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Davis K, Pickles M, Gregson S, Hargreaves JR, Ayles H, Bock P, Pliakas T, Thomas R, Ohrnberger J, Bwalya J, Bell-Mandla N, Shanaube K, Probert W, Hoddinott G, Bond V, Hayes R, Fidler S, Hauck K. The effect of universal testing and treatment for HIV on health-related quality of life - An analysis of data from the HPTN 071 (PopART) cluster randomised trial. SSM Popul Health 2023; 23:101473. [PMID: 37575363 PMCID: PMC10413193 DOI: 10.1016/j.ssmph.2023.101473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/26/2023] [Accepted: 07/21/2023] [Indexed: 08/15/2023] Open
Abstract
Background HIV treatment has clear Health-Related Quality-of-Life (HRQoL) benefits. However, little is known about how Universal Testing and Treatment (UTT) for HIV affects HRQoL. This study aimed to examine the effect of a combination prevention intervention, including UTT, on HRQoL among People Living with HIV (PLHIV). Methods Data were from HPTN 071 (PopART), a three-arm cluster randomised controlled trial in 21 communities in Zambia and South Africa (2013-2018). Arm A received the full UTT intervention of door-to-door HIV testing plus access to antiretroviral therapy (ART) regardless of CD4 count, Arm B received the intervention but followed national treatment guidelines (universal ART from 2016), and Arm C received standard care. The intervention effect was measured in a cohort of randomly selected adults, over 36 months. HRQoL scores, and the prevalence of problems in five HRQoL dimensions (mobility, self-care, performing daily activities, pain/discomfort, anxiety/depression) were assessed among all participants using the EuroQol-5-dimensions-5-levels questionnaire (EQ-5D-5L). We compared HRQoL among PLHIV with laboratory confirmed HIV status between arms, using adjusted two-stage cluster-level analyses. Results At baseline, 7,856 PLHIV provided HRQoL data. At 36 months, the mean HRQoL score was 0.892 (95% confidence interval: 0.887-0.898) in Arm A, 0.886 (0.877-0.894) in Arm B and 0.888 (0.884-0.892) in Arm C. There was no evidence of a difference in HRQoL scores between arms (A vs C, adjusted mean difference: 0.003, -0.001-0.006; B vs C: -0.004, -0.014-0.005). The prevalence of problems with pain/discomfort was lower in Arm A than C (adjusted prevalence ratio: 0.37, 0.14-0.97). There was no evidence of differences for other HRQoL dimensions. Conclusions The intervention did not change overall HRQoL, suggesting that raising HRQoL among PLHIV might require more than improved testing and treatment. However, PLHIV had fewer problems with pain/discomfort under the full intervention; this benefit of UTT should be maximised during roll-out.
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Affiliation(s)
- Katherine Davis
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, W2 1PG, UK
- Abdul Latif Jameel Institute for Disease and Emergency Analytics, School of Public Health, Imperial College London, London, W2 1PG, UK
| | - Michael Pickles
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, W2 1PG, UK
- Abdul Latif Jameel Institute for Disease and Emergency Analytics, School of Public Health, Imperial College London, London, W2 1PG, UK
| | - Simon Gregson
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, W2 1PG, UK
- Abdul Latif Jameel Institute for Disease and Emergency Analytics, School of Public Health, Imperial College London, London, W2 1PG, UK
| | - James R. Hargreaves
- Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Helen Ayles
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Zambart, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health, University of Stellenbosch, Cape Town, South Africa
| | - Triantafyllos Pliakas
- Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Ranjeeta Thomas
- Department of Health Policy, London School of Economics, London, WC2A 2AE, UK
| | - Julius Ohrnberger
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, W2 1PG, UK
- Abdul Latif Jameel Institute for Disease and Emergency Analytics, School of Public Health, Imperial College London, London, W2 1PG, UK
| | - Justin Bwalya
- Zambart, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Nomtha Bell-Mandla
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health, University of Stellenbosch, Cape Town, South Africa
| | - Kwame Shanaube
- Zambart, School of Medicine, University of Zambia, Lusaka, Zambia
| | - William Probert
- Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7LF, UK
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health, University of Stellenbosch, Cape Town, South Africa
| | - Virginia Bond
- Zambart, School of Medicine, University of Zambia, Lusaka, Zambia
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Sarah Fidler
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, W2 1PG, UK
| | - Katharina Hauck
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, W2 1PG, UK
- Abdul Latif Jameel Institute for Disease and Emergency Analytics, School of Public Health, Imperial College London, London, W2 1PG, UK
| | - the HPTN 071 (PopART) Study Team
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, W2 1PG, UK
- Abdul Latif Jameel Institute for Disease and Emergency Analytics, School of Public Health, Imperial College London, London, W2 1PG, UK
- Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Zambart, School of Medicine, University of Zambia, Lusaka, Zambia
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health, University of Stellenbosch, Cape Town, South Africa
- Department of Health Policy, London School of Economics, London, WC2A 2AE, UK
- Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7LF, UK
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, W2 1PG, UK
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Mugenyi L, Hansen CH, Mayaud P, Seeley J, Newton R, Nanfuka M, Abaasa A, Mugisha K, Etukoit M, Kaleebu P, Ruzagira E. Effect of the "universal test and treat" policy on the characteristics of persons registering for HIV care and initiating antiretroviral therapy in Uganda. Front Public Health 2023; 11:1187274. [PMID: 37361157 PMCID: PMC10289544 DOI: 10.3389/fpubh.2023.1187274] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/22/2023] [Indexed: 06/28/2023] Open
Abstract
We examined the effect of the Universal Test and Treat (UTT) policy on the characteristics of people living with HIV (PLHIV) at enrolment in HIV care and initiation of antiretroviral therapy (ART) in Uganda using data from 11 nationally representative clinics of The AIDS Support Organisation (TASO). We created two retrospective PLHIV cohorts: pre-UTT (2004-2016), where ART initiation was conditional on CD4 cell count and UTT (2017-2022), where ART was initiated regardless of World Health Organisation (WHO) clinical stage or CD4 cell count. We used a two-sample test of proportions and Wilcoxon rank-sum test to compare proportions and medians, respectively, between the cohorts. A total of 244,693 PLHIV were enrolled at the clinics [pre-UTT, 210,251 (85.9%); UTT, 34,442 (14.1%)]. Compared to the pre-UTT cohort, the UTT cohort had higher proportions of PLHIV that were male (p < 0.001), aged 18-29 years (p < 0.001), aged >69 years, never married (p < 0.001), and educated to primary (p < 0.001) and post-primary (p < 0.001) school level at enrolment in HIV care and ART initiation. Overall, 97.9% of UTT PLHIV initiated ART compared to 45.2% under pre-UTT. The median time from enrolment in HIV care to ART initiation decreased from 301 [interquartile range (IQR): 58-878] pre-UTT to 0 (IQR: 0-0) under UTT. The median CD4 count at ART initiation increased from 254 cells/μL pre-UTT to 482 cells/μL under UTT (p < 0.001). Compared to the pre-UTT cohort, the UTT cohort had higher proportions of PLHIV with a CD4 count >500 cells/μL (47.3% vs. 13.2%, p < 0.001) and WHO stage 1 (31.7% vs. 4.5%, p < 0.001) at ART initiation. Adoption of the UTT policy in Uganda was successful in enrolling previously unreached individuals, such as men and younger and older adults, as well as those with less advanced HIV disease. Future research will investigate the effect of UTT on long-term outcomes such as retention in care, HIV viral suppression, morbidity, and mortality.
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Affiliation(s)
| | - Christian H. Hansen
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Philippe Mayaud
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Janet Seeley
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Robert Newton
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | | | - Andrew Abaasa
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | | | | | - Pontiano Kaleebu
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Eugene Ruzagira
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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Mwebaza S, Senyonga B, Atuhairwe C, Taremwa IM. Prevalence and associated factors of intestinal parasitic infections among HIV clients attending Masaka Regional Referral Hospital, Uganda. Pan Afr Med J 2022; 43:122. [PMID: 36762162 PMCID: PMC9883790 DOI: 10.11604/pamj.2022.43.122.15957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 08/24/2019] [Indexed: 11/06/2022] Open
Abstract
Introduction infection with Human Immune deficiency Virus (HIV) increases the risk of opportunistic infections, which aggravates life-long complications. We report the prevalence and the associated factors of intestinal parasites among HIV infected clients attending anti-retroviral therapy (ART) clinic at Masaka Regional Referral Hospital, in Uganda. Methods this was a cross-sectional study that purposefully enrolled 410 HIV infected clients. Stool samples were macroscopically assessed, and analyzed using wet preparations, Formol ether concentration and Modified Ziehl Neelsen (ZN) techniques to identify cysts and ova of intestinal parasites. Further, a questionnaire was used to obtain data on socio-demographic, hygiene and immunologic markers. Logistic regression analysis was used to determine the associated factors of intestinal parasitic infection. Results of the 410 adult HIV sero-positive clients enrolled, 58.0% (238/410) were females. Participants mean age was 26.8 years, (range of 18-59 years). The prevalence of intestinal parasites was 49/410 (11.95%; 95% confidence interval: 10.3 - 14.7). Intestinal parasites isolated were Giardia lamblia (N=10, 20.4%), strongloides stercolaris (N=4, 8.2%), and modified ZN showed Cryptosporidium species (N=35, 71.4%). Hand washing, history of not deworming in the previous 1 year, deteriorating HIV clinical stage and unprotected open water sources were the associated factors. Conclusion this study reports a high prevalence of opportunistic intestinal parasites. As these are neglected tropical infections, early detection and exploration of the associated factors is key to their proper management.
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Affiliation(s)
- Sarah Mwebaza
- Institute of Allied Health Sciences, Clarke International University (Formerly, International Health Sciences University), Kampala, Uganda
| | - Benedict Senyonga
- Institute of Allied Health Sciences, Clarke International University (Formerly, International Health Sciences University), Kampala, Uganda
| | - Christine Atuhairwe
- Institute of Allied Health Sciences, Clarke International University (Formerly, International Health Sciences University), Kampala, Uganda
| | - Ivan Mugisha Taremwa
- Institute of Allied Health Sciences, Clarke International University (Formerly, International Health Sciences University), Kampala, Uganda,Corresponding author: Ivan Mugisha Taremwa, Institute of Allied Health Sciences, Clarke International University (Formerly, International Health Sciences University), Kampala, Uganda.
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Factors Influencing Rapid Antiretroviral Therapy Initiation at Four eThekwini Clinics, KwaZulu-Natal, South Africa. AIDS Behav 2022; 26:1821-1828. [PMID: 34779941 PMCID: PMC9046140 DOI: 10.1007/s10461-021-03530-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2021] [Indexed: 12/01/2022]
Abstract
Timely uptake of Antiretroviral therapy considerably improves the health of people living with the Human Immunodeficiency virus. We conducted a cross-sectional study of newly HIV diagnosed individuals in four clinics in eThekwini municipality, KwaZulu-Natal. Data was collected between June 2020 and December 2020. Participants completed an interviewer-administered questionnaire after HIV testing, on the day of HIV diagnosis. We evaluated factors influencing uptake of same-day ART initiation in eThekwini clinics, KwaZulu Natal, South Africa. Demographic information, health status, sexual behaviour, knowledge of universal test and treat (UTT), ART initiation uptake, and disclosure data was collected. Among the 403 participants, same-day initiation (SDI) was 69.2% (n = 279). We observed the number of sexual partners (aOR 0.35; 95% CI 0.15–0.81), HIV status of the partner (aOR 5.03; 95% CI 2.74–9.26) and knowledge of UTT (aOR 1.97; 95% CI 1.34–2.90) were identified as major factors influencing uptake of same-day ART initiation. More strategies are needed to achieve the SDI uptake within the framework of UTT.
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5
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Sussenbach AE, van Gijzel SW, Lalla-Edward ST, Venter WD, Shaddock E, Feldman C, Klipstein-Grobusch K, Vos AG. The influence of smoking and HIV infection on pulmonary function. South Afr J HIV Med 2022; 23:1329. [PMID: 35284096 PMCID: PMC8905446 DOI: 10.4102/sajhivmed.v23i1.1329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 11/29/2021] [Indexed: 12/02/2022] Open
Abstract
Background Prevalence of HIV, smoking, and pulmonary infections in South Africa are high. Objectives We investigated the role of smoking and HIV status on lung function. Methods This is a secondary analysis of a cross-sectional study conducted in South Africa. Data included demographics, pulmonary risk factors and a spirometry test to obtain the forced expiratory volume in one second (FEV1) and the ratio of FEV1/forced vital capacity (FVC). In the initial multivariable regression analysis, the effect of smoking on pulmonary function in HIV-positive adults was assessed. The analysis was repeated, assessing the influence of HIV status on lung function in both HIV-negative and HIV-positive smokers. The models were adjusted for age, sex, body mass index (BMI), time since HIV diagnosis, antiretroviral treatment (ART) use, occupational hazards, history of tuberculosis or pneumonia, indoor smoking and the presence of an indoor fireplace during childhood. Results This study included 524 people living with HIV (PLWH, 66.7% female, mean age 40.9 years [s.d.; 9.4]) and 79 HIV-negative smokers (77.2% male, mean age 34.4 years [s.d.: 12.1]). Of the PLWH, 118 (22.5%) were past or current smokers and 406 (77.5%) were non-smokers. Smoking was not associated with changes in the FEV1 or FEV1/FVC ratio in multivariable regression analysis. In the second analysis, HIV status was also not associated with reduced pulmonary function following adjustment for confounders. Conclusion Neither smoking nor being HIV-positive was associated with decreased pulmonary function in this relatively young population. These findings should be confirmed in a longitudinal study, including an older population.
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Affiliation(s)
- Annelotte E. Sussenbach
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Sjors W.L. van Gijzel
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Samanta T. Lalla-Edward
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Willem D.F. Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Erica Shaddock
- Division of Pulmonology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
- Division of Pulmonology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Charles Feldman
- Division of Pulmonology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
- Division of Pulmonology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alinda G. Vos
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Likindikoki SL, Meyrowitsch DW, Mizinduko MM, Ishungisa AM, Tersbøl BP, Leyna GH, Moen K, Makyao N, Lange T, Leshabari MT, Mmbaga EJ. Socio-cognitive factors influencing access to HIV prevention services among people who inject drugs in Dar es Salaam, Tanzania: An integrated bio-behavioural survey. PLoS One 2022; 17:e0261500. [PMID: 35089928 PMCID: PMC8797198 DOI: 10.1371/journal.pone.0261500] [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: 08/26/2020] [Accepted: 12/03/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction People who inject drugs (PWID) in Sub-Saharan Africa have limited access to comprehensive HIV services. While it is important to inform programming, knowledge about factors influencing access to comprehensive HIV services is scarce. We assessed the proportions of PWID with access to HIV prevention services and associated socio-cognitive factors in Tanzania. Methods A cross-sectional survey was conducted among PWID between October and December 2017 in Dar es Salaam, Tanzania. Data on access to HIV prevention services, demographics and selected socio-cognitive factors were collected through structured face-to-face interviews. Weighted descriptive and forward selection multivariable logistics regression analyses were done to assess independent associations between HIV prevention services and predictors of interest. The results were two tailed and a p-value of less than 0.05 was considered statistically significant. Results The study included 611 PWID (males: 94.4%) with a median age of 34 years (Interquartile Range (IQR), 29–38). A large majority of participants reported to have access to condoms (87.8%), sterile needles/syringes (72.8%) and ever tested for HIV (66.0%). About half (52.0%) reported to have used condoms in the past one month and about a third (28.5%) accessed a peer educator. The odds of testing for HIV decreased among participants who perceived their HIV risk to be high (aOR = 0.29; 95%CI: 0.17–0.49) and those experienced sexual violence (aOR = 0.60; 95%CI 0.37–0.98). However, the odds of testing for HIV increased among participants with secondary level of education (aOR = 2.16; 95%CI: 1.06–5.55), and those who reported having correct comprehensive HIV knowledge (CCHK) (aOR = 1.63; 95%CI 1.12–2.41). The odds of access to condoms increased among females (aOR = 2.23; 95%CI: 1.04–5.02) but decreased among participants with secondary level of education (aOR = 0.41; 95%CI: 0.19–0.84), an income of >TZS 200,000 (aOR = 0.39; 95%CI: 0.23–0.66) and those who perceived their HIV risk to be high (aOR = 0.13; 95%CI: 0.03–0.36). The odds of access to peer educators was higher among participants with primary (aOR = 1.61; 95%CI: 1.01–2.26), and secondary (aOR = 2.71; 95%CI: 1.39–5.33) levels of education. The odds of access to sterile needle and syringe decreased among participants who perceived their HIV risk to be high (aOR = 0.11;95%CI 0.05–0.22), and low-medium (aOR = 0.25;95%CI 0.11–0.52) but increased among those with primary level of education (aOR = 1.72;95%CI 1.06–2.78). Conclusion Access to condom, HIV testing, sterile needles and syringes were relatively high among PWID. However, condom use and access to peer educators was relatively low. HIV knowledge and risk perception, gender, education, and sexual violence influenced access to HIV prevention services. There is an urgent need to address the identified socio-cognitive factors and scale up all aspects of HIV prevention services to fast-track attainment of the 2025 UNAIDS goals and ending the HIV epidemic.
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Affiliation(s)
- Samuel L. Likindikoki
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- * E-mail:
| | - Dan W. Meyrowitsch
- Department of Public Health, Global Health Section, University of Copenhagen, Copenhagen, Denmark
| | - Mucho M. Mizinduko
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Alexander M. Ishungisa
- Department of Behavioural Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Britt P. Tersbøl
- Department of Public Health, Global Health Section, University of Copenhagen, Copenhagen, Denmark
| | - Germana H. Leyna
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Tanzania Food and Nutrition Centre, Dar es Salaam, Tanzania
| | - Kåre Moen
- Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Neema Makyao
- National AIDS Control Programme, Ministry of Health, Community Development, Gender, Children and Elderly, Dodoma, Tanzania
| | - Theis Lange
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Melkizedeck T. Leshabari
- Department of Behavioural Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Elia J. Mmbaga
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway
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Spagnolello O, Reed MJ. Targeted HIV screening in the emergency department. Intern Emerg Med 2021; 16:1273-1287. [PMID: 33550535 DOI: 10.1007/s11739-021-02648-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/19/2021] [Indexed: 12/18/2022]
Abstract
Despite considerable improvement in human immunodeficiency virus (HIV) knowledge and treatment in the last 3 decades, the overall number of people living with HIV (PLHIV) is still rising with up to one quarter being unaware of their HIV status. Early HIV diagnosis and treatment prolongs life, reduces transmission, improves quality of life, and is a cost-effective public health intervention. The emergency department (ED) sees a large number of patients from marginalized and traditionally underserved populations in whom HIV is known to be more prevalent and who may not attend traditional services because of either cultural reasons or because of a chaotic lifestyle. This article discusses the two main approaches to screening; 'Opt-out' screening offers testing routinely in all clinical settings, and 'Targeted' screening offers testing to individuals presenting with indicator conditions. There are many studies of 'Opt-out' ED HIV screening in urban areas of high-HIV prevalence. However, little is known about the effectiveness of 'targeted' HIV screening, especially in areas of low prevalence. This review discusses the background to HIV screening in the ED and reviews the evidence around 'targeted' HIV screening in adult EDs in different HIV prevalence settings, concluding that targeted HIV screening at the ED can be impactful, cost-effective, and well accepted in the ED population, but its long-term implementation requires extra funding and increased staffing resource limiting its application in low resource setting. Despite most evidence being from areas of high-HIV prevalence, targeted screening might also be appropriate in low-HIV prevalence areas.
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Affiliation(s)
- Ornella Spagnolello
- Department of Public Health and Infectious Diseases, University of Rome Sapienza, Rome, Italy
| | - Matthew J Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK.
- Usher Institute, University of Edinburgh, NINE, 9 Little France Road, Edinburgh BioQuarter, Edinburgh, EH16 4UX, UK.
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Lofgren SM, Tsui S, Atuyambe L, Ankunda L, Komuhendo R, Wamala N, Sadiq A, Kirumira P, Srishyla D, Flynn A, Pastick KA, Meya DB, Nakasujja N, Porta C. Barriers to HIV care in Uganda and implications for universal test-and-treat: a qualitative study. AIDS Care 2021; 34:597-605. [PMID: 34314261 PMCID: PMC8792098 DOI: 10.1080/09540121.2021.1946000] [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] [Indexed: 10/20/2022]
Abstract
Achieving universal HIV test-and-treat will require targeted interventions for those with worse outcomes, including advanced HIV. We conducted qualitative, semi-structured interviews with healthcare workers (HCWs) and people living with HIV (PLWH) at 5 HIV clinics in Kampala, Uganda, to understand barriers to care. PLWH enrolled started/restarted on HIV treatment ≤3 months prior. PLWH were grouped as 1) "ART-experienced" or those restarted therapy after ≥12 months off, 2) ART naïve CD4 count <100 cells/uL "late presenters" or 3) ART naïve CD4 count >350 cells/uL "early presenters". In-depth interviews were conducted in Luganda, translated, and transcribed verbatim. Between May and August 2017, 58 PLWH and 20 HCWs were interviewed. High stigma and low social support emerged as themes among all as barriers to care. Alcohol abuse was a barrier for men. Fear of domestic violence and abandonment were barriers for women, limiting disclosure of their HIV status to their male partners. Clinic factors such as rapport with staff, distance, efficiency, and privacy impacted care. Future interventions to decrease delayed ART initiation should target stigma and social support. Assisted disclosure, contact tracing, and alcohol abuse treatment should be implemented. Strengthening client support, reducing wait times, and increasing privacy assurances would improve care-seeking behaviors.
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Affiliation(s)
- Sarah M Lofgren
- University of Minnesota, Division of Infectious Diseases and International Medicine, Department of Medicine, Minneapolis, MN, USA.,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Sharon Tsui
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Lynn Atuyambe
- Makerere University, School of Public Health, Kampala, Uganda
| | - Leander Ankunda
- Makerere University, School of Public Health, Kampala, Uganda
| | | | - Nathan Wamala
- Makerere University, School of Public Health, Kampala, Uganda
| | - Alisat Sadiq
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Paul Kirumira
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Diksha Srishyla
- University of Minnesota, School of Public Health, Minneapolis, MN, USA
| | - Andrew Flynn
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Katelyn A Pastick
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,University of Minnesota, School of Medicine, Minneapolis, MN, USA
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Noeline Nakasujja
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,Makerere University, Department of Psychiatry, Kampala, Uganda
| | - Carolyn Porta
- University of Minnesota, School of Public Health, Minneapolis, MN, USA
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9
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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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10
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Damtie Y, Tadese F. Antiretroviral therapy adherence among patients enrolled after the initiation of the Universal Test and Treat strategy in Dessie town: a cross-sectional study. Int J STD AIDS 2021; 31:886-893. [PMID: 32702282 DOI: 10.1177/0956462420927205] [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] [Indexed: 11/16/2022]
Abstract
Poor adherence was the major challenge in providing treatment, care, and support for people living with HIV (PLHIV). Evidence of adherence to antiretroviral therapy (ART) after initiation of the Universal Test and Treat (UTT) strategy was limited in Ethiopia. So, this study aimed to determine the proportion of ART adherence after the initiation of UTT strategy and associated factors among adult PLHIV in Dessie town using two adherence measurements. A cross-sectional study was conducted on 293 PLHIV selected using a systematic sampling technique. The data were collected by face-to face-interview using a pretested questionnaire; chart review was also used to collect the data. The proportion of ART adherence measured by using the Morisky scale and seven-day recall was 49.3% (95% CI: [43.5%, 54.8%]) and 95.9% (95% CI: [93.2%, 98.2%]), respectively. Being urban in residence (AOR = 3.72, 95% CI: [1.80, 7.68]), the absence of depression (adjusted odds ratio [AOR] = 3.72, 95% CI: [1.22, 11.35]), taking one tablet per day (AOR = 3.26, 95% CI: [1.64, 6.49]), and the absence of concomitant illness (AOR = 0.23, 95% CI: [0.09, 0.59]) were factors associated with ART adherence. The proportion of ART adherence measured by the Morisky scale was very low; however, adherence measured by seven-day recall was higher and consistent with World Health Organization recommendations. Residence, depression, and the number of tablets taken per day had a positive association with good ART adherence whereas having concomitant illness had a negative association with good ART adherence. Efforts should be made to improve adherence and interventions should be given to overcome factors linked with poor adherence.
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Affiliation(s)
- Yitayish Damtie
- Department of Reproductive and Family Health, School of Public Health, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
| | - Fentaw Tadese
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
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11
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Robertson MM, Braunstein SL, Hoover DR, Li S, Nash D. Estimates of the Time From Seroconversion to Antiretroviral Therapy Initiation Among People Newly Diagnosed With Human Immunodeficiency Virus From 2006 to 2015, New York City. Clin Infect Dis 2021; 71:e308-e315. [PMID: 31813966 DOI: 10.1093/cid/ciz1178] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 12/06/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND We estimated the time from human immunodeficiency virus (HIV) seroconversion to antiretroviral therapy (ART) initiation during an era of expanding HIV testing and treatment efforts. METHODS Applying CD4 depletion parameters from seroconverter cohort data to our population-based sample, we related the square root of the first pretreatment CD4 count to time of seroconversion through a linear mixed model and estimated the time from seroconversion. RESULTS Among 28 162 people diagnosed with HIV during 2006-2015, 89% initiated ART by June 2017. The median CD4 count at diagnosis increased from 326 (interquartile range [IQR], 132-504) cells/µL to 390 (IQR, 216-571) cells/µL from 2006 to 2015. The median time from estimated seroconversion to ART initiation decreased by 42% from 6.4 (IQR, 3.3-11.4) years in 2006 to 3.7 (IQR, 0.5-8.3) years in 2015. The time from estimated seroconversion to diagnosis decreased by 28%, from a median of 4.6 (IQR, 0.5-10.5) years to 3.3 (IQR, 0-8.1) years from 2006 to 2015, and the time from diagnosis to ART initiation reduced by 60%, from a median of 0.5 (IQR, 0.2-2.1) years to 0.2 (IQR, 0.1-0.3) years from 2006 to 2015. CONCLUSIONS The estimated time from seroconversion to ART initiation was reduced in tandem with expanded HIV testing and treatment efforts. While the time from diagnosis to ART initiation decreased to 0.2 years, the time from seroconversion to diagnosis was 3.3 years among people diagnosed in 2015, highlighting the need for more effective strategies for earlier HIV diagnosis.
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Affiliation(s)
- McKaylee M Robertson
- Institute for Implementation Science in Population Health, Graduate School of Public Health and Health Policy, City University of New York, New York City, New York, USA
| | - Sarah L Braunstein
- Bureau of HIV/AIDS Prevention and Control, New York City Department of Health and Mental Hygiene, New York City, New York, USA
| | - Donald R Hoover
- Rutgers University, Department of Statistics and Institute for Health, Health Care Policy and Aging Research, Piscataway, New Jersey, USA
| | - Sheng Li
- Graduate School of Public Health and Health Policy, City University of New York, New York City, New York, USA
| | - Denis Nash
- Institute for Implementation Science in Population Health, Graduate School of Public Health and Health Policy, City University of New York, New York City, New York, USA
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12
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Mubekapi-Musadaidzwa C, Wademan D, Peton N, Hendricks P, Carolus G, Mbaezue R, Kelley KF, Kruger J, Jennings K, Grobbelaar N, Louis F, Beyers N, Ayles H, Fidler S, Hayes R, Bock P, Hoddinott G. Motivating people living with HIV to initiate antiretroviral treatment outside national guidelines in three clinics in the HPTN 071 (PopART) trial, South Africa. AFRICAN JOURNAL OF AIDS RESEARCH : AJAR 2021; 20:32-41. [PMID: 33635735 PMCID: PMC10577307 DOI: 10.2989/16085906.2020.1854795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background: The HPTN 071 (PopART) trial implemented universal test and treat (UTT) in three clinics in the Western Cape, South Africa at a time when antiretroviral treatment (ART) was only offered by CD4 threshold and World Health Organization clinical staging. This required a concomitant shift in the way health workers communicated ART initiation messages. We provide insight into front-line ART initiation communication pre-national policy shift.Method: The design of this study was exploratory with a case descriptive analysis of ART initiation in three clinics. To characterise their demographic profiles, we reviewed 134 randomly selected patient clinical folders of people who initiated ART at CD4 counts greater than the recommended standard. Further, we conducted 12 key informant interviews with health workers at these facilities and thematically analysed health workers' responses.Results: The median age of patients initiating ART regardless of CD4 count (above the threshold level) was 33 years and most were women (73.9%), married (76.1%), and unemployed (48.5%). The median CD4 count of patients initiating outside guidelines was 566.5 cells/µl. Contrary to expectations, key informants indicated no radical shift in messaging to explain ART initiation regardless of CD4 count. Rather, they encouraged people living with HIV (PLHIV) to initiate ART while they still "feel well". The reduced risk of onward HIV transmission did not factor significantly in how health workers motivated clients.Conclusion: Motivating PLHIV to initiate ART regardless of CD4 count in high burden settings is possible. However, there are still opportunities to improve messaging about immediate ART initiation or at high CD4 counts for the prevention of onward transmission.
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Affiliation(s)
| | - Dillon Wademan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, South Africa
| | - Neshaan Peton
- Department of Health, Western Cape, Cape Town, South Africa
| | | | - Gabriela Carolus
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, South Africa
| | - Rheiner Mbaezue
- Department of Health, City of Cape Town, Cape Town, South Africa
| | - Karen F Kelley
- United States Agency for International Development, Pretoria, South Africa
| | - James Kruger
- Department of Health, Western Cape, Cape Town, South Africa
| | - Karen Jennings
- Department of Health, City of Cape Town, Cape Town, South Africa
| | | | | | - Nulda Beyers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, South Africa
| | - Helen Ayles
- Zambia AIDS Related TB Project, University of Zambia, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Sarah Fidler
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, South Africa
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, South Africa
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13
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Spagnolello O, Gallagher B, Lone N, Ceccarelli G, D'Ettorre G, Reed MJ. The Role of Targeted HIV Screening in the Emergency Department: A Scoping Review. Curr HIV Res 2021; 19:106-120. [PMID: 33231157 DOI: 10.2174/1570162x18666201123113905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 10/22/2020] [Accepted: 10/26/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Human immunodeficiency virus (HIV) infection continues to expand worldwide, and a significant proportion of infection is still undiagnosed. Recent studies have addressed the impact and feasibility of 'opt-out' HIV screening in Emergency Departments (EDs) in urban settings at high HIV prevalence, whereas little is known about the yield of implementing 'targeted' HIV testing, especially in low-prevalence areas. OBJECTIVE The present study undertakes a scoping review of research carried out on the implementation of targeted HIV screening of adult in EDs to determine the impact, feasibility and acceptability of HIV testing in different HIV prevalence settings. DESIGN Online databases (EMBASE, MEDLINE) were used to identify papers published between 2000 to 2020. A three-concept search was employed with HIV (HIV, Human immunodeficiency virus infection, HIV infections), targeted testing (Target, screening or testing) and emergency medicine (Emergency Service, emergency ward, A&E, accident and emergency or Emergency Department) (28th February 2020). Only full-text articles written in English, French, Spanish or Italian and using impact and/or feasibility and/or acceptability of the program as primary or secondary outcomes were analysed. RESULTS The search provided 416 articles. Of these, 12 met inclusion criteria and were included in the final review. Most of the included studies were carried out in the United States (n=8; 67%) and in areas of high HIV prevalence (n=11; 92%). Three (20%) were randomized control studies. While the rate of newly diagnosed HIV cases varied widely (0.03-2.2%), likely due to methodological heterogeneity between studies, the linkage of new HIV diagnosis was often high (80-100%) and median CD4+ cell count was always greater than 200 cells per microliter. Targeted HIV screening was found to be cost-effective (out of 2 studies) and well accepted by participants (out 2 studies). CONCLUSIONS Targeted HIV screening at the ED can be impactful, feasible and well accepted, but often requires extra funding and staff. Most previous work has focused on areas of high disease prevalence.
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Affiliation(s)
- Ornella Spagnolello
- Department of Public Health and Infectious Diseases, University of Rome Sapienza, Rome, Italy
| | - Bernadette Gallagher
- Emergency Medicine Research Group Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, United Kingdom
| | - Nazir Lone
- Department of Critical Care, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, EH16 4SA, United Kingdom
| | - Giancarlo Ceccarelli
- Department of Public Health and Infectious Diseases, University of Rome Sapienza, Rome, Italy
| | - Gabriella D'Ettorre
- Department of Public Health and Infectious Diseases, University of Rome Sapienza, Rome, Italy
| | - Matthew J Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, United Kingdom
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14
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Robertson MM, Braunstein SL, Hoover DR, Li S, Nash D. Assessing linear CD4 decline quantifying diagnosis delay after HIV seroconversion: assessing the linearity assumption of CD4 decline. Ann Epidemiol 2020; 52:1-6. [PMID: 32791198 DOI: 10.1016/j.annepidem.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/30/2020] [Accepted: 08/05/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE To estimate time from seroconversion to diagnosis, researchers have modeled time based on CD4 decline, assuming the square root of the CD4 count decreases linearly over time before antiretroviral treatment (ART) initiation. If true, utilizing CD4 counts reported anytime in the pre-ART period would result in estimates of diagnosis delay that are not appreciably different. METHODS We applied CD4 depletion model parameters from seroconverter cohorts to New York City residents diagnosed from 2006 to 2015, having two or more pre-ART CD4 counts. RESULTS Median diagnosis delays based on first or second pre-ART CD4 counts were similar (n = 12,849; 2.8 years, interquartile range [IQR]: 0-7.7, and 2.8 years, IQR: 0-7.6, respectively; P = .09, Wilcoxon signed-rank test). Among people whose second pre-ART CD4 count was measured more than 6 months after diagnosis (n = 2761), the average diagnosis delay based on first pre-ART CD4 count was shorter (1.5 years, IQR: 0-5.4) than the second pre-ART CD4 count (1.7 years, IQR: 0-6.0) but not significantly (P = .12). CONCLUSIONS Results are consistent with the linearity assumption of the CD4 depletion model. To estimate population-level diagnosis delay, researchers may use pre-ART CD4 counts reported more than 6 months post-diagnosis.
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Affiliation(s)
- McKaylee M Robertson
- Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), New York City; Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York City.
| | - Sarah L Braunstein
- Bureau of HIV/AIDS Prevention and Control, New York City Department of Health and Mental Hygiene, New York City
| | - Donald R Hoover
- Department of Statistics, Institute for Health, Health Care Policy and Aging Research, Rutgers University, Piscataway, NJ
| | - Sheng Li
- Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York City
| | - Denis Nash
- Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), New York City; Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York City
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15
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Robertson MM, Braunstein SL, Hoover DR, Li S, Nash D. Timeliness of Human Immunodeficiency Virus Diagnosis and Antiretroviral Treatment Initiation in the Era of Universal Testing and Treatment. J Infect Dis 2020; 220:648-656. [PMID: 30997508 DOI: 10.1093/infdis/jiz148] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 03/29/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We describe the timing of human immunodeficiency virus (HIV) diagnosis and antiretroviral treatment (ART) initiation after implementation of universal testing and treatment policies in New York City (NYC). METHODS Using NYC population-based HIV registry data for persons with HIV diagnosed from 2012 through 2015 and followed up through June 2017, we examined trends in the proportion with diagnosis soon after HIV infection (ie, with CD4 cell count ≥500/μL or with acute HIV infection) and used Kaplan-Meier plots and proportional hazards regression to examine the timing of ART initiation after diagnosis. RESULTS Among 9987 NYC residents with HIV diagnosed from 2012 to 2015, diagnosis was early in 35%, and 87% started ART by June 2017. The annual proportion of persons with early diagnosis did not increase appreciably (35% in 2012 vs 37% in 2015; P = .08). By 6 months after diagnosis, 62%, 67%, 72% and 77% of persons with HIV diagnosed in 2012, 2013, 2014, or 2015, respectively, had started ART, with median (interquartile range) times to ART initiation of 3.34 (1.34-12.75), 2.62 (1.28-10.13), 2.16 (1.15-7.11), and 2.03 (1.11-5.61) months, respectively. CONCLUSIONS Although recommendations for ART initiation on diagnosis are increasingly being implemented, the findings of the current study suggest that immediate treatment initiation is not universal. Continued efforts are needed to expand and better target HIV testing to promote earlier diagnosis.
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Affiliation(s)
- McKaylee M Robertson
- Institute for Implementation Science in Population Health, City University of New York, New York.,Graduate School of Public Health and Health Policy, City University of New York, New York
| | - Sarah L Braunstein
- Bureau of HIV/AIDS Prevention and Control, New York City Department of Health and Mental Hygiene, New York
| | - Donald R Hoover
- Rutgers University, Department of Biostatistics, Piscataway, New Jersey
| | - Sheng Li
- Graduate School of Public Health and Health Policy, City University of New York, New York
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York.,Graduate School of Public Health and Health Policy, City University of New York, New York
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16
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Optimizing PMTCT efforts by repeat HIV testing during antenatal and perinatal care in resource-limited settings: A longitudinal assessment of HIV seroconversion. PLoS One 2020; 15:e0233396. [PMID: 32470004 PMCID: PMC7259594 DOI: 10.1371/journal.pone.0233396] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 05/04/2020] [Indexed: 02/07/2023] Open
Abstract
Background Mother to child transmission (MTCT) of HIV remains a challenge in resource-limited settings. Central to elimination of MTCT is effective Provider Initiated HIV Counseling and Testing (PICT). Research has shown that conducting PICT only at the initial antenatal care (ANC) visit fails to benefit pregnant women who seroconvert later in their pregnancy. This study aimed to determine the most cost effective time to perform repeat HIV testing during ANC and perinatal care (PNC). Methods We studied the repeat HIV testing results of pregnant women ≥ 18 and adolescent girls aged 15–17 in the Sauri, Kenya Millennium Villages Project (MVP) site. Nurses provided HIV screening to 1,403 expectant women and 256 adolescent girls following the 1st, 2nd, 3rd and 4th ANC visits, at birth and 6 and 14 weeks postpartum. Results Five women seroconverted during the study period (incidence proportion 0.41%). One woman seroconverted at the 2nd ANC visit, another one at the 3rd, two at the 4th and one at 6 weeks post-partum. Of all the women who seroconverted, four reported an HIV negative primary partner, while one reported an unknown partner status. None of the participants reported condom use during pregnancy. Two of the seroconverters vertically transmitted HIV to their babies. The results did not suggest a clear pattern of seroconversion during ANC and PNC. Conclusions The low rates of seroconversion suggest that testing pregnant women multiple times during ANC and PNC may not be cost effective, but a follow-up test during birth may be protective of the newborn.
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17
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Jooste S, Mabaso M, Taylor M, North A, Tadokera R, Simbayi L. Trends and determinants of ever having tested for HIV among youth and adults in South Africa from 2005-2017: Results from four repeated cross-sectional nationally representative household-based HIV prevalence, incidence, and behaviour surveys. PLoS One 2020; 15:e0232883. [PMID: 32407342 PMCID: PMC7224525 DOI: 10.1371/journal.pone.0232883] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 04/23/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND HIV testing contributes to the prevention and control of the HIV epidemic in the general population. South Africa has made strides to improve HIV testing towards reaching the first of the UNAIDS 90-90-90 targets by 2020. However, to date no nationally representative analysis has examined temporal trends and factors associated with HIV testing among youth and adults in the country. AIM This study aimed to examine the trends and associations with ever having tested for HIV among youth and adults aged 15 years and older in South Africa using the 2005, 2008, 2012 and 2017 nationally representative population-based household surveys. METHODS The analysis of the data collected used multi-stage stratified cluster randomised cross-sectional design. P-trend chi-squared test was used to identify any significant changes over the four study periods. Bivariate and multivariate logistic regression analysis was conducted to determine factors associated with HIV testing in each of the survey periods. RESULTS Ever having tested for HIV increased substantially from 2005 (30.6%, n = 16 112), 2008 (50.4%, n = 13 084), 2012 (65.5%, n = 26 381), to 2017 (75.2%, n = 23 190). Those aged 50 years and older were significantly less likely to ever have tested for HIV than those aged 25-49 years. Those residing in rural areas were significantly less likely to have tested for HIV as compared to people from urban areas. There was a change in HIV testing among race groups with Whites, Coloureds and Indian/Asians testing more in 2005 and 2008 and Black Africans in 2017. Marriage, education and employment were significantly associated with increased likelihood of ever testing for HIV. Those who provided a blood specimen for laboratory HIV testing in the survey rounds and were found to have tested positive were more likely to have ever tested for HIV previously. CONCLUSION The results show that overall there has been an increase in ever having an HIV test in the South African population over time. The findings also suggest that for South Africa to close the testing gap and reach the first of the UNAIDS 90-90-90 targets by 2020, targeted programmes aimed at increasing access and utilization of HIV testing in young people, males, those not married, the less educated, unemployed and those residing in rural areas of South Africa should be prioritised.
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Affiliation(s)
- Sean Jooste
- Social Aspects of Public Health Research Programme, Human Sciences Research Council, Cape Town, South Africa
| | - Musawenkosi Mabaso
- Social Aspects of Public Health Research Programme, Human Sciences Research Council, Cape Town, South Africa
| | - Myra Taylor
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Alicia North
- Social Aspects of Public Health Research Programme, Human Sciences Research Council, Cape Town, South Africa
| | - Rebecca Tadokera
- Social Aspects of Public Health Research Programme, Human Sciences Research Council, Cape Town, South Africa
- Division of Molecular Biology and Human Genetics, NRF/DST Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Leickness Simbayi
- Deputy CEO for Research, Human Sciences Research Council, Cape Town, South Africa
- Department of Psychiatry & Mental Health, University of Cape Town, Cape Town, South Africa
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18
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Hopkins KL, Hlongwane KE, Otwombe K, Dietrich J, Cheyip M, Khanyile N, Doherty T, Gray GE. Level of adult client satisfaction with clinic flow time and services of an integrated non-communicable disease-HIV testing services clinic in Soweto, South Africa: a cross-sectional study. BMC Health Serv Res 2020; 20:404. [PMID: 32393224 PMCID: PMC7212607 DOI: 10.1186/s12913-020-05256-9] [Citation(s) in RCA: 2] [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] [Received: 10/21/2019] [Accepted: 04/27/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND While HIV Testing Services (HTS) have increased, many South Africans have not been tested. Non-communicable diseases (NCDs) are the top cause of death worldwide. Integrated NCD-HTS could be a strategy to control both epidemics. Healthcare service strategies depends partially on positive user experience. We investigated client satisfaction of services and clinic flow time of an integrated NCD-HTS clinic. METHODS This prospective, cross-sectional study evaluated HTS client satisfaction with an HTS clinic at two phases. Phase 1 (February-June 2018) utilised standard HTS services: counsellor-led height/weight/blood pressure measurements, HIV rapid testing, and symptoms screening for sexually transmitted infections/Tuberculosis. Phase 2 (June 2018-March 2019) further integrated counsellor-led obesity screening (body mass index/abdominal circumference measurements), rapid cholesterol/glucose testing; and nurse-led Chlamydia and human papilloma virus (HPV)/cervical cancer screening. Socio-demographics, proportion of repeat clients, clinic flow time, and client survey data (open/closed-ended questions using five-point Likert scale) are reported. Fisher's exact test, chi-square analysis, and Kruskal Wallis test conducted comparisons. Multiple linear regression determined predictors associated with clinic time. Content thematic analysis was conducted for free response data. RESULTS Two hundred eighty-four and three hundred thirty-three participants were from Phase 1 and 2, respectively (N = 617). Phase 1 participants were significantly older (median age 36.5 (28.0-43.0) years vs. 31.0 (25.0-40.0) years; p = 0.0003), divorced/widowed (6.7%, [n = 19/282] vs. 2.4%, [n = 8/332]; p = 0.0091); had tertiary education (27.9%, [n = 79/283] vs. 20.1%, [n = 67/333]; p = 0.0234); and less female (53.9%, [n = 153/284] vs 67.6%, [n = 225/333]; p = 0.0005), compared to Phase 2. Phase 2 had 10.2% repeat clients (n = 34/333), and 97.9% (n = 320/327) were 'very satisfied' with integrated NCD-HTS, despite standard HTS having significantly shorter median time for counsellor-led HTS (36.5, interquartile range [IQR]: 31.0-45.0 vs. 41.5, IQR: 35.0-51.0; p < 0.0001). Phase 2 associations with longer clinic time were clients living together/married (est = 6.548; p = 0.0467), more tests conducted (est = 3.922; p < 0.0001), higher overall satisfaction score (est = 1.210; p = 0.0201). Those who matriculated experienced less clinic time (est = - 7.250; p = 0.0253). CONCLUSIONS It is possible to integrate counsellor-led NCD rapid testing into standard HTS within historical HTS timeframes, yielding client satisfaction. Rapid cholesterol/glucose testing should be integrated into standard HTS. Research is required on the impact of cervical cancer/HPV screenings to HTS clinic flow to determine if it could be scaled up within the public sector.
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Affiliation(s)
- Kathryn L Hopkins
- Perinatal HIV Research Unit, Faculty of Clinical Medicine, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Khuthadzo E Hlongwane
- Perinatal HIV Research Unit, Faculty of Clinical Medicine, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Kennedy Otwombe
- Perinatal HIV Research Unit, Faculty of Clinical Medicine, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Janan Dietrich
- Perinatal HIV Research Unit, Faculty of Clinical Medicine, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Mireille Cheyip
- Centers for Disease Control and Prevention, Pretoria, South Africa
| | | | - Tanya Doherty
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Glenda E Gray
- Perinatal HIV Research Unit, Faculty of Clinical Medicine, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
- Office of the President, South African Medical Research Council, Cape Town, South Africa
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19
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Krishnaratne S, Bond V, Stangl A, Pliakas T, Mathema H, Lilleston P, Hoddinott G, Bock P, Ayles H, Fidler S, Hargreaves JR. Stigma and Judgment Toward People Living with HIV and Key Population Groups Among Three Cadres of Health Workers in South Africa and Zambia: Analysis of Data from the HPTN 071 (PopART) Trial. AIDS Patient Care STDS 2020; 34:38-50. [PMID: 31944852 DOI: 10.1089/apc.2019.0131] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Stigma and judgment by health workers toward people living with HIV (PLHIV) and key populations can undermine the uptake of HIV services. In 2014, we recruited health workers delivering HIV services from 21 urban communities in South Africa and Zambia participating in the first year of the HPTN 071 (PopART) cluster-randomized trial. We analyzed self-reported levels of stigma and judgment toward (1) PLHIV, (2) women who sell sex, (3) men who have sex with men (MSM), and (4) young women who become pregnant before marriage. Using logistic regression, we compared responses between three health worker cadres and explored risk factors for stigmatizing attitudes. Highest levels of stigma and judgment were in relation to women who sell sex and MSM, especially in Zambia. Heath workers did not generally think that clients should be denied services, although this was reported slightly more commonly by community health workers. Higher education levels were associated with lower judgmental beliefs, whereas higher perceptions of coworker stigmatizing behaviors toward PLHIV and each key population were associated with holding judgmental beliefs. Training experience was not associated with judgmental attitudes for any of the key populations. Our findings confirm a high prevalence of judgmental attitudes toward key population groups but lower levels in relation to PLHIV, among all cadres of health workers in both countries. Planning and implementing targeted stigma reduction interventions within health settings are critical to meet the needs of vulnerable populations that face more stigmatizing attitudes from health workers.
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Affiliation(s)
- Shari Krishnaratne
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Virginia Bond
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Zambart, The School of Medicine, University of Zambia, Lusaka, Zambia
| | - Anne Stangl
- International Centre for Research on Women, Washington, District of Columbia
| | - Triantafyllos Pliakas
- Department of Public Health Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Hlengani Mathema
- Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Pamela Lilleston
- International Centre for Research on Women, Washington, District of Columbia
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Helen Ayles
- Zambart, The School of Medicine, University of Zambia, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sarah Fidler
- Department of Medicine, Imperial College London, London, United Kingdom
| | - James R. Hargreaves
- Department of Public Health Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
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20
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Mukumbang FC, Knight L, Masquillier C, Delport A, Sematlane N, Dube LT, Lembani M, Wouters E. Household-focused interventions to enhance the treatment and management of HIV in low- and middle-income countries: a scoping review. BMC Public Health 2019; 19:1682. [PMID: 31842846 PMCID: PMC6916449 DOI: 10.1186/s12889-019-8020-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 11/29/2019] [Indexed: 12/31/2022] Open
Abstract
Background HIV remains a major public health challenge in many low- and middle-income countries (LMICs). The initiation of a greater number of people living with HIV (PLHIV) onto antiretroviral therapy (ART) following the World Health Organization’s ‘universal test and treat’ recommendation has the potential to overstretch already challenged health systems in LMICs. While various mainstream and community-based care models have been implemented to improve the treatment outcomes of PLHIV, little effort has been made to harness the potential of the families or households of PLHIV to enhance their treatment outcomes. To this end, we sought to explore the characteristics and effectiveness of household-focused interventions in LMICs on the management of HIV as measured by levels of adherence, viral suppression and different dimensions of HIV competence. Additionally, we sought to explore the mechanisms of change to explain how the interventions achieved the expected outcomes. Methods We systematically reviewed the literature published from 2003 to 2018, obtained from six electronic databases. We thematically analysed the 11 selected articles guided by the population, intervention, comparison and outcome (PICO) framework. Following the generative causality logic, whereby mechanisms are postulated to mediate an intervention and the outcomes, we applied a mechanism-based inferential reasoning, retroduction, to identify the mechanisms underlying the interventions to understand how these interventions are expected to work. Results The identified HIV-related interventions with a household focus were multi-component and multi-dimensional, incorporating aspects of information sharing on HIV; improving communication; stimulating social support and promoting mental health. Most of the interventions sought to empower and stimulate self-efficacy while strengthening the perceived social support of the PLHIV. Studies reported a significant positive impact on improving various aspects of HIV competent household – positive effects on HIV knowledge, communication between household members, and improved mental health outcomes of youths living in HIV-affected households. Conclusion By aiming to strengthen the perceived social support and self-efficacy of PLHIV, household-focused HIV interventions can address various aspects of household HIV competency. Nevertheless, the role of the household as an enabling resource to improve the outcomes of PLHIV remains largely untapped by public HIV programmes; more research on improving household HIV competency is therefore required. Trial registration PROSPERO registration: CRD42018094383.
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Affiliation(s)
| | - Lucia Knight
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | | | - Anton Delport
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Neo Sematlane
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | | | - Martina Lembani
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Edwin Wouters
- Department of Social Sciences, Antwerp University, Antwerp, Belgium
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21
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Gómez-Ayerbe C, Martínez-Sanz J, Muriel A, Pérez Elías P, Moreno A, Barea R, Polo L, Cano A, Uranga A, Santos C, Casado JL, Quereda C, Robledillo G, Díaz-de Santiago A, Vivancos MJ, Dronda F, Navas E, Moreno S, Pérez Elías MJ. Impact of a structured HIV testing program in a hospital emergency department and a primary care center. PLoS One 2019; 14:e0220375. [PMID: 31369594 PMCID: PMC6675098 DOI: 10.1371/journal.pone.0220375] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 07/14/2019] [Indexed: 12/28/2022] Open
Abstract
Introduction HIV testing guidelines are poorly implemented in most clinical settings. The best screening strategy and healthcare scenario are still unknown. The aim of our study is to evaluate the impact of a structured HIV testing intervention (DRIVE), compared to HIV testing as routinely performed in clinical practice, in two different clinical settings: a primary care center and an emergency department. Methods Prospective evaluation of an HIV testing strategy in two clinical settings from the same healthcare area. The DRIVE program included trained nurse practitioners to perform the screening, a questionnaire to assess the risk of exposure and HIV indicator conditions (RE&IC), and rapid HIV tests. The main variables between the DRIVE program and clinical practice were the absolute number of newly diagnosed HIV infections and testing coverage. Results The DRIVE program included 5,329 participants, of which 51.2% reported at least one positive answer in the questionnaire. The estimated HIV testing coverage was significantly higher in the DRIVE program than in the routine clinical practice (7.17% vs. 0.96%, p < 0.001), and was better in the primary care center than in the emergency department with the two strategies. Twenty-two HIV-positive people were identified, with a rate of 8.6‰ in the emergency department vs. 2.2‰ in the primary care center (p = 0.001). A higher rate of new HIV diagnoses was found in the DRIVE program compared to routine clinical practice (29.6 vs. 3.1 per 100,000 patients attended; p < 0.001). Conclusions An easy-to-implement, structured intervention increased the absolute number of new HIV diagnoses and HIV tests, compared to routine clinical practice.
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Affiliation(s)
- Cristina Gómez-Ayerbe
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Javier Martínez-Sanz
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Alfonso Muriel
- Biostatistics Unit, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain, CIBERESP, Departamento de Enfermería, Universidad de Alcalá, Madrid, Spain
| | | | - Ana Moreno
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | | | - Lidia Polo
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | | | - José Luis Casado
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Carmen Quereda
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Gema Robledillo
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | | | - María Jesús Vivancos
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Fernando Dronda
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Enrique Navas
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Santiago Moreno
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
- * E-mail:
| | - María Jesús Pérez Elías
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
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22
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Perriat D, Balzer L, Hayes R, Lockman S, Walsh F, Ayles H, Floyd S, Havlir D, Kamya M, Lebelonyane R, Mills LA, Okello V, Petersen M, Pillay D, Sabapathy K, Wirth K, Orne-Gliemann J, Dabis F. Comparative assessment of five trials of universal HIV testing and treatment in sub-Saharan Africa. J Int AIDS Soc 2019; 21. [PMID: 29314658 PMCID: PMC5810333 DOI: 10.1002/jia2.25048] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 11/27/2017] [Indexed: 02/03/2023] Open
Abstract
Design Universal voluntary HIV counselling and testing followed by prompt initiation of antiretroviral therapy (ART) for all those diagnosed HIV‐infected (universal test and treat, UTT) is now a global health standard. However, its population‐level impact, feasibility and cost remain unknown. Five community‐based trials have been implemented in sub‐Saharan Africa to measure the effects of various UTT strategies at population level: BCPP/YaTsie in Botswana, MaxART in Swaziland, HPTN 071 (PopART) in South Africa and Zambia, SEARCH in Uganda and Kenya and ANRS 12249 TasP in South Africa. This report describes and contrasts the contexts, research methodologies, intervention packages, themes explored, evolution of study designs and interventions related to each of these five UTT trials. Methods We conducted a comparative assessment of the five trials using data extracted from study protocols and collected during baseline studies, with additional input from study investigators. We organized differences and commonalities across the trials in five categories: trial contexts, research designs, intervention packages, trial themes and adaptations. Results All performed in the context of generalized HIV epidemics, the trials highly differ in their social, demographic, economic, political and health systems settings. They share the common aim of assessing the impact of UTT on the HIV epidemic but differ in methodological aspects such as study design and eligibility criteria for trial populations. In addition to universal ART initiation, the trials deliver a wide range of biomedical, behavioural and structural interventions as part of their UTT strategies. The five studies explore common issues, including the uptake rates of the trial services and individual health outcomes. All trials have adapted since their initiation to the evolving political, economic and public health contexts, including adopting the successive national recommendations for ART initiation. Conclusions We found substantial commonalities but also differences between the five UTT trials in their design, conduct and multidisciplinary outputs. As empirical literature on how UTT may improve efficiency and quality of HIV care at population level is still scarce, this article provides a foundation for more collaborative research on UTT and supports evidence‐based decision making for HIV care in country and internationally.
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Affiliation(s)
- Delphine Perriat
- Inserm, Bordeaux Population Health Research Center, UMR 1219, University Bordeaux, Bordeaux, France.,Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France.,Africa Health Research Institute, Somkhele, KwaZulu-Natal, South Africa (ANRS TasP trial)
| | - Laura Balzer
- University of California San Francisco, San Francisco, CA, USA (SEARCH trial).,University of Massachusetts Amherst, Amherst, MA, USA
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom (PopART trial)
| | - Shahin Lockman
- Harvard School of Public Health, Boston, MA, USA (BCPP trial).,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana (BCPP trial).,Brigham and Women's Hospital, Boston, MA, USA (BCPP trial)
| | - Fiona Walsh
- Clinton Health Access Initiative, Boston, MA, USA (MaxART trial)
| | - Helen Ayles
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom (PopART trial).,Zambart, Lusaka, Zambia
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom (PopART trial)
| | - Diane Havlir
- University of California San Francisco, San Francisco, CA, USA (SEARCH trial)
| | - Moses Kamya
- Makerere University School of Medicine, Uganda (SEARCH trial)
| | | | - Lisa A Mills
- Centers for Disease Control, Gaborone, Botswana (BCPP trial)
| | - Velephi Okello
- Ministry of Health, Kingdom of Swaziland, Mbabane, Swaziland (MaxART trial)
| | - Maya Petersen
- University of California Berkeley School of Public Health, Berkeley, CA, USA (SEARCH trial)
| | - Deenan Pillay
- Africa Health Research Institute, Somkhele, KwaZulu-Natal, South Africa (ANRS TasP trial).,Department of Infection, University College London, London, United Kingdom (ANRS TasP trial)
| | - Kalpana Sabapathy
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom (PopART trial)
| | - Kathleen Wirth
- Department of Infection, University College London, London, United Kingdom (ANRS TasP trial)
| | - Joanna Orne-Gliemann
- Inserm, Bordeaux Population Health Research Center, UMR 1219, University Bordeaux, Bordeaux, France.,Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France.,Africa Health Research Institute, Somkhele, KwaZulu-Natal, South Africa (ANRS TasP trial)
| | - François Dabis
- Inserm, Bordeaux Population Health Research Center, UMR 1219, University Bordeaux, Bordeaux, France.,Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France.,Africa Health Research Institute, Somkhele, KwaZulu-Natal, South Africa (ANRS TasP trial)
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23
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Allan-Blitz LT, Herrera MC, Calvo GM, Vargas SK, Caceres CF, Klausner JD, Konda KA. Venue-Based HIV-Testing: An Effective Screening Strategy for High-Risk Populations in Lima, Peru. AIDS Behav 2019; 23:813-819. [PMID: 30506350 DOI: 10.1007/s10461-018-2342-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Venue-based testing may improve screening efforts for HIV and syphilis, thereby reducing transmission. We offered onsite rapid dual HIV and syphilis testing at venues popular among MSM and/or transgender women in Lima, Peru. We used Poisson regression to calculate adjusted prevalence ratios (aPRs) for factors associated with each infection. Most (90.4%) of the 303 participants would test more frequently if testing was available at alternative venues. New cases of HIV (69) and syphilis infection (84) were identified. HIV was associated with recent sex work (aPR 1.11; 95% CI 1.02-1.22), sex with a partner of unknown serostatus (aPR 1.18; 95% CI 1.09-1.27), exclusively receptive anal sex role (aPR 1.16; 95% CI 1.03-1.30) or versatile sex role (aPR 1.17; 95% CI 1.06-1.30) compared to insertive. Syphilis was associated with reporting role versatility (aPR = 2.69; 95% CI 1.52-5.74). Sex work venues had higher syphilis prevalence 47% versus 28% in other venues, p value = 0.012. Venue-based testing may improve case finding.
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Affiliation(s)
- Lao-Tzu Allan-Blitz
- David Geffen School of Medicine, University of California, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA.
| | - M Christina Herrera
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
| | - Gino M Calvo
- Center for Interdisciplinary Investigation in Sexuality, AIDS, and Society and Laboratory of Sexual Health, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Silver K Vargas
- Center for Interdisciplinary Investigation in Sexuality, AIDS, and Society and Laboratory of Sexual Health, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Carlos F Caceres
- Center for Interdisciplinary Investigation in Sexuality, AIDS, and Society and Laboratory of Sexual Health, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Jeffrey D Klausner
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
- Fielding School of Public Health, University of California, Los Angeles, USA
| | - Kelika A Konda
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA.
- Center for Interdisciplinary Investigation in Sexuality, AIDS, and Society and Laboratory of Sexual Health, Universidad Peruana Cayetano Heredia, Lima, Peru.
- Fielding School of Public Health, University of California, Los Angeles, USA.
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24
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Sowell RL. Stigma and Discrimination: Threats to Living Positively with Human Immunodeficiency Virus. Nurs Clin North Am 2019; 53:111-121. [PMID: 29362055 DOI: 10.1016/j.cnur.2017.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Antiretroviral therapy and care advances have resulted in people with human immunodeficiency virus (HIV) living longer and enjoying a higher level of physical well-being. Despite such advances, individuals with HIV continue to confront challenges to living positively, including facing the secondary epidemic of stigma and discrimination. Following is a historical overview of the concept of stigma and an exploration of the causes and consequences of multilevel stigma for individuals with HIV. Strategies used by individuals and societies to manage stigma and avoid negative experiences also are examined.
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Affiliation(s)
- Richard L Sowell
- Academy of Inclusive Learning and Social Growth, WellStar College of Health and Human Services, Kennesaw State University, 520 Parliament Garden Way, Prillaman Hall, Room 4211, Kennesaw, GA 30144, USA.
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25
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Alhaj M, Amberbir A, Singogo E, Banda V, van Lettow M, Matengeni A, Kawalazira G, Theu J, Jagriti MR, Chan AK, van Oosterhout JJ. Retention on antiretroviral therapy during Universal Test and Treat implementation in Zomba district, Malawi: a retrospective cohort study. J Int AIDS Soc 2019; 22:e25239. [PMID: 30734510 PMCID: PMC6367572 DOI: 10.1002/jia2.25239] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 12/19/2018] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Since June 2016, the national HIV programme in Malawi has adopted Universal Test and Treat (UTT) guidelines requiring that all persons who test HIV positive will be referred to start antiretroviral therapy (ART). Although there is strong evidence from clinical trials that early initiation of ART leads to reduced morbidity and mortality, the impact of UTT on retention on ART in real-life programmatic settings in Africa is not yet known. METHODS We conducted a retrospective cohort study in Zomba district, Malawi to compare ART outcomes of patients who initiated ART under 2016 UTT guidelines and those who started ART prior to rollout of UTT (pre-UTT). We analysed data from 32 rural and urban health facilities of various sizes. Cox proportional hazards modelling was used to determine the independent risk factors of attrition from ART at 12 months. All analyses were adjusted for clustering by health facility using a robust standard errors approach. RESULTS Among 1492 patients (mean age 34.4 years, 933 (63%) female) who initiated ART during the study period, 501 were enrolled in the pre-UTT cohort and 911 during UTT. At 12 months, retention on ART in the UTT cohort was higher than in the pre-UTT cohort 83.0% (95% confidence interval (CI): 81.0% to 85.0%) versus 76.2% (95% CI 73.9% to 78.5%). Adolescents, aged 10 to 19 years (adjusted hazard ratio (aHR) 1.53; 95% CI 1.01 to 2.32), and women who were pregnant or breastfeeding at ART initiation (aHR 1.87; 95% CI 1.30 to 2.38) were at higher risk of attrition in the combined pre-UTT and UTT cohort. CONCLUSIONS Retention on ART was nearly 6% higher after UTT introduction. Young adults and women who were pregnant or breastfeeding at the start of ART were at increased risk of attrition, emphasizing the need for targeted interventions for these groups to achieve the 90-90-90 UNAIDS targets in the UTT era.
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Affiliation(s)
- Mohammad Alhaj
- Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
- Dignitas InternationalZombaMalawi
| | - Alemayehu Amberbir
- Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
- Dignitas InternationalZombaMalawi
| | | | | | - Monique van Lettow
- Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
- Dignitas InternationalZombaMalawi
| | | | - Gift Kawalazira
- Zomba District Health OfficeMalawi Ministry of HealthZombaMalawi
| | - Joe Theu
- Dignitas InternationalZombaMalawi
| | | | - Adrienne K Chan
- Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
- Dignitas InternationalZombaMalawi
- Division of Infectious DiseasesSunnybrook Health Sciences CentreUniversity of TorontoTorontoCanada
| | - Joep J van Oosterhout
- Dignitas InternationalZombaMalawi
- Department of MedicineCollege of MedicineUniversity of MalawiBlantyreMalawi
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26
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Acceptability of Home-Based Human Immunodeficiency Virus Testing and Counseling in Low- and Middle-Income Countries. POINT OF CARE 2018. [DOI: 10.1097/poc.0000000000000172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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"If you are here at the clinic, you do not know how many people need help in the community": Perspectives of home-based HIV services from health care workers in rural KwaZulu-Natal, South Africa in the era of universal test-and-treat. PLoS One 2018; 13:e0202473. [PMID: 30412926 PMCID: PMC6226311 DOI: 10.1371/journal.pone.0202473] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 08/03/2018] [Indexed: 12/21/2022] Open
Abstract
Background Limited engagement in clinic-based care is affecting the HIV response. We explored the field experiences and perceptions of local health care workers regarding home-based strategies as opportunities to improve the cascade of care of people living with HIV in rural South Africa as part of a Universal Test-and-Treat approach. Methods In Hlabisa sub-district, home-based HIV services, including rapid HIV testing and counselling, and support for linkage to and retention in clinic-based HIV care, were implemented by health care workers within the ANRS 12249 Treatment-as-Prevention (TasP) trial. From April to July 2016, we conducted a mixed-methods study among health care workers from the TasP trial and from local government clinics, using self-administrated questionnaires (n = 90 in the TasP trial, n = 56 in government clinics), semi-structured interviews (n = 13 in the TasP trial, n = 5 in government clinics) and three focus group discussions (n = 6–10 health care workers of the TasP trial per group). Descriptive statistics were used for quantitative data and qualitative data were analysed thematically. Results More than 90% of health care workers assessed home-based testing and support for linkage to care as feasible and acceptable by the population they serve. Many health care workers underlined how home visits could facilitate reaching people who had slipped through the cracks of the clinic-based health care system and encourage them to successfully access care. Health care workers however expressed concerns about the ability of home-based services to answer the HIV care needs of all community members, including people working outside their home during the day or those who fear HIV-related stigmatization. Overall, health care workers encouraged policy-makers to more formally integrate home-based services in the local health system. They promoted reshaping the disease-specific and care-oriented services towards more comprehensive goals. Conclusion Because home-based services allow identification of people early during their infection and encourage them to take actions leading to viral suppression, HCWs assessed them as valuable components within the panel of UTT interventions, aiming to reach the 90-90-90 UNAIDS targets, especially in the rural Southern African region. Trial registration The registration number of the ANRS 12249 TasP trial on ClinicalTrials.gov is NCT01509508.
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Alexandra MO, Carolina PJ, Andrea GR, Patricia VF. Impact and barriers of an HIV rapid test program implementation at an oncological referral center in Mexico. Int J STD AIDS 2018; 29:884-889. [PMID: 29629655 DOI: 10.1177/0956462418762235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The aim of this study was to evaluate the implementation of human immunodeficiency virus (HIV) screening with rapid tests in an oncologic center in Mexico City, report the HIV prevalence, and describe contacts screening and linkage to HIV care while identifying barriers to the performance of the program. In 2014, an HIV rapid test program was implemented in four departments of the hospital "Instituto Nacional de Cancerología". From 2014 to 2016, 3032 HIV rapid tests were performed in the hospital. The overall HIV prevalence was 0.8%, with the highest prevalence in the Hematology Department (2.4%). In the Gynecology Department, prevalence was 0.05%. Only 25 and 22 tests were performed in the lung cancer and germ cell tumor clinic, respectively, with one positive test. The health staff not offering the test was the main limitation to the full implementation of the program in those departments. The contacts screening led to three positive cases. The acceptance of the test was 99%. Patients who tested positive were seen by an infectious diseases physician on the same day the test was performed. Rapid HIV tests are a useful tool to expand HIV diagnosis in patients with cancer and to establish a rapid linkage to HIV care. Staff education needs to be improved to raise awareness of the health staff for a successful scale up of the program.
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Affiliation(s)
| | - Perez-Jimenez Carolina
- 1 Infectious Diseases Department, Instituto Nacional de Cancerología, Mexico City, Mexico
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Individual and community-level risk factors for HIV stigma in 21 Zambian and South African communities: analysis of data from the HPTN071 (PopART) study. AIDS 2018; 32:783-793. [PMID: 29369164 PMCID: PMC5854764 DOI: 10.1097/qad.0000000000001757] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Supplemental Digital Content is available in the text Objective: To describe the prevalence and determinants of HIV stigma in 21 communities in Zambia and South Africa. Design: Analysis of baseline data from the HPTN 071 (PopART) cluster-randomized trial. HIV stigma data came from a random sample of 3859 people living with HIV. Community-level exposures reflecting HIV fears and judgements and perceptions of HIV stigma came from a random sample of community members not living with HIV (n = 5088), and from health workers (HW) (n = 851). Methods: We calculated the prevalence of internalized stigma, and stigma experienced in the community or in a healthcare setting in the past year. We conducted risk-factor analyses using logistic regression, adjusting for clustering. Results: Internalized stigma (868/3859, prevalence 22.5%) was not associated with sociodemographic characteristics but was less common among those with a longer period since diagnosis (P = 0.043). Stigma experienced in the community (853/3859, 22.1%) was more common among women (P = 0.016), older (P = 0.011) and unmarried (P = 0.009) individuals, those who had disclosed to others (P < 0.001), and those with more lifetime sexual partners (P < 0.001). Stigma experienced in a healthcare setting (280/3859, 7.3%) was more common among women (P = 0.019) and those reporting more lifetime sexual partners (P = 0.001) and higher wealth (P = 0.003). Experienced stigma was more common in clusters wherever community members perceived higher levels of stigma, but was not associated with the beliefs of community members or HW. Conclusion: HIV stigma remains unacceptably high in South Africa and Zambia and may act as barrier to HIV prevention and treatment. Further research is needed to understand its determinants.
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Plazy M, Perriat D, Gumede D, Boyer S, Pillay D, Dabis F, Seeley J, Orne-Gliemann J. Implementing universal HIV treatment in a high HIV prevalence and rural South African setting - Field experiences and recommendations of health care providers. PLoS One 2017; 12:e0186883. [PMID: 29155832 PMCID: PMC5695789 DOI: 10.1371/journal.pone.0186883] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 10/09/2017] [Indexed: 12/18/2022] Open
Abstract
Background We aimed to describe the field experiences and recommendations of clinic-based health care providers (HCP) regarding the implementation of universal antiretroviral therapy (ART) in rural KwaZulu-Natal, South Africa. Methods In Hlabisa sub-district, the local HIV programme of the Department of Health (DoH) is decentralized in 18 clinics, where ART was offered at a CD4 count ≤500 cells/μL from January 2015 to September 2016. Within the ANRS 12249 TasP trial, implemented in part of the sub-district, universal ART (no eligibility criteria) was offered in 11 mobile clinics between March 2012 and June 2016. A cross-sectional qualitative survey was conducted in April–July 2016 among clinic-based nurses and counsellors providing HIV care in the DoH and TasP trial clinics. In total, 13 individual interviews and two focus groups discussions (including 6 and 7 participants) were conducted, audio-recorded, transcribed, and thematically analyzed. Results All HCPs reported an overall good experience of delivering ART early in the course of HIV infection, with most patients willing to initiate ART before being symptomatic. Yet, HCPs underlined that not feeling sick could challenge early ART initiation and adherence, and thus highlighted the need to take time for counselling as an important component to achieve universal ART. HCPs also foresaw logistical challenges of universal ART, and were especially concerned about increasing workload and ART shortage. HCPs finally recommended the need to strengthen the existing model of care to facilitate access to ART, e.g., community-based and integrated HIV services. Conclusions The provision of universal ART is feasible and acceptable according to HCPs in this rural South-African area. However their experiences suggest that universal ART, and more generally the 90-90-90 UNAIDS targets, will be difficult to achieve without the implementation of new models of health service delivery.
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Affiliation(s)
- Melanie Plazy
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
- Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
- * E-mail:
| | - Delphine Perriat
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
- Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
| | - Dumile Gumede
- Africa Health Research Institute, Somkhele, South Africa
| | - Sylvie Boyer
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France
| | - Deenan Pillay
- Africa Health Research Institute, Somkhele, South Africa
- University College London, Division of Infection and Immunity, London, United Kingdom
| | - François Dabis
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
- Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
| | - Janet Seeley
- Africa Health Research Institute, Somkhele, South Africa
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Joanna Orne-Gliemann
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
- Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
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Wand H, Bryant J, Pitts M, Delaney-Thiele D, Kaldor JM, Worth H, Ward J. Development of a Risk Algorithm to Better Target STI Testing and Treatment Among Australian Aboriginal and Torres Strait Islander People. ARCHIVES OF SEXUAL BEHAVIOR 2017; 46:2145-2156. [PMID: 28550341 DOI: 10.1007/s10508-017-0958-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 01/25/2017] [Accepted: 02/06/2017] [Indexed: 06/07/2023]
Abstract
Identifying and targeting those at greatest risk will likely play a significant role in developing the most efficient and cost-effective sexually transmissible infections (STI) prevention programs. We aimed to develop a risk prediction algorithm to identify those who are at increased risk of STI. A cohort (N = 2320) of young sexually active Aboriginal and Torres Strait Islander people (hereafter referred to as Aboriginal people) were included in this study. The primary outcomes were self-reported high-risk sexual behaviors and past STI diagnosis. In developing a risk algorithm, our study population was randomly assigned to either a development (67%) or an internal validation data set (33%). Logistic regression models were used to create a risk prediction algorithm from the development data set for males and females separately. In the risk prediction models, older age, methamphetamine, ecstasy, and cannabis use, and frequent alcohol intake were all consistently associated with high-risk sexual behaviors as well as with a past STI diagnosis; identifying as gay/bisexual was one of the strongest factors among males. Those who had never tested for STIs, 52% (males) and 66% (females), had a risk score >15, and prevalence of undiagnosed STI was estimated between 30 and 40%. Since universal STI screening is not cost-effective, nor practical in many settings, targeted screening strategies remain a crucial and effective approach to managing STIs among young Aboriginal people. Risk prediction tools such as the one developed in this study may help in prioritizing screening for STIs among those most at risk.
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Affiliation(s)
- Handan Wand
- Kirby Institute, University of New South Wales, Kensington, NSW, 2052, Australia.
| | - Joanne Bryant
- Centre for Social Research in Health, University of New South Wales, Kensington, NSW, 2052, Australia
| | - Marian Pitts
- Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, VIC, Australia
| | | | - John M Kaldor
- Kirby Institute, University of New South Wales, Kensington, NSW, 2052, Australia
| | - Heather Worth
- School of Public Health and Community Medicine, University of New South Wales, Kensington, NSW, 2052, Australia
| | - James Ward
- South Australian Health and Medical Research Institute, Adelaide, SA, Australia
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Nah K, Nishiura H, Tsuchiya N, Sun X, Asai Y, Imamura A. Test-and-treat approach to HIV/AIDS: a primer for mathematical modeling. Theor Biol Med Model 2017; 14:16. [PMID: 28870213 PMCID: PMC5583977 DOI: 10.1186/s12976-017-0062-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 08/18/2017] [Indexed: 12/13/2022] Open
Abstract
The public benefit of test-and-treat has induced a need to justify goodness for the public, and mathematical modeling studies have played a key role in designing and evaluating the test-and-treat strategy for controlling HIV/AIDS. Here we briefly and comprehensively review the essence of contemporary understanding of the test-and-treat policy through mathematical modeling approaches and identify key pitfalls that have been identified to date. While the decrease in HIV incidence is achieved with certain coverages of diagnosis, care and continued treatment, HIV prevalence is not necessarily decreased and sometimes the test-and-treat is accompanied by increased long-term cost of antiretroviral therapy (ART). To confront with the complexity of assessment on this policy, the elimination threshold or the effective reproduction number has been proposed for its use in determining the overall success to anticipate the eventual elimination. Since the publication of original model in 2009, key issues of test-and-treat modeling studies have been identified, including theoretical problems surrounding the sexual partnership network, heterogeneities in the transmission dynamics, and realistic issues of achieving and maintaining high treatment coverage in the most hard-to-reach populations. To explicitly design country-specific control policy, quantitative modeling approaches to each single setting with differing epidemiological context would require multi-disciplinary collaborations among clinicians, public health practitioners, laboratory technologists, epidemiologists and mathematical modelers.
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Affiliation(s)
- Kyeongah Nah
- Graduate School of Medicine, Hokkaido University, Kita 15 Jo Nishi 7 Chome, Kita-ku, Sapporo, 060-8638, Japan.,CREST, Japan Science and Technology Agency, 4-1-8, Honcho, Kawaguchi-shi, Saitama, 332-0012, Japan
| | - Hiroshi Nishiura
- Graduate School of Medicine, Hokkaido University, Kita 15 Jo Nishi 7 Chome, Kita-ku, Sapporo, 060-8638, Japan. .,CREST, Japan Science and Technology Agency, 4-1-8, Honcho, Kawaguchi-shi, Saitama, 332-0012, Japan.
| | - Naho Tsuchiya
- Department of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, Tohoku University, 2-1 Seiryo-machi, Aoba-ku, Sendai, 980-8573, Japan
| | - Xiaodan Sun
- Graduate School of Medicine, Hokkaido University, Kita 15 Jo Nishi 7 Chome, Kita-ku, Sapporo, 060-8638, Japan.,Department of Applied Mathematics, Xi'an Jiaotong University, Xi'an, 710049, China
| | - Yusuke Asai
- Graduate School of Medicine, Hokkaido University, Kita 15 Jo Nishi 7 Chome, Kita-ku, Sapporo, 060-8638, Japan.,CREST, Japan Science and Technology Agency, 4-1-8, Honcho, Kawaguchi-shi, Saitama, 332-0012, Japan
| | - Akifumi Imamura
- Department of Infectious Diseases, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
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Bigna JJR, Plottel CS, Koulla-Shiro S. Challenges in initiating antiretroviral therapy for all HIV-infected people regardless of CD4 cell count. Infect Dis Poverty 2016; 5:85. [PMID: 27593965 PMCID: PMC5011352 DOI: 10.1186/s40249-016-0179-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 07/29/2016] [Indexed: 11/10/2022] Open
Abstract
Introduction Recently published large randomized controlled trials, START, TEMPRANO and HPTN 052 show the clinical benefit of early initiation of antiretroviral treatment (ART) in HIV-infected persons and in reducing HIV transmission. The trials influenced the World Health Organization (WHO) decision to issue updated recommendations to prescribe ART to all individuals living with HIV, irrespective of age and CD4 cell count. Discussion It is clear that the new 2015 WHO recommendations if followed, will change the face of the HIV epidemic and probably curb its burden over time. Implementation however, requires that health systems, especially those in low and middle-income settings, be ready to face this challenge on a large scale. HIV prevention and treatment are easy in theory yet hard in practice. The new WHO guidelines for initiation of ART regardless of CD4 cell count will lead to upfront increases in the costs of healthcare delivery as the goal is to treat all those now newly eligible for ART. Around 22 million people living with HIV qualify and will therefore require ART. Related challenges immediately follow: firstly, that everyone must be tested for HIV; secondly, that anyone who has had an HIV test should know their result and understand its significance; and, thirdly, that every person identified as HIV-positive should receive and remain on ART. The emergence of HIV drug resistant strains when treatment is started at higher CD4 cell count thresholds is a further concern as persons on HIV treatment for longer periods of time are at increased risk of intermittent medication adherence. Conclusions The new WHO recommendations for ART are welcome, but lacking as they fail to consider meaningful solutions to the challenges inherent to implementation. They fail to incorporate actual strategies on how to disseminate and adopt these far-reaching guidelines, especially in sub-Saharan Africa, an area with weak healthcare infrastructures. Well-designed, high-quality research is needed to assess the feasibility, safety, acceptability, impact, and cost of innovations such as the universal voluntary testing and immediate treatment approaches, and broad consultation must address community, human rights, ethical, and political concerns. Electronic supplementary material The online version of this article (doi:10.1186/s40249-016-0179-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jean Joel R Bigna
- Department of Epidemiology and Public Health, Centre Pasteur of Cameroon, 451, Rue 2005, P.O. Box 1274, Yaounde, Cameroon. .,Bordeaux School of Public Health, University of Bordeaux, Bordeaux, France.
| | - Claudia S Plottel
- Department of Medicine, Division of Translational Medicine, New York University Langone Medical Center, New York, NY, USA
| | - Sinata Koulla-Shiro
- Faculty of Medicine and Biomedical Sciences, University of Yaounde 1, Yaoundé, Cameroon.,Infectious Diseases Unit, Yaounde Central Hospital, Yaounde, Cameroon
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Reaching the unreached: treatment as prevention as a workable strategy to mitigate HIV and its consequences in high-risk groups. Curr HIV/AIDS Rep 2015; 11:505-12. [PMID: 25342571 DOI: 10.1007/s11904-014-0238-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
While there have been significant advances in curbing the HIV disease epidemic worldwide, there continues to be significant number of incident cases with 2.3 million new infections in the year 2012 alone. Treatment as prevention (TasP), which involves the use of antiretroviral drugs to decrease the likelihood of HIV illness, death and transmission from infected individuals to their noninfected sexual and /or drug paraphernalia-sharing injecting partners, must be incorporated into any HIV prevention strategy that is going to be successful on a large scale. Especially in resource-limited settings, the focus of the prevention approach should be on high-risk groups who contribute disproportionately to community HIV transmission, including people who inject drugs (PWID), men who have sex with men (MSM) and sex workers. Innovative strategies including integrated care services adapted to different patient care settings have to and can be employed to reach these at-risk populations.
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Luo S, Han L, Lu H, Dou Z, Tao Q, Khoshnood K, Wu Z, Xu J. Evaluating the Impact of Test-and-Treat on the HIV Epidemic among MSM in China Using a Mathematical Model. PLoS One 2015; 10:e0126893. [PMID: 26039075 PMCID: PMC4454496 DOI: 10.1371/journal.pone.0126893] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 04/08/2015] [Indexed: 02/07/2023] Open
Abstract
Background Various studies have modeled the impact of test-and-treat policies on the HIV epidemics worldwide. However, few modeling studies have taken into account China’s context. To understand the potential effect of test-and-treat on the HIV epidemic among men who have sex with men (MSM) in China, we developed a mathematical model to evaluate the impact of the strategy. Method Based on the natural history of the CD4 count of people living with HIV and AIDS (PLWHA), we constructed a dynamic compartmental model of HIV transmission among Chinese MSM to project the number of HIV new infections and prevalence over 10 years. We predicted the annual number of HIV new infections and the total number of MSM living with HIV and AIDS (based on Beijing data) between 2010 and 2022 under the following conditions: (1) current practice (testing rate of 50% and ART coverage of 39%); (2) both testing rate and ART coverage increasing to 70% in 2013; (3) both testing rate and ART coverage increasing to 90% in 2013; and (4) both testing rate and ART coverage increasing gradually every year until 90% since 2013. Results Based on our model, if the HIV test-and-treat policy was implemented among Chinese MSM, the total number of HIV new infections over 10 years (2013-2022) would be reduced by 50.6-70.9% compared with the current policy. When ART coverage for PLWHA increased to 58% since 2013, the ‘turning point’ would occur on the curve of HIV new infections by 2015. A 25% reduction in annual number of HIV new infections by 2015 might be achieved if the testing rate increased from 50% to 70% and treatment coverage for PLWHA increased to 55% since 2013. Conclusion Implementation of the test-and-treat strategy may significantly reduce HIV new infections among MSM in China. Great efforts need to be made to scale up HIV testing rate and ART coverage among Chinese MSM.
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Affiliation(s)
- Sitong Luo
- Division of Prevention Intervention, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
- Department of Epidemiology and Biostatistics, Peking Union Medical College, Beijing, China
| | - Litao Han
- School of Information, Renmin University of China, Beijing, China
- * E-mail: (JX); (LH)
| | - Hongyan Lu
- Institute for AIDS/STD Control and Prevention, Beijing Center for Disease Control and Prevention, Beijing, China
| | - Zhi Dou
- Division of Prevention Intervention, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Qian Tao
- School of Information, Renmin University of China, Beijing, China
| | - Kaveh Khoshnood
- Department of Epidemiology of Microbial Diseases, Yale University, New Haven, Connecticut, United States of America
| | - Zunyou Wu
- Division of Prevention Intervention, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Jie Xu
- Division of Prevention Intervention, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
- * E-mail: (JX); (LH)
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Yap L, Reekie J, Liu W, Chen Y, Wu Z, Li J, Zhang L, Wand H, Donovan B, Butler T. HIV testing in re-education through labour camps in Guangxi Autonomous Region, China (a cross-sectional survey). Sex Transm Infect 2015; 91:401-6. [PMID: 25739879 PMCID: PMC4552917 DOI: 10.1136/sextrans-2014-051658] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 01/19/2015] [Indexed: 11/30/2022] Open
Abstract
Objective HIV testing is mandatory in re-education-through-labour camps (laojiaosuo) in China yet no studies have reported on the process. Methods The survey response rate was 100% although 29 detainees were excluded because they were under 18 years of age. A cross-sectional face-to-face survey was conducted in three labour camps in Guangxi, located in the south-western region of China. Results Of the 755 detainees surveyed, 725 (96%) reported having a blood test in the labour camps of whom 493 (68%) thought this included an HIV test. 61 detainees self-reported they were HIV infected, their status confirmed by medical records, if available. Of these, 53 (87%) recalled receiving post-test HIV education, and 15 (25%) were currently receiving HIV antiretroviral therapy. Pretest education on HIV was provided to 233/725 (32%) detainees. The study further reports on detainees’ reactions and feelings towards non-disclosure and disclosure of their HIV test results in the labour camps. Conclusions Mandatory testing is almost universal in the labour camps although a proportion of detainees were unaware that this included an HIV test. HIV test results should be disclosed to all labour camp detainees to reduce their distress of not knowing and prevent misconceptions about their HIV status. Labour camps provide another opportunity to implement universal treatment (‘Test and Treat’) to prevent the spread of HIV.
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Affiliation(s)
- Lorraine Yap
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Joanne Reekie
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Wei Liu
- Division of HIV/AIDS Prevention and Control, Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Yi Chen
- Division of HIV/AIDS Prevention and Control, Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Zunyou Wu
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention (China CDC), Beijing, China
| | - Jianghong Li
- President's Research Project Group, WZB Berlin Social Research Center, Berlin, Germany The Centre for Population Health Research, Curtin University, Perth, Australia
| | - Lei Zhang
- The Kirby Institute, University of New South Wales, Sydney, Australia Research Center for Public Health, School of Medicine, Tsinghua University, Beijing, China
| | - Handan Wand
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Basil Donovan
- The Kirby Institute, University of New South Wales, Sydney, Australia Sydney Sexual Health Centre, Sydney Hospital, Sydney, Australia
| | - Tony Butler
- The Kirby Institute, University of New South Wales, Sydney, Australia
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Abstract
Global trends in HIV incidence are estimated typically by serial prevalence surveys in selected sentinel populations or less often in representative population samples. Incidence estimates are often modeled because cohorts are costly to maintain and are rarely representative of larger populations. From global trends, we can see reason for cautious optimism. Downward trends in generalized epidemics in Africa, concentrated epidemics in persons who inject drugs (PWID), some female sex worker cohorts, and among older men who have sex with men (MSM) have been noted. However, younger MSM and those from minority populations, as with black MSM in the United States, show continued transmission at high rates. Among the many HIV prevention strategies, current efforts to expand testing, linkage to effective care, and adherence to antiretroviral therapy are known as "treatment as prevention" (TasP). A concept first forged for the prevention of mother to child transmission, TasP generates high hopes that persons treated early will derive considerable clinical benefits and that lower infectiousness will reduce transmission in communities. With the global successes of risk reduction for PWID, we have learned that reducing marginalization of the at-risk population, implementation of nonjudgmental and pragmatic sterile needle and syringe exchange programs, and offering of opiate substitution therapy to help persons eschew needle use altogether can work to reduce the HIV epidemic. Never has the urgency of stigma reduction and guarantees of human rights been more urgent; a public health approach to at-risk populations requires that to avail themselves of prevention services and they must feel welcomed.
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Affiliation(s)
- Sten H Vermund
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA,
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Firestone R, Rivas J, Lungo S, Cabrera A, Ruether S, Wheeler J, Vu L. Effectiveness of a combination prevention strategy for HIV risk reduction with men who have sex with men in Central America: a mid-term evaluation. BMC Public Health 2014; 14:1244. [PMID: 25471459 PMCID: PMC4289249 DOI: 10.1186/1471-2458-14-1244] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 11/18/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite over a decade of research and programming, little evidence is available on effective strategies to reduce HIV risks among Central American men who have sex with men (MSM). The Pan-American Social Marketing Organization (PASMO) and partners are implementing a HIV Combination Prevention Program to provide key populations with an essential package of prevention interventions and services: 1) behavioral, including interpersonal communications, and online outreach; 2) biomedical services including HIV testing and counseling and screening for STIs; and 3) complementary support, including legal support and treatment for substance abuse. Two years into implementation, we evaluated this program's effectiveness for MSM by testing whether exposure to any or a combination of program components could reduce HIV risks. METHODS PASMO surveyed MSM in 10 cities across Guatemala, El Salvador, Nicaragua, Costa Rica, and Panama in 2012 using respondent-driven sampling. We used coarsened exact matching to create statistically equivalent groups of men exposed and non-exposed to the program, matching on education, measures of social interaction, and exposure to other HIV prevention programs. We estimated average treatment effects of each component and all combined to assess HIV testing and condom use outcomes, using multivariable logistic regression. We also linked survey data to routine service data to assess program coverage. RESULTS Exposure to any program component was 32% in the study area (n = 3531). Only 2.8% of men received all components. Men exposed to both behavioral and biomedical components were more likely to use condoms and lubricant at last sex (AOR 3.05, 95% CI 1.08, 8.64), and those exposed to behavioral interventions were more likely to have tested for HIV in the past year (AOR 1.76, 95% CI 1.01, 3.10). CONCLUSIONS PASMO's strategies to reach MSM with HIV prevention programming are still achieving low levels of population coverage, and few men are receiving the complete essential package. However, those reached are able to practice HIV prevention. Combination prevention is a promising approach in Central America, requiring expansion in coverage and intensity.
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Affiliation(s)
- Rebecca Firestone
- Population Services International, 1120 19th Street, NW, Suite 600, Washington, DC 20036, USA.
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Comparison of routine versus targeted HIV testing strategies: coverage and estimated missed infections in emergency room and primary care centre. J Int AIDS Soc 2014; 17:19671. [PMID: 25397421 PMCID: PMC4225402 DOI: 10.7448/ias.17.4.19671] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction Different HIV Testing Strategies (TS) and clinical care settings had not been face to face evaluated [1]. We compared coverage, Newly Diagnosed HIV Infection (NDHI) and Estimated Missing HIV Infections (MHI) in Hospital Emergency Room (HER) and Primary Care Center (PCC), in DRIVE study (Spanish acronym of HIV infection Rapid Diagnosis) and in clinical practice the year before DRIVE. Materials and Methods In DRIVE study, 18–60 years old, non-HIV-infected population visiting an HER or a PCC were proposed both a structured risk practices and clinical conditions questionnaire (RP&CC-Q) and a rapid HIV test. This arm is the HIV Routine TS. We analyze a hypothetical arm, where risk practices were universally assessed with an RP&CC-Q, subsequently risk-positive patients where HIV tested, Targeted-TS. Coverage was assessed as the ratio of tested population (TP)/attended population (AP) in HER and PCC. TP/AP ratios were also calculated in the year before, the Clinical Practice-TS. NDHI was expressed per ‰ tests performed. MHI was estimated assuming in the non-tested population, overall DRIVE rate of NDHI ‰ and NDHI ‰ in negative RP&CC-Q. Results A total of 5329 RP&CC-Q and rapid HIV tests were performed to 49.64% women, median age 37 (28–47) years old, mainly 74.9% Spaniards. Confirmed NDHI was 4.1‰, and in 48, 8% of RP&CC-Q negative NDH was 0‰. HIV screening coverage was always better in PCC than in HER, and higher in DRIVE study than in clinical practice. Estimated MHI was higher in HER and in the clinical practice-TS. Targeted-TS coverage was lower, but resulted in similar NDHI and MHI than routine-TS, testing half the population, see Table 1. Conclusions Best HIV Testing Strategy is routine-TS in Primary Care Center. Targeted-TS resulted in same newly HIV diagnoses and missed HIV infections than routine-TS with half the resources employed.
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Incremental cost per newly diagnosed HIV infection (NDHI): routine (RTS), targeted (TTS), and current clinical practice testing strategies (CPTS). J Int AIDS Soc 2014; 17:19606. [PMID: 25394110 PMCID: PMC4224887 DOI: 10.7448/ias.17.4.19606] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Although RTS as HIV Diagnosis was considered cost effectiveness [1], overall budget may be unaffordable for some countries. We explore Incremental cost per NDHI associated with different TS. Materials and Methods From a health care perspective, using direct costs and Euros currency, we calculated budget and cost per NDHI of RTS (all patients were tested), TTS (Universal risk practices and clinical conditions-RP&CC - only positive were tested), and CPTS (Only patients physicians considered were tested). We considered DRIVE (Spanish acronym of HIV infection Rapid Diagnosis) study and clinical Practice outcomes. Population between 18–60 years, attending to a Hospital Emergency Room or to a Primary Care Center performed an HIV RP&CC questionnaire (Q) and an HIV rapid test (HIV RT). Unitary costs considered were: HIV RT, nurse, registry, transport and HIV confirmation when necessary, imputed to all population in RTS and CPTS and only in HIV RP&CC-Q positive in TTS analysis, while HIV RP&CC-Q costs were added to all population in TTS. Sensitivity analyses were performed with varying rates of NDHI and of positive HIV RP&CC-Q population, and different RP&CC Q sensitivity (SE) to predict HIV infection. Results 5,329 HIV RP&CC-Q and HIV RT were performed to 49.64% women, median age 37 years old, 74.9% Spaniards. In DRIVE and CP, NDHI were 4.1‰, and 1.6‰, while HIV RP&CC-Q was positive in 51.2%. HIV RP&CC-Q SE was 100%. Overall budget employed in HIV testing was in RTS 43,503€, in TTS 24,472€ and in CPTS 5,032€. Cost per 1 NDHI was 1,977€, 1,112€ and 5,032€, respectively. A reduction in cost of 865€, favouring TTS vs. RTS, while an increased cost of 824€ in CPTS vs. RTS was obtained. Considering NDHI rate of 2.6‰ saving costs increased to 1379€ in TTS, while were reduced to 576€ if NDHI rate increases 6.2‰. Effect of RP&CC-Q positivity rate was similar, if 25% saving costs were 1368€, while if 75% were reduced to 399€. Varying SE of RP&CC-Q to 95%, 91% and 50% cost saving was 810€, 754€, and 208€, and number of MHI one, two and 11. Conclusions In DRIVE study Targeted TS with universal screening of RP&CC before an HIV rapid test is cost saving, without missing NDHI, with respect to Routine TS. Lower rates of HIV infection and RP&CC in the population, increase costs savings.
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International Congress of Drug Therapy in HIV Infection 2-6 November 2014, Glasgow, UK. J Int AIDS Soc 2014. [DOI: 10.7448/ias.17.4.19856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Abstract
: Many behavior change interventions for the prevention and treatment of HIV have been evaluated, but suboptimal reporting of evaluations hinders the accumulation of evidence and the replication of interventions. In this article, we address 4 practices contributing to this problem. First, detailed descriptions of the interventions and their implementation are often unavailable. Second, content of active control group content (such as usual care or support designed by researchers) often varies markedly between trials; yet, descriptions of this content are routinely omitted. Third, detailed process evaluations revealing the mechanisms by which interventions generate their effects, and among whom, frequently are not available. Fourth, there is a lack of replication in other contexts, which limits knowledge of external validity. This article advances recommendations made by an international group of scholars constituting the Workgroup for Intervention Development and Evaluation Research (WIDER), which has developed brief guidance to journal editors to improve the reporting of evaluations of behavior change interventions, thereby serving as an addition to reporting statements such as CONSORT. Improved reporting standards would facilitate and accelerate the development of the science of behavior change and its application in implementation science to improve public health.
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Vermund SH, Van Lith LM, Holtgrave D. Strategic roles for health communication in combination HIV prevention and care programs. J Acquir Immune Defic Syndr 2014; 66 Suppl 3:S237-40. [PMID: 25007259 DOI: 10.1097/qai.0000000000000244] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
This special issue of JAIDS: Journal of Acquired Immune Deficiency Syndromes is devoted to health communication and its role in and impact on HIV prevention and care. The authors in this special issue have tackled a wide swath of topics, seeking to introduce a wider biomedical audience to core health communication principles, strategies, and evidence of effectiveness. Better awareness of health communication strategies and concepts can enable the broader biomedical community to partner with health communication experts in reducing the risk of HIV, sexually transmitted infections, and tuberculosis and maximize linkage and adherence to care. Interventions can be strengthened when biomedical and health communication approaches are combined in strategic and evidence-based ways. Several of the articles in this special issue present the current evidence for health communication's impact. These articles show how far we have come and yet how much further we have to go to document impact convincingly. Examples of the biomedical approaches to HIV control include treatment as prevention, voluntary medical male circumcision, preexposure prophylaxis, sterile needle exchange, opiate substitution therapy, and prevention of mother-to-child transmission. None will succeed without behavior change, which can be facilitated by effective health communication.
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Affiliation(s)
- Sten H Vermund
- *Vanderbilt Institute for Global Health and Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN; †Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; and ‡Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Chanzu N, Ondondo B. Induction of Potent and Long-Lived Antibody and Cellular Immune Responses in the Genitorectal Mucosa Could be the Critical Determinant of HIV Vaccine Efficacy. Front Immunol 2014; 5:202. [PMID: 24847327 PMCID: PMC4021115 DOI: 10.3389/fimmu.2014.00202] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 04/23/2014] [Indexed: 01/28/2023] Open
Abstract
The field of HIV prevention has indeed progressed in leaps and bounds, but with major limitations of the current prevention and treatment options, the world remains desperate for an HIV vaccine. Sadly, this continues to be elusive, because more than 30 years since its discovery there is no licensed HIV vaccine. Research aiming to define immunological biomarkers to accurately predict vaccine efficacy have focused mainly on systemic immune responses, and as such, studies defining correlates of protection in the genitorectal mucosa, the primary target site for HIV entry and seeding are sparse. Clearly, difficulties in sampling and analysis of mucosal specimens, as well as their limited size have been a major deterrent in characterizing the type (mucosal antibodies, cytokines, chemokines, or CTL), threshold (magnitude, depth, and breadth) and viral inhibitory capacity of HIV-1-specific immune responses in the genitorectal mucosa, where they are needed to immediately block HIV acquisition and arrest subsequent virus dissemination. Nevertheless, a few studies document the existence of HIV-specific immune responses in the genitorectal mucosa of HIV-infected aviremic and viremic controllers, as well as in highly exposed persistently seronegative (HEPS) individuals with natural resistance to HIV-1. Some of these responses strongly correlate with protection from HIV acquisition and/or disease progression, thus providing significant clues of the ideal components of an efficacious HIV vaccine. In this study, we provide an overview of the key features of protective immune responses found in HEPS, elite and viremic controllers, and discuss how these can be achieved through mucosal immunization. Inevitably, HIV vaccine development research will have to consider strategies that elicit potent antibody and cellular immune responses within the genitorectal mucosa or induction of systemic immune cells with an inherent potential to home and persist at mucosal sites of HIV entry.
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Affiliation(s)
- Nadia Chanzu
- Institute of Tropical and Infectious Diseases, College of Health Sciences, University of Nairobi , Nairobi , Kenya
| | - Beatrice Ondondo
- The Jenner Institute, Nuffield Department of Medicine, University of Oxford , Oxford , UK
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Hayes R, Ayles H, Beyers N, Sabapathy K, Floyd S, Shanaube K, Bock P, Griffith S, Moore A, Watson-Jones D, Fraser C, Vermund SH, Fidler S. HPTN 071 (PopART): rationale and design of a cluster-randomised trial of the population impact of an HIV combination prevention intervention including universal testing and treatment - a study protocol for a cluster randomised trial. Trials 2014; 15:57. [PMID: 24524229 PMCID: PMC3929317 DOI: 10.1186/1745-6215-15-57] [Citation(s) in RCA: 175] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 02/03/2014] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Effective interventions to reduce HIV incidence in sub-Saharan Africa are urgently needed. Mathematical modelling and the HIV Prevention Trials Network (HPTN) 052 trial results suggest that universal HIV testing combined with immediate antiretroviral treatment (ART) should substantially reduce incidence and may eliminate HIV as a public health problem. We describe the rationale and design of a trial to evaluate this hypothesis. METHODS/DESIGN A rigorously-designed trial of universal testing and treatment (UTT) interventions is needed because: i) it is unknown whether these interventions can be delivered to scale with adequate uptake; ii) there are many uncertainties in the models such that the population-level impact of these interventions is unknown; and ii) there are potential adverse effects including sexual risk disinhibition, HIV-related stigma, over-burdening of health systems, poor adherence, toxicity, and drug resistance.In the HPTN 071 (PopART) trial, 21 communities in Zambia and South Africa (total population 1.2 m) will be randomly allocated to three arms. Arm A will receive the full PopART combination HIV prevention package including annual home-based HIV testing, promotion of medical male circumcision for HIV-negative men, and offer of immediate ART for those testing HIV-positive; Arm B will receive the full package except that ART initiation will follow current national guidelines; Arm C will receive standard of care. A Population Cohort of 2,500 adults will be randomly selected in each community and followed for 3 years to measure the primary outcome of HIV incidence. Based on model projections, the trial will be well-powered to detect predicted effects on HIV incidence and secondary outcomes. DISCUSSION Trial results, combined with modelling and cost data, will provide short-term and long-term estimates of cost-effectiveness of UTT interventions. Importantly, the three-arm design will enable assessment of how much could be achieved by optimal delivery of current policies and the costs and benefits of extending this to UTT. TRIAL REGISTRATION ClinicalTrials.gov NCT01900977.
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Affiliation(s)
- Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Helen Ayles
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
- Zambia AIDS Related TB Project, University of Zambia, Rideway Campus, Nationalist Road, Lusaka, Zambia
| | - Nulda Beyers
- Desmond Tutu TB Centre, Stellenbosch University, Francie van Zijl Avenue, Clinical Building, K Floor, Romm 0065, Tygerberg Campus, Western Cape 7505, South Africa
| | - Kalpana Sabapathy
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Kwame Shanaube
- Zambia AIDS Related TB Project, University of Zambia, Rideway Campus, Nationalist Road, Lusaka, Zambia
| | - Peter Bock
- Desmond Tutu TB Centre, Stellenbosch University, Francie van Zijl Avenue, Clinical Building, K Floor, Romm 0065, Tygerberg Campus, Western Cape 7505, South Africa
| | - Sam Griffith
- FHI360, Science Facilitation Department, 2224 E NC Hwy 54, Durham, NC 27713, USA
| | - Ayana Moore
- FHI360, Science Facilitation Department, 2224 E NC Hwy 54, Durham, NC 27713, USA
| | - Deborah Watson-Jones
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Christophe Fraser
- St Mary’s Campus, HIV Clinical Trials Unit, Winston Churchill Wing, London W2 1NY, UK
| | - Sten H Vermund
- Institute for Global Health and Department of Pediatrics, Vanderbilt University, Institute for Global Health, 2525 West End Avenue, Suite 750, Nashville, TN 32703, USA
| | - Sarah Fidler
- Department of Infectious Disease Epidemiology, Imperial College London, St Mary’s Campus, Norfolk Place, London W2 1PG, UK
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Keita M, Perbost I, Pugliese-Wehrlen S, Abel S, Pugliese P, Enel P, Cuzin L, Lang T, Delpierre C. Incidences and risk factors of first-line HAART discontinuation: a limitation to the success of the “seek, test, treat, and retain” strategy? AIDS Care 2014; 26:1058-69. [DOI: 10.1080/09540121.2014.882490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Momory Keita
- Inserm, UMR1027 Inserm-Université de Toulouse III, Toulouse, France
| | - Isabelle Perbost
- CHU de Nice, Infectiologie, Route de St Antoine de Ginestière, Nice, France
| | | | - Sylvie Abel
- CHU de Martinique, Service de maladies Infectieuses et Tropicales, Fort-de-France, France
| | - Pascal Pugliese
- CHU de Nice, Infectiologie, Route de St Antoine de Ginestière, Nice, France
| | - Patricia Enel
- Marseilles University Hospital, Public health Department, Marseilles, France
| | - Lise Cuzin
- CHU de Toulouse, Infectiologie, Toulouse, France
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Cori A, Ayles H, Beyers N, Schaap A, Floyd S, Sabapathy K, Eaton JW, Hauck K, Smith P, Griffith S, Moore A, Donnell D, Vermund SH, Fidler S, Hayes R, Fraser C. HPTN 071 (PopART): a cluster-randomized trial of the population impact of an HIV combination prevention intervention including universal testing and treatment: mathematical model. PLoS One 2014; 9:e84511. [PMID: 24454728 PMCID: PMC3893126 DOI: 10.1371/journal.pone.0084511] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 11/20/2013] [Indexed: 02/08/2023] Open
Abstract
Background The HPTN 052 trial confirmed that antiretroviral therapy (ART) can nearly eliminate HIV transmission from successfully treated HIV-infected individuals within couples. Here, we present the mathematical modeling used to inform the design and monitoring of a new trial aiming to test whether widespread provision of ART is feasible and can substantially reduce population-level HIV incidence. Methods and Findings The HPTN 071 (PopART) trial is a three-arm cluster-randomized trial of 21 large population clusters in Zambia and South Africa, starting in 2013. A combination prevention package including home-based voluntary testing and counseling, and ART for HIV positive individuals, will be delivered in arms A and B, with ART offered universally in arm A and according to national guidelines in arm B. Arm C will be the control arm. The primary endpoint is the cumulative three-year HIV incidence. We developed a mathematical model of heterosexual HIV transmission, informed by recent data on HIV-1 natural history. We focused on realistically modeling the intervention package. Parameters were calibrated to data previously collected in these communities and national surveillance data. We predict that, if targets are reached, HIV incidence over three years will drop by >60% in arm A and >25% in arm B, relative to arm C. The considerable uncertainty in the predicted reduction in incidence justifies the need for a trial. The main drivers of this uncertainty are possible community-level behavioral changes associated with the intervention, uptake of testing and treatment, as well as ART retention and adherence. Conclusions The HPTN 071 (PopART) trial intervention could reduce HIV population-level incidence by >60% over three years. This intervention could serve as a paradigm for national or supra-national implementation. Our analysis highlights the role mathematical modeling can play in trial development and monitoring, and more widely in evaluating the impact of treatment as prevention.
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Affiliation(s)
- Anne Cori
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Helen Ayles
- ZAMBART, University of Zambia, School of Medicine, Ridgeway Campus, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nulda Beyers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Ab Schaap
- ZAMBART, University of Zambia, School of Medicine, Ridgeway Campus, 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
| | - Kalpana Sabapathy
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jeffrey W. Eaton
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Katharina Hauck
- Business School, Imperial College London, South Kensington, London, United Kingdom
| | - Peter Smith
- Business School, Imperial College London, South Kensington, London, United Kingdom
| | - Sam Griffith
- FHI 360, Research Triangle Park, North Carolina, United States of America
| | - Ayana Moore
- FHI 360, Research Triangle Park, North Carolina, United States of America
| | - Deborah Donnell
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Sten H. Vermund
- Vanderbilt Institute for Global Health and Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Sarah Fidler
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Christophe Fraser
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
- * E-mail:
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Affiliation(s)
- Sten H Vermund
- Vanderbilt Institute for Global Health and Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN 37203, USA.
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Can combination prevention strategies reduce HIV transmission in generalized epidemic settings in Africa? The HPTN 071 (PopART) study plan in South Africa and Zambia. J Acquir Immune Defic Syndr 2013; 63 Suppl 2:S221-7. [PMID: 23764639 DOI: 10.1097/qai.0b013e318299c3f4] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The HIV Prevention Trials Network (HPTN) is conducting the HPTN 071 (PopART) study in 21 communities in Zambia and South Africa with support from a consortium of funders. HPTN 071 (PopART) is a community-randomized trial of a combination prevention strategy to reduce HIV incidence in the context of the generalized epidemic of southern Africa. The full PopART intervention strategy is anchored in home-based HIV testing and facilitated linkage of HIV-infected persons to care through community health workers and universal antiretroviral therapy for seropositive persons regardless of CD4+ cell count or HIV viral load. To further reduce the risk of HIV acquisition among uninfected individuals, the study aims to expand voluntary medical male circumcision, diagnosis and treatment of sexually transmitted infections, behavioral counseling, and condom distribution. The full PopART intervention strategy also incorporates promotion of other interventions designed to reduce HIV and tuberculosis transmission, including optimization of the prevention of mother-to-child HIV transmission and enhanced individual and public health tuberculosis services. Success for the PopART strategy depends on the ability to increase coverage for the study interventions whose uptake is a necessary antecedent to a prevention effect. Processes will be measured to assess the degree of penetration of the interventions into the communities. A randomly sampled population cohort from each community will be used to measure the impact of the PopART strategy on HIV incidence over 3 years. We describe the strategy being tested and progress to date in the HPTN 071 (PopART) study.
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Audet CM, Salato J, Blevins M, Amsalem D, Vermund SH, Gaspar F. Educational intervention increased referrals to allopathic care by traditional healers in three high HIV-prevalence rural districts in Mozambique. PLoS One 2013; 8:e70326. [PMID: 23936407 PMCID: PMC3731350 DOI: 10.1371/journal.pone.0070326] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 06/18/2013] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Delayed uptake of clinical services impedes favorable clinical outcomes in Mozambique. Care is delayed among patients who initiate care with traditional healers; patients with conditions like human immunodeficiency virus (HIV) or tuberculosis are rarely referred to the health system in a timely fashion. METHODS We conducted a pre-post educational intervention with traditional healers, assessing healer referral rates and HIV knowledge in three rural districts in Zambézia Province. RESULTS The median monthly referral rate prior to the intervention was 0.25 patients (interquartile range [IQR]: 0-0.54) compared with a post-intervention rate of 0.34 patients (IQR: 0-0.71), a 35% increase (p=0.046). A median HIV knowledge score of 67% (IQR: 59-78) was noted 4-months pre-intervention and a median score of 81% (IQR: 74-89) was recorded 2½ months post-intervention (p<0.001). One hundred and eleven healers referred 127 adults, 36 pregnant women, and 188 children to health facilities. Referred patients were most likely to be diagnosed with bronchopneumonia (20% adults; 13% children) and/or malaria (15% adults; 37% children). Of 315 non-pregnant persons referred, 3.5% were tested for HIV and 2.5% were tested for tuberculosis. DISCUSSION We engaged traditional healers with some success; referral rates were low, but increased post-intervention. Once seen in the clinics, patients were rarely tested for HIV or tuberculosis, though symptoms suggested screening was indicated. We found increased referral rates through an inexpensive intervention with traditional healers, a viable, cost-effective method of directing patients to health facilities. However, quality improvement within the clinics is necessary before a substantial impact can be expected.
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Affiliation(s)
- Carolyn M Audet
- Institute for Global Health Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
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