom use with non-marital/casual partners (vs. persons with marital/permanent partners only; adjRR = 1.38, 95% CI: 1.10-1.74) and persons reporting hazardous alcohol use (adjRR = 1.09, 95% CI: 1.03-1.16). The prevalence of persistent high-level viraemia was highest among males <30 years (32.0%). CONCLUSIONS Following universal ART provision, most persons living with HIV in south-central Uganda are durably suppressed. Among persons exhibiting any viraemia, nearly half exhibited high-level viraemia for ≥12 months and reported higher-risk behaviours associated with onward HIV transmission. Intensified efforts linking individuals to HIV treatment services could accelerate momentum towards HIV epidemic control.
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Affiliation(s)
- Joseph Gregory Rosen
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | | | - Larry W. Chang
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Rakai Health Sciences ProgramEntebbeUganda
- Division of Infectious DiseasesJohns Hopkins School of MedicineBaltimoreMarylandUSA
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Victor Ssempijja
- Rakai Health Sciences ProgramEntebbeUganda
- Clinical Monitoring Research Program DirectorateFrederick National Laboratory for Cancer ResearchFrederickMarylandUSA
| | | | - Joseph Ssekasanvu
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Rakai Health Sciences ProgramEntebbeUganda
| | | | | | | | - Katherine B. Rucinski
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Eshan U. Patel
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Caitlin E. Kennedy
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Rakai Health Sciences ProgramEntebbeUganda
| | | | | | | | - Lisa J. Nelson
- Division of Global HIV and TBCenters for Disease Control and PreventionKampalaUganda
| | - Lisa A. Mills
- Division of Global HIV and TBCenters for Disease Control and PreventionKampalaUganda
| | - Donna Kabatesi
- Division of Global HIV and TBCenters for Disease Control and PreventionKampalaUganda
| | - Aaron A. R. Tobian
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Department of PathologyJohns Hopkins School of MedicineBaltimoreMarylandUSA
| | - Thomas C. Quinn
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Rakai Health Sciences ProgramEntebbeUganda
- Division of Infectious DiseasesJohns Hopkins School of MedicineBaltimoreMarylandUSA
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Division of Intramural ResearchNational Institute of Allergy and Infectious DiseasesNational Institutes of HealthBethesdaMarylandUSA
| | | | - Steven J. Reynolds
- Rakai Health Sciences ProgramEntebbeUganda
- Division of Infectious DiseasesJohns Hopkins School of MedicineBaltimoreMarylandUSA
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Division of Intramural ResearchNational Institute of Allergy and Infectious DiseasesNational Institutes of HealthBethesdaMarylandUSA
| | - Mary Kathryn Grabowski
- Rakai Health Sciences ProgramEntebbeUganda
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Department of PathologyJohns Hopkins School of MedicineBaltimoreMarylandUSA
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Song J, Okano JT, Ponce J, Busang L, Seipone K, Valdano E, Blower S. The role of migration networks in the development of Botswana's generalized HIV epidemic. eLife 2023; 12:e85435. [PMID: 37665629 PMCID: PMC10476964 DOI: 10.7554/elife.85435] [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: 12/08/2022] [Accepted: 08/02/2023] [Indexed: 09/05/2023] Open
Abstract
The majority of people with HIV live in sub-Saharan Africa, where epidemics are generalized. For these epidemics to develop, populations need to be mobile. However, the role of population-level mobility in the development of generalized HIV epidemics has not been studied. Here we do so by studying historical migration data from Botswana, which has one of the most severe generalized HIV epidemics worldwide; HIV prevalence was 21% in 2021. The country reported its first AIDS case in 1985 when it began to rapidly urbanize. We hypothesize that, during the development of Botswana's epidemic, the population was extremely mobile and the country was highly connected by substantial migratory flows. We test this mobility hypothesis by conducting a network analysis using a historical time series (1981-2011) of micro-census data from Botswana. Our results support our hypothesis. We found complex migration networks with very high rates of rural-to-urban, and urban-to-rural, migration: 10% of the population moved annually. Mining towns (where AIDS cases were first reported, and risk behavior was high) were important in-flow and out-flow migration hubs, suggesting that they functioned as 'core groups' for HIV transmission and dissemination. Migration networks could have dispersed HIV throughout Botswana and generated the current hyperendemic epidemic.
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Affiliation(s)
- Janet Song
- Center for Biomedical Modeling, Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los AngelesLos AngelesUnited States
| | - Justin T Okano
- Center for Biomedical Modeling, Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los AngelesLos AngelesUnited States
| | - Joan Ponce
- Center for Biomedical Modeling, Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los AngelesLos AngelesUnited States
| | - Lesego Busang
- The African Comprehensive HIV/AIDS Partnerships (ACHAP)GaboroneBotswana
| | - Khumo Seipone
- The African Comprehensive HIV/AIDS Partnerships (ACHAP)GaboroneBotswana
| | - Eugenio Valdano
- Sorbonne Université, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé PubliqueParisFrance
| | - Sally Blower
- Center for Biomedical Modeling, Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los AngelesLos AngelesUnited States
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Khalifa A, Ssekubugu R, Lessler J, Wawer M, Santelli JS, Hoffman S, Nalugoda F, Lutalo T, Ndyanabo A, Ssekasanvu J, Kigozi G, Kagaayi J, Chang LW, Grabowski MK. Implications of rapid population growth on survey design and HIV estimates in the Rakai Community Cohort Study (RCCS), Uganda. BMJ Open 2023; 13:e071108. [PMID: 37495389 PMCID: PMC10373715 DOI: 10.1136/bmjopen-2022-071108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
Abstract
OBJECTIVE Since rapid population growth challenges longitudinal population-based HIV cohorts in Africa to maintain coverage of their target populations, this study evaluated whether the exclusion of some residents due to growing population size biases key HIV metrics like prevalence and population-level viremia. DESIGN, SETTING AND PARTICIPANTS Data were obtained from the Rakai Community Cohort Study (RCCS) in south central Uganda, an open population-based cohort which began excluding some residents of newly constructed household structures within its surveillance boundaries in 2008. The study includes adults aged 15-49 years who were censused from 2019 to 2020. MEASURES We fit ensemble machine learning models to RCCS census and survey data to predict HIV seroprevalence and viremia (prevalence of those with viral load >1000 copies/mL) in the excluded population and evaluated whether their inclusion would change overall estimates. RESULTS Of the 24 729 census-eligible residents, 2920 (12%) residents were excluded from the RCCS because they were living in new households. The predicted seroprevalence for these excluded residents was 10.8% (95% CI: 9.6% to 11.8%)-somewhat lower than 11.7% (95% CI: 11.2% to 12.3%) in the observed sample. Predicted seroprevalence for younger excluded residents aged 15-24 years was 4.9% (95% CI: 3.6% to 6.1%)-significantly higher than that in the observed sample for the same age group (2.6% (95% CI: 2.2% to 3.1%)), while predicted seroprevalence for older excluded residents aged 25-49 years was 15.0% (95% CI: 13.3% to 16.4%)-significantly lower than their counterparts in the observed sample (17.2% (95% CI: 16.4% to 18.1%)). Over all ages, the predicted prevalence of viremia in excluded residents (3.7% (95% CI: 3.0% to 4.5%)) was significantly higher than that in the observed sample (1.7% (95% CI: 1.5% to 1.9%)), resulting in a higher overall population-level viremia estimate of 2.1% (95% CI: 1.8% to 2.4%). CONCLUSIONS Exclusion of residents in new households may modestly bias HIV viremia estimates and some age-specific seroprevalence estimates in the RCCS. Overall, HIV seroprevalence estimates were not significantly affected.
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Affiliation(s)
- Aleya Khalifa
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
- ICAP, Columbia University, New York, New York, USA
| | - Robert Ssekubugu
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Global and Sexual Health, Karolinska Institutet, Stockholm, Sweden
| | - Justin Lessler
- Department of Epidemiology, University of North Carolina School of Public Health, Chapel Hill, North Carolina, USA
- Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Maria Wawer
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - John S Santelli
- Population and Family Health, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Susie Hoffman
- Department of Epidemiology, Columbia University, New York, New York, USA
- HIV Centre for Clinical and Behavioural Studies, Columbia University Irving Medical Centre, New York, New York, USA
| | | | - Tom Lutalo
- Rakai Health Sciences Program, Kalisizo, Uganda
| | | | - Joseph Ssekasanvu
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | - Larry W Chang
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mary Kathryn Grabowski
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Rosen JG, Ssekubugu R, Chang LW, Ssempijja V, Galiwango RM, Ssekasanvu J, Ndyanabo A, Kisakye A, Nakigozi G, Rucinski KB, Patel EU, Kennedy CE, Nalugoda F, Kigozi G, Ratmann O, Nelson LJ, Mills LA, Kabatesi D, Tobian AAR, Quinn TC, Kagaayi J, Reynolds SJ, Grabowski MK. Temporal dynamics and drivers of durable HIV viral load suppression and persistent high- and low-level viremia during Universal Test and Treat scale-up in Uganda: a population-based study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.06.15.23291445. [PMID: 37398460 PMCID: PMC10312875 DOI: 10.1101/2023.06.15.23291445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Introduction Population-level data on durable HIV viral load suppression (VLS) following implementation of Universal Test and Treat (UTT) in Africa are limited. We assessed trends in durable VLS and viremia among persons living with HIV in 40 Ugandan communities during UTT scale-up. Methods In 2015-2020, we measured VLS (defined as <200 RNA copies/mL) among participants in the Rakai Community Cohort Study, a longitudinal population-based HIV surveillance cohort in southern Uganda. Persons with unsuppressed viral loads were characterized as having low-level (200-999 copies/mL) or high-level (≥1,000 copies/mL) viremia. Individual virologic outcomes were assessed over two consecutive RCCS survey visits (i.e., visit-pairs; ∼18 month visit intervals) and classified as durable VLS (<200 copies/mL at both visits), new/renewed VLS (<200 copies/mL at follow-up only), viral rebound (<200 copies/mL at initial visit only), or persistent viremia (<200 copies/mL at neither visit). Population prevalence of each outcome was assessed over calendar time. Community-level prevalence and individual-level predictors of persistent high-level viremia were also assessed using multivariable Poisson regression with generalized estimating equations. Results Overall, 3,080 participants contributed 4,604 visit-pairs over three survey rounds. Most visit-pairs (72.4%) exhibited durable VLS, with few (2.5%) experiencing viral rebound. Among those with viremia at the initial visit ( n =1,083), 46.9% maintained viremia through follow-up, 91.3% of which was high-level viremia. One-fifth (20.8%) of visit-pairs exhibiting persistent high-level viremia self-reported antiretroviral therapy (ART) use for ≥12 months. Prevalence of persistent high-level viremia varied substantially across communities and was significantly elevated among young persons aged 15-29 years (versus 40-49-year-olds; adjusted risk ratio [adjRR]=2.96; 95% confidence interval [95%CI]:2.21-3.96), men (versus women; adjRR=2.40, 95%CI:1.87-3.07), persons reporting inconsistent condom use with non-marital/casual partners (versus persons with marital/permanent partners only; adjRR=1.38, 95%CI:1.10-1.74), and persons exhibiting hazardous alcohol use (adjRR=1.09, 95%CI:1.03-1.16). The prevalence of persistent high-level viremia was highest among men <30 years (32.0%). Conclusions Following universal ART provision, most persons living with HIV in south-central Uganda are durably suppressed. Among persons exhibiting viremia, nearly half maintain high-level viremia for ≥12 months and report higher-risk behaviors associated with onward HIV transmission. Enhanced linkage to HIV care and optimized treatment retention could accelerate momentum towards HIV epidemic control.
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Khalifa A, Findley S, Gummerson E, Mantell JE, Hakim AJ, Philip NM, Ginindza C, Hassani AS, Hong SY, Jalloh MF, Kirungi WL, Maile L, Mgomella GS, Miller LA, Minchella P, Mutenda N, Njau P, Schwitters A, Ward J, Low A. Associations Between Mobility, Food Insecurity, and Transactional Sex Among Women in Cohabitating Partnerships: An Analysis From 6 African Countries 2016-2017. J Acquir Immune Defic Syndr 2022; 90:388-398. [PMID: 35389376 PMCID: PMC9909688 DOI: 10.1097/qai.0000000000002995] [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: 12/14/2021] [Accepted: 03/16/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mobile women are at risk of HIV infection in sub-Saharan Africa, although we lack evidence for HIV risk among women in mobile partnerships, especially in the context of household food insecurity, a growing concern in the region. SETTING Women aged 15-59 years with a cohabitating male partner who participated in population-based HIV impact assessment surveys in Eswatini, Lesotho, Namibia, Tanzania, Uganda, and Zambia. METHODS We evaluated the association between women's and their partner's mobility (being away from home for more than 1 month or staying elsewhere) and transactional sex (selling sex or receiving money or goods in exchange for sex). We examined associations for effect measure modification by food insecurity level in the household in the past month. We used survey-weighted logistic regression, pooled and by country, adjusting for individual, partner, and household-level variables. RESULTS Among women with a cohabitating male partner, 8.0% reported transactional sex, ranging from 2.7% in Lesotho to 13.4% in Uganda. Women's mobility [aOR 1.35 (95% CI: 1.08 to 1.68)], but not their partner's mobility [aOR 0.91 (0.74-1.12)], was associated with transactional sex. Food insecurity was associated with transactional sex independent of mobility [aOR 1.29 (1.10-1.52)]. Among those who were food insecure, mobility was not associated with increased odds of transactional sex. CONCLUSION Food insecurity and women's mobility each increased the odds of transactional sex. Because transactional sex is associated with HIV risk, prevention programs can address the needs of mobile and food-insecure women, including those in cohabitating relationships.
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Affiliation(s)
- Aleya Khalifa
- ICAP at Columbia University, New York USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York USA
| | - Sally Findley
- Population & Family Health Department, Mailman School of Public Health, Columbia University, New York USA
| | | | - Joanne E. Mantell
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Department of Psychiatry, Columbia University Irving Medical Center
| | - Avi J. Hakim
- Division of Global HIV and TB, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, USA
| | | | | | - Ahmed Saadani Hassani
- Division of Parasitic Diseases and Malaria, US Centers for Disease Control and Prevention, Atlanta, USA
| | - Steven Y. Hong
- Division of Global HIV and TB, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, USA
| | | | | | | | | | | | | | | | - Prosper Njau
- National AIDS Control Programme, Dar es Salaam, Tanzania
| | | | - Jennifer Ward
- Centers for Disease Control and Prevention, Kampala, Uganda
| | - Andrea Low
- ICAP at Columbia University, New York USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York USA
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