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Robson I, Mphande M, Lee J, Hubbard JA, Daniels J, Phiri K, Chikuse E, Coates TJ, Cornell M, Dovel K. Implementing a male-specific ART counselling curriculum: a quality assessment with healthcare workers in Malawi. J Int AIDS Soc 2024; 27:e26270. [PMID: 39039724 PMCID: PMC11263468 DOI: 10.1002/jia2.26270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 04/29/2024] [Indexed: 07/24/2024] Open
Abstract
INTRODUCTION There is little HIV counselling that directly meets the needs of men in Eastern and Southern Africa, limiting men's knowledge about the benefits of HIV treatment and how to overcome barriers to engagement, contributing to poorer HIV-related outcomes than women. Male-specific approaches are needed to improve men's outcomes but may be difficult for healthcare workers (HCWs) to implement with fidelity and quality in low-resource settings. We developed a male-specific counselling curriculum which was implemented by male HCWs and then conducted a mixed-methods quality assessment. METHODS We audio-recorded counselling sessions to assess the quality of implementation (n = 50) by male HCWs from two cadres (nurse, n = 10 and lay cadre, n = 10) and conducted focus group discussions (FGDs) with HCWs at 6 and 9 months after rollout to understand barriers and facilitators to implementation. Counselling sessions and FGDs were translated, transcribed and analysed using thematic analysis adapted from WHO Quality Counselling Guidelines. We assessed if sessions were respectful, informative, interactive, motivating and included tailored action plans for overcoming barriers to care. All data were collected September 2021-June 2022. RESULTS All sessions used respectful, non-judgemental language. Sessions were highly interactive with most HCWs frequently asking open-ended questions (n = 46, 92%) and often incorporating motivational explanations of how antiretroviral therapy contributes to life goals (n = 42, 84%). Few sessions included individually tailored action plans for clients to overcome barriers to care (n = 9, 18%). New counselling themes were well covered; however, occasionally themes of self-compassion and safe sex were not covered during sessions (n = 16 and n = 11). HCWs believed that having male HCWs conduct counselling, ongoing professional development and keeping detailed counselling notes facilitated quality implementation. Perceived barriers included curriculum length and client hesitancy to participate in action plan development. Findings were similar across cadres. CONCLUSIONS Implementing high-quality male-specific counselling using male nurses and/or lay cadre is feasible. Efforts to utilize lay cadres should be prioritized, particularly in low-resource settings. Programmes should provide comprehensive job aids to support HCWs. Ongoing training and professional development are needed to (1) improve HCWs' skills in tailored action plans, and (2) sensitize HCWs to the need for self-compassion within male clients to promote holistic sexual health.
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Affiliation(s)
- Isabella Robson
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
- Implementation Science DepartmentPartners in HopeLilongweMalawi
| | - Misheck Mphande
- Implementation Science DepartmentPartners in HopeLilongweMalawi
| | - Jiyoung Lee
- David Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - Julie Anne Hubbard
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - Joseph Daniels
- Edson College of Nursing and Health InnovationArizona State UniversityPhoenixArizonaUSA
| | - Khumbo Phiri
- Implementation Science DepartmentPartners in HopeLilongweMalawi
| | - Elijah Chikuse
- Implementation Science DepartmentPartners in HopeLilongweMalawi
| | - Thomas J. Coates
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
- University of California Global Health InstituteSan FranciscoCaliforniaUSA
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Kathryn Dovel
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
- Implementation Science DepartmentPartners in HopeLilongweMalawi
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Gottert A, Malone S, Pulerwitz J. The encouraging early successes of a dynamic choice HIV prevention model for both women and men in East Africa. AIDS 2024; 38:913-915. [PMID: 38578960 DOI: 10.1097/qad.0000000000003854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Affiliation(s)
- Ann Gottert
- Population Council, Social and Behavioral Science Research division, Washington, DC, USA
| | - Shawn Malone
- Population Services International, Johannesburg, South Africa
| | - Julie Pulerwitz
- Population Council, Social and Behavioral Science Research division, Washington, DC, USA
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Han AX, Hannay E, Carmona S, Rodriguez B, Nichols BE, Russell CA. Estimating the potential impact and diagnostic requirements for SARS-CoV-2 test-and-treat programs. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2022.10.05.22280727. [PMID: 36238715 PMCID: PMC9558441 DOI: 10.1101/2022.10.05.22280727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Oral antivirals have the potential to reduce the public health burden of COVID-19. However, now that we have exited the emergency phase of the COVID-19 pandemic, declining SARS-CoV-2 clinical testing rates (average testing rates = ≪10 tests/100,000 people/day in low- and-middle income countries; <100 tests/100,000 people/day in high-income countries; September 2023) make the development of effective test-and-treat programs challenging. We used an agent-based model to investigate how testing rates and strategies affect the use and effectiveness of oral antiviral test-to-treat programs in four country archetypes of different income levels and demographies. We find that in the post-emergency phase of the pandemic, in countries where low testing rates are driven by limited testing capacity, significant population-level impact of test-and-treat programs can only be achieved by both increasing testing rates and prioritizing individuals with greater risk of severe disease. However, for all countries, significant reductions in severe cases with antivirals are only possible if testing rates were substantially increased with high willingness of people to seek testing. Comparing the potential population-level reductions in severe disease outcomes of test-to-treat programs and vaccination shows that test-and-treat strategies are likely substantially more resource intensive requiring very high levels of testing (>>100 tests/100,000 people/day) and antiviral use suggesting that vaccination should be a higher priority.
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Affiliation(s)
- Alvin X. Han
- Department of Medical Microbiology & Infection Prevention, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Emma Hannay
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Sergio Carmona
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Bill Rodriguez
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Brooke E. Nichols
- Department of Medical Microbiology & Infection Prevention, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA
| | - Colin A. Russell
- Department of Medical Microbiology & Infection Prevention, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA
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Jamal A, Srinivasan M, Kim G, Nevins AB, Vohra S. Factors associated with HIV Testing within the National Health Interview Survey (2006-2018). J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01728-w. [PMID: 37526879 DOI: 10.1007/s40615-023-01728-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 07/15/2023] [Accepted: 07/21/2023] [Indexed: 08/02/2023]
Abstract
The Centers for Disease Control and Prevention recommends that individuals aged 13-64 test for HIV at least once during their lifetime. However, screening has been disproportionate among racial/ethnic populations. Using the National Health Interview Survey data (2006-2018), we examined HIV screening prevalence within racial/ethnic groups in the United States (US), and factors associated with testing among 301,191 individuals. This consisted of 195,696 White, 42,409 Black, 47,705 Hispanic and 15,381 Asian individuals. Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI) to estimate the association between ever testing for HIV and demographic, socioeconomic and health-related factors. Approximately 36% of White, 61% of Black, 47% of Hispanic and 36% of Asian individuals reported ever testing for HIV. Hispanic (OR = 1.28, 95% CI [1.25-1.32]) and Black individuals (OR = 2.44, 95% CI [2.38-2.50]) had higher odds of HIV testing, whereas Asian individuals (OR = 0.74, 95% CI [0.71-0.77]) had lower odds of HIV testing compared to White individuals. Individuals who identified as males, married, between the ages of 18-26 years or greater than or equal to 50 years were less likely to ever test for HIV compared to their counterparts. Similarly, those with lower education, lower income, better self-reported health, no health professional visits or living in the midwestern US were less likely to ever test for HIV compared to their counterparts (OR range: 0.14-0.92). Understanding the factors associated with HIV testing opens opportunities to increase testing rates for all and reduce health disparities in HIV detection.
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Affiliation(s)
- Armaan Jamal
- Stanford Center for Asian Health Research and Education, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Medicine, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross Research Building Room 1064, Baltimore, MD, 21205, USA.
| | - Malathi Srinivasan
- Stanford Center for Asian Health Research and Education, Stanford University School of Medicine, Stanford, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Gloria Kim
- Stanford Center for Asian Health Research and Education, Stanford University School of Medicine, Stanford, CA, USA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrew B Nevins
- Division of Infectious Diseases, Stanford University School of Medicine, Stanford, CA, USA
| | - Sanah Vohra
- Stanford Center for Asian Health Research and Education, Stanford University School of Medicine, Stanford, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Dovel K, Balakasi K, Phiri K, Shaba F, Offorjebe OA, Gupta SK, Wong V, Lungu E, Nichols BE, Masina T, Worku A, Hoffman R, Nyirenda M. Effect of index HIV self-testing for sexual partners of clients enrolled in antiretroviral therapy (ART) programs in Malawi: A randomized controlled trial. PLoS Med 2023; 20:e1004270. [PMID: 37540649 PMCID: PMC10403056 DOI: 10.1371/journal.pmed.1004270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 06/28/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND HIV testing among the sexual partners of HIV-positive clients is critical for case identification and reduced transmission in southern and eastern Africa. HIV self-testing (HIVST) may improve uptake of HIV services among sexual partners of antiretroviral therapy (ART) clients, but the impact of HIVST on partner testing and subsequent ART initiation remains unclear. METHODS AND FINDINGS We conducted an individually randomized, unblinded trial to assess if an index HIVST intervention targeting the partners of ART clients improves uptake of testing and treatment services in Malawi. The trial was conducted at 3 high-burden facilities in central and southern Malawi. ART clients attending HIV treatment clinics were randomized using simple randomization 1:2·5 to: (1) standard partner referral slip (PRS) whereby ART clients were given facility referral slips to distribute to their primary sexual partners; or (2) index HIVST whereby ART clients were given HIVST kits + HIVST instructions and facility referral slips to distribute to their primary sexual partners. Inclusion criteria for ART clients were: ≥15 years of age, primary partner with unknown HIV status, no history of interpersonal violence (IPV) with partner, and partner lives in facility catchment area. The primary outcome was partner testing 4-weeks after enrollment, reported by ART clients using endline surveys. Medical chart reviews and tracing activities with partners with a reactive HIV test measured ART initiation at 12 months. Analyses were conducted based on modified intention-to-treat principles, whereby we excluded individuals who did not have complete endline data (i.e., were loss to follow up from the study). Adjusted models controlled for the effects of age and marital status. A total of 4,237 ART clients were screened and 484 were eligible and enrolled (77% female) between March 28, 2018 and January 5, 2020. A total of 365 participants completed an endline survey (257/34 index HIVST arm; 107/13 PRS arm) and were included in the final analysis (78% female). Testing coverage among sexual partners was 71% (183/257) in the index HIVST arm and 25% (27/107) in the PRS arm (aRR: 2·77, 95% CI [2·56 to 3·00], p ≤ 0.001). Reported HIV positivity rates did not significantly differ by arm (16% (30/183) in HIVST versus 15% (4/27) in PRS; p = 0.99). ART initiation at 12 months was 47% (14/30) in HIVST versus 75% (3/4) in PRS arms; however, index HIVST still resulted in a 94% increase in the proportion of all partners initiating ART due to higher HIV testing rates in the HIVST arm (5% partners initiated ART in HVIST versus 3% in PRS). Adverse events including IPV and termination of the relationship did not vary by arm (IPV: 3/257 index HIVST versus 4/10 PRS; p = 0.57). Limitations include reliance on secondary report by ART clients, potential social desirability bias, and not powered for sex disaggregated analyses. CONCLUSIONS Index HIVST significantly increased HIV testing and the absolute number of partners initiating ART in Malawi, without increased risk of adverse events. Additional research is needed to improve linkage to HIV treatment services after HIVST use. TRIAL REGISTRATION ClinicalTrials.gov, NCT03271307, and Pan African Clinical Trials, PACTR201711002697316.
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Affiliation(s)
- Kathryn Dovel
- Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
- Partners in Hope, Lilongwe, Malawi
| | | | | | | | - Ogechukwu Agatha Offorjebe
- David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
- School of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, California, United States of America
| | | | - Vincent Wong
- USAID Global Health Bureau, Arlington, Virginia, United States of America
| | | | - Brooke E. Nichols
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, United States of America
| | - Tobias Masina
- Malawi Ministry of Health, HIV/AIDS Unit, Lilongwe, Malawi
| | | | - Risa Hoffman
- Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
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Dovel K, Balakasi K, Hubbard J, Phiri K, Nichols BE, Coates TJ, Kulich M, Chikuse E, Phiri S, Long LC, Hoffman RM, Choko AT. Identifying efficient linkage strategies for men (IDEaL): a study protocol for an individually randomised control trial. BMJ Open 2023; 13:e070896. [PMID: 37438067 DOI: 10.1136/bmjopen-2022-070896] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023] Open
Abstract
INTRODUCTION Men in sub-Saharan Africa are less likely than women to initiate antiretroviral therapy (ART) and more likely to have longer cycles of disengagement from ART programmes. Treatment interventions that meet the unique needs of men are needed, but they must be scalable. We will test the impact of various interventions on 6-month retention in ART programmes among men living with HIV who are not currently engaged in care (never initiated ART and ART clients with treatment interruption). METHODS AND ANALYSIS We will conduct a programmatic, individually randomised, non-blinded, controlled trial. 'Non-engaged' men will be randomised 1:1:1 to either a low-intensity, high-intensity or stepped arm. The low-intensity intervention includes one-time male-specific counseling+facility navigation only. The high-intensity intervention offers immediate outside-facility ART initiation+male-specific counselling+facility navigation for follow-up ART visits. In the stepped arm, intervention activities build in intensity over time for those who do not re-engage in care with the following steps: (1) one-time male-specific counselling+facility navigation→(2) ongoing male mentorship+facility navigation→(3) outside-facility ART initiation+male-specific counselling+facility navigation for follow-up ART visits. Our primary outcome is 6-month retention in care. Secondary outcomes include cost-effectiveness and rates of adverse events. The primary analysis will be intention to treat with all eligible men in the denominator and all men retained in care at 6 months in the numerator. The proportions achieving the primary outcome will be compared with a risk ratio, corresponding 95% CI and p value computed using binomial regression accounting for clustering at facility level. ETHICS AND DISSEMINATION The Institutional Review Board of the University of California, Los Angeles and the National Health Sciences Research Council in Malawi have approved the trial protocol. Findings will be disseminated rapidly in national and international forums and in peer-reviewed journals and are expected to provide urgently needed information to other countries and donors. TRIAL REGISTRATION NUMBER NCT05137210. DATE AND VERSION 5 May 2023; version 3.
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Affiliation(s)
- Kathryn Dovel
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
- Department of Implementation Science, Partners in Hope, Lilongwe, Malawi
| | - Kelvin Balakasi
- Department of Implementation Science, Partners in Hope, Lilongwe, Malawi
| | - Julie Hubbard
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Khumbo Phiri
- Department of Implementation Science, Partners in Hope, Lilongwe, Malawi
| | - Brooke E Nichols
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Medical Microbiology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Thomas J Coates
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
- Global Health Institute, University of California, San Francisco, California, USA
| | - Michal Kulich
- Department of Probability and Statistics, Faculty of Mathematics and Physics, Charles University, Prague, Czechia
| | - Elijah Chikuse
- Department of Implementation Science, Partners in Hope, Lilongwe, Malawi
| | - Sam Phiri
- Department of Implementation Science, Partners in Hope, Lilongwe, Malawi
| | - Lawrence C Long
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Risa M Hoffman
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Augustine T Choko
- Clinical Research Programme, Malawi Liverpool Wellcome Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
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Choko AT, Coates TJ, Mphande M, Balakasi K, Robson I, Phiri K, Phiri S, Kulich M, Sweat M, Cornell M, Hoffman RM, Dovel K. Engaging men through HIV self-testing with differentiated care to improve ART initiation and viral suppression among men in Malawi (ENGAGE): A study protocol for a randomized control trial. PLoS One 2023; 18:e0281472. [PMID: 36827327 PMCID: PMC9956026 DOI: 10.1371/journal.pone.0281472] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/22/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Men experience twice the mortality of women while on ART in sub-Saharan Africa (SSA) largely due to late HIV diagnosis and poor retention. Here we propose to conduct an individually randomized control trial (RCT) to investigate the impact of three-month home-based ART (hbART) on viral suppression among men who were not engaged in care. METHODS AND DESIGN A programmatic, individually randomized non-blinded, non-inferiority-controlled trial design (ClinicalTrials.org NCT04858243). Through medical chart reviews we will identify "non-engaged" men living with HIV, ≥15years of age who are not currently engaged in ART care, including (1) men who have tested HIV-positive and have not initiated ART within 7 days; (2) men who have initiated ART but are at risk of immediate default; and (3) men who have defaulted from ART. With 1:1 computer block randomization to either hbART or facility-based ART (fbART) arms, we will recruit men from 10-15 high-burden health facilities in central and southern Malawi. The hbART intervention will consist of 3 home-visits in a 3-month period by a certified male study nurse ART provider. In the fbART arm, male participants will be offered counselling at male participant's home, or a nearby location that is preferred by participants, followed with an escort to the local health facility and facility navigation. The primary outcome is the proportion of men who are virally suppressed at 6-months after ART initiation. Assuming primary outcome achievement of 24.0% and 33.6% in the two arms, 350 men per arm will provide 80% power to detect the stated difference. DISCUSSION Identifying effective ART strategies that are convenient and accessible for men in SSA is a priority in the HIV world. Men may not (re-)engage in facility-based care due to a myriad of barriers. Two previous trials investigated the impact of hbART on viral suppression in the general population whereas this trial focuses on men. Additionally, this trial involves a longer duration of hbART i.e., three months compared to two weeks allowing men more time to overcome the initial psychological denial of taking ART.
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Affiliation(s)
- Augustine T. Choko
- Partners in Hope, Lilongwe, Malawi
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Thomas J. Coates
- David Geffen School of Medicine, Division of Infectious Diseases, Los Angeles, California, United States of America
| | | | | | | | | | | | - Michal Kulich
- Department of Probability and Statistics, Faculty of Mathematics and Physics, Charles University, Prague, Czech Republic
| | - Michael Sweat
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology & Research, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Risa M. Hoffman
- David Geffen School of Medicine, Division of Infectious Diseases, Los Angeles, California, United States of America
| | - Kathryn Dovel
- Partners in Hope, Lilongwe, Malawi
- David Geffen School of Medicine, Division of Infectious Diseases, Los Angeles, California, United States of America
- * E-mail:
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Han AX, Girdwood SJ, Khan S, Sacks JA, Toporowski A, Huq N, Hannay E, Russell CA, Nichols BE. Strategies for Using Antigen Rapid Diagnostic Tests to Reduce Transmission of Severe Acute Respiratory Syndrome Coronavirus 2 in Low- and Middle-Income Countries: A Mathematical Modelling Study Applied to Zambia. Clin Infect Dis 2023; 76:620-630. [PMID: 36208211 PMCID: PMC9619661 DOI: 10.1093/cid/ciac814] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/17/2022] [Accepted: 10/05/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Increasing the availability of antigen rapid diagnostic tests (Ag-RDTs) in low- and middle-income countries (LMICs) is key to alleviating global SARS-CoV-2 testing inequity (median testing rate in December 2021-March 2022 when the Omicron variant was spreading in multiple countries: high-income countries = 600 tests/100 000 people/day; LMICs = 14 tests/100 000 people/day). However, target testing levels and effectiveness of asymptomatic community screening to impact SARS-CoV-2 transmission in LMICs are unclear. METHODS We used Propelling Action for Testing and Treating (PATAT), an LMIC-focused agent-based model to simulate coronavirus disease 2019 (COVID-19) epidemics, varying the amount of Ag-RDTs available for symptomatic testing at healthcare facilities and asymptomatic community testing in different social settings. We assumed that testing was a function of access to healthcare facilities and availability of Ag-RDTs. We explicitly modelled symptomatic testing demand from individuals without SARS-CoV-2 and measured impact based on the number of infections averted due to test-and-isolate. RESULTS Testing symptomatic individuals yields greater benefits than any asymptomatic community testing strategy until most symptomatic individuals who sought testing have been tested. Meeting symptomatic testing demand likely requires at least 200-400 tests/100 000 people/day, on average, as symptomatic testing demand is highly influenced by individuals without SARS-CoV-2. After symptomatic testing demand is satisfied, excess tests to proactively screen for asymptomatic infections among household members yield the largest additional infections averted. CONCLUSIONS Testing strategies aimed at reducing transmission should prioritize symptomatic testing and incentivizing test-positive individuals to adhere to isolation to maximize effectiveness.
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Affiliation(s)
- Alvin X Han
- Department of Medical Microbiology and Infection Prevention, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Sarah J Girdwood
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shaukat Khan
- Clinton Health Access Initiative, Boston, Massachusetts, USA
| | - Jilian A Sacks
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Amy Toporowski
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Naushin Huq
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Emma Hannay
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Colin A Russell
- Department of Medical Microbiology and Infection Prevention, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Brooke E Nichols
- Department of Medical Microbiology and Infection Prevention, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, USA
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SARS-CoV-2 diagnostic testing rates determine the sensitivity of genomic surveillance programs. Nat Genet 2023; 55:26-33. [PMID: 36624344 PMCID: PMC9839449 DOI: 10.1038/s41588-022-01267-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 11/11/2022] [Indexed: 01/11/2023]
Abstract
The first step in SARS-CoV-2 genomic surveillance is testing to identify people who are infected. However, global testing rates are falling as we emerge from the acute health emergency and remain low in many low- and middle-income countries (mean = 27 tests per 100,000 people per day). We simulated COVID-19 epidemics in a prototypical low- and middle-income country to investigate how testing rates, sampling strategies and sequencing proportions jointly impact surveillance outcomes, and showed that low testing rates and spatiotemporal biases delay time to detection of new variants by weeks to months and can lead to unreliable estimates of variant prevalence, even when the proportion of samples sequenced is increased. Accordingly, investments in wider access to diagnostics to support testing rates of approximately 100 tests per 100,000 people per day could enable more timely detection of new variants and reliable estimates of variant prevalence. The performance of global SARS-CoV-2 genomic surveillance programs is fundamentally limited by access to diagnostic testing.
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Nichols BE, de Nooy A, Benade M, Balakasi K, Mphande M, Rao G, Claassen CW, Khan S, Stillson C, Russell CA, Doi N, Dovel K. Facility-based HIV self-testing strategies may substantially and cost-effectively increase the number of men and youth tested for HIV in Malawi: results from an individual-based mathematical model. J Int AIDS Soc 2022; 25:e26020. [PMID: 36251161 PMCID: PMC9575938 DOI: 10.1002/jia2.26020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 09/15/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Malawi is rapidly closing the gap in achieving the UNAIDS 95-95-95 targets, with 90% of people living with HIV in Malawi aware of their status. As we approach epidemic control, interventions to improve coverage will become more costly. There is, therefore, an urgent need to identify innovative and low-cost strategies to maintain and increase testing coverage without diverting resources from other HIV services. The objective of this study is to model different combinations of facility-based HIV testing modalities and determine the most cost-effective strategy to increase the proportion of men and youth testing for HIV. METHODS A data-driven individual-based model was parameterized with data from a community-representative survey (socio-demographic, health service utilization and HIV testing history) of men and youth in Malawi (data collected August 2019). In total, 79 different strategies for the implementation of HIV self-testing (HIVST) and provider-initiated-testing-and-counselling at the outpatient department (OPD) were evaluated. Outcomes included percent of men/youth tested for HIV in a 12-month period, cost-effectiveness and human resource requirements. The testing yield was assumed to be constant across the scenarios. RESULTS Facility-based HIVST offered year-round resulted in the greatest increase in the proportion of men and youth tested in the OPD (from 45% to 72%-83%), was considered cost-saving for HIVST kit priced at $1.00, and generally reduced required personnel as compared to the status quo. At higher HIVST kit prices, and more relaxed eligibility criteria, all scenarios that considered year-round HIVST in the OPD remained on the cost-effectiveness frontier. CONCLUSIONS Facility-based HIVST is a cost-effective strategy to increase the proportion of men/youth tested for HIV in Malawi and decreases the human resource requirements for HIV testing in the OPD-providing additional healthcare worker time for other priority healthcare activities.
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Affiliation(s)
- Brooke E. Nichols
- Department of Global Health, School of Public HealthBoston UniversityBostonMassachusettsUSA,Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the WitwatersrandJohannesburgSouth Africa,Department of Medical MicrobiologyAmsterdam University Medical CentreAmsterdamthe Netherlands,Foundation for Innovative New DiagnosticsGenevaSwitzerland
| | - Alexandra de Nooy
- Department of Medical MicrobiologyAmsterdam University Medical CentreAmsterdamthe Netherlands,Right to CareJohannesburgSouth Africa
| | - Mariet Benade
- Department of Global Health, School of Public HealthBoston UniversityBostonMassachusettsUSA
| | | | | | | | - Cassidy W. Claassen
- Center for International Health, Education, and BiosecurityUniversity of Maryland School of MedicineBaltimoreMarylandUSA,Division of Infectious Diseases, Department of MedicineUniversity of Zambia School of MedicineLusakaZambia
| | - Shaukat Khan
- Clinton Health Access InitiativeBostonMarylandUSA
| | | | - Colin A. Russell
- Department of Global Health, School of Public HealthBoston UniversityBostonMassachusettsUSA,Department of Medical MicrobiologyAmsterdam University Medical CentreAmsterdamthe Netherlands
| | - Naoko Doi
- Clinton Health Access InitiativeBostonMarylandUSA
| | - Kathryn Dovel
- Right to CareJohannesburgSouth Africa,Division of Infectious Diseases, Department of MedicineUniversity of California Los Angeles David Geffen School of MedicineLos AngelesCaliforniaUSA
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11
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Thorp M, Balakasi KT, Mphande M, Robson I, Khan S, Stillson C, Doi N, Nichols BE, Dovel K. Factors associated with men's health facility attendance as clients and caregivers in Malawi: a community-representative survey. BMC Public Health 2022; 22:1904. [PMID: 36224573 PMCID: PMC9558411 DOI: 10.1186/s12889-022-14300-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 10/04/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction Men have higher rates of morbidity and mortality across nearly all top ten causes of mortality worldwide. Much of this disparity is attributed to men’s lower utilization of routine health services; however, little is known about men’s general healthcare utilization in sub-Saharan Africa. Methods We analyze the responses of 1,116 men in a community-representative survey of men drawn from a multi-staged sample of residents of 36 villages in Malawi to identify factors associated with men’s facility attendance in the last 12 months, either for men’s own health (client visit) or to support the health care of someone else (caregiver visit). We conducted single-variable tests of association and multivariable logistic regression with random effects to account for clustering at the village level. Results Median age of participants was 34, 74% were married, and 82% attended a health facility in the last year (63% as client, 47% as caregiver). Neither gender norm beliefs nor socioeconomic factors were independently associated with attending a client visit. Only problems with quality of health services (adjusted odds ratio [aOR] 0.294, 95% confidence interval [CI] 0.10—0.823) and good health (aOR 0.668, 95% CI 0.462–0.967) were independently associated with client visit attendance. Stronger beliefs in gender norms were associated with caregiver visits (beliefs about acceptability of violence [aOR = 0.661, 95% CI 0.488–0.896], male sexual dominance [aOR = 0.703, 95% CI 0.505–0.978], and traditional women’s roles [aOR = 0.718, 95% CI 0.533–0.966]). Older age (aOR 0.542, 95% CI 0.401–0.731) and being married (aOR 2.380, 95% CI 1.196–4.737) were also independently associated with caregiver visits. Conclusion Quality of services offered at local health facilities and men’s health status were the only variables associated with client facility visits among men, while harmful gender norms, not being married, and being younger were negatively associated with caregiver visits. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-14300-8.
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Affiliation(s)
- Marguerite Thorp
- Division of Infectious Diseases David Geffen School of Medicine, University of California - Los Angeles, 10833 Le Conte Blvd CHS 37-121, 90095, Los Angeles, CA, USA.
| | | | | | | | - Shaukat Khan
- Division of Infectious Diseases David Geffen School of Medicine, University of California - Los Angeles, 10833 Le Conte Blvd CHS 37-121, 90095, Los Angeles, CA, USA
| | | | - Naoko Doi
- Clinton Health Access Initiative, Boston, USA
| | | | - Kathryn Dovel
- Division of Infectious Diseases, University of California - Los Angeles, Los Angeles, USA
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12
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Han AX, Toporowski A, Sacks JA, Perkins MD, Briand S, van Kerkhove M, Hannay E, Carmona S, Rodriguez B, Parker E, Nichols BE, Russell CA. SARS-CoV-2 diagnostic testing rates determine the sensitivity of genomic surveillance programs. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2022:2022.05.20.22275319. [PMID: 35664998 PMCID: PMC9164450 DOI: 10.1101/2022.05.20.22275319] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The first step in SARS-CoV-2 genomic surveillance is testing to identify infected people. However, global testing rates are falling as we emerge from the acute health emergency and remain low in many low- and middle-income countries (LMICs) (mean = 27 tests/100,000 people/day). We simulated COVID-19 epidemics in a prototypical LMIC to investigate how testing rates, sampling strategies, and sequencing proportions jointly impact surveillance outcomes and showed that low testing rates and spatiotemporal biases delay time-to-detection of new variants by weeks-to-months and can lead to unreliable estimates of variant prevalence even when the proportion of samples sequenced is increased. Accordingly, investments in wider access to diagnostics to support testing rates of ~100 tests/100,000 people/day could enable more timely detection of new variants and reliable estimates of variant prevalence. The performance of global SARS-CoV-2 genomic surveillance programs is fundamentally limited by access to diagnostic testing.
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Affiliation(s)
- Alvin X. Han
- Department of Medical Microbiology & Infection Prevention, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands,Corresponding authors. and
| | - Amy Toporowski
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Jilian A. Sacks
- Department of Epidemic and Pandemic Preparedness and Prevention, Emergency Preparedness Programme, World Health Organization, Geneva, Switzerland
| | - Mark D. Perkins
- Department of Epidemic and Pandemic Preparedness and Prevention, Emergency Preparedness Programme, World Health Organization, Geneva, Switzerland
| | - Sylvie Briand
- Department of Epidemic and Pandemic Preparedness and Prevention, Emergency Preparedness Programme, World Health Organization, Geneva, Switzerland
| | - Maria van Kerkhove
- Department of Epidemic and Pandemic Preparedness and Prevention, Emergency Preparedness Programme, World Health Organization, Geneva, Switzerland
| | - Emma Hannay
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Sergio Carmona
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Bill Rodriguez
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Edyth Parker
- Department of Immunology and Microbiology, The Scripps Research Institute, La Jolla, CA, USA
| | - Brooke E. Nichols
- Department of Medical Microbiology & Infection Prevention, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands,Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland,Department of Global Health, School of Public Health, Boston University, Boston, MA, USA
| | - Colin A. Russell
- Department of Medical Microbiology & Infection Prevention, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands,Department of Global Health, School of Public Health, Boston University, Boston, MA, USA,Corresponding authors. and
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13
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Wada PY, Kim A, Jayathilake K, Duda SN, Abo Y, Althoff KN, Cornell M, Musick B, Brown S, Sohn AH, Chan YJ, Wools-Kaloustian KK, Nash D, Yiannoutsos CT, Cesar C, McGowan CC, Rebeiro PF. Site-Level Comprehensiveness of Care Is Associated with Individual Clinical Retention Among Adults Living with HIV in International Epidemiology Databases to Evaluate AIDS, a Global HIV Cohort Collaboration, 2000-2016. AIDS Patient Care STDS 2022; 36:343-355. [PMID: 36037010 PMCID: PMC9514598 DOI: 10.1089/apc.2022.0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Retention in care (RIC) reduces HIV transmission and associated morbidity and mortality. We examined whether delivery of comprehensive services influenced individual RIC within the International epidemiology Databases to Evaluate AIDS (IeDEA) network. We collected site data through IeDEA assessments 1.0 (2000-2009) and 2.0 (2010-2016). Each site received a comprehensiveness score for service availability (1 = present, 0 = absent), with tallies ranging from 0 to 7. We obtained individual-level cohort data for adults with at least one visit from 2000 to 2016 at sites responding to either assessment. Person-time was recorded annually, with RIC defined as completing two visits at least 90 days apart in each calendar year. Multivariable modified Poisson regression clustered by site yielded risk ratios and predicted probabilities for individual RIC by comprehensiveness. Among 347,060 individuals in care at 122 sites with 1,619,558 person-years of follow-up, 69.8% of person-time was retained in care, varying by region from 53.8% (Asia-Pacific) to 82.7% (East Africa); RIC improved by about 2% per year from 2000 to 2016 (p = 0.012). Every site provided CD4+ count testing, and >90% of individuals received care at sites that provided combination antiretroviral therapy adherence measures, prevention of mother-to-child transmission, tuberculosis screening, HIV-related prevention, and community tracing services. In adjusted models, individuals at sites with more comprehensive services had higher probabilities of RIC (0.71, 0.74, and 0.83 for scores 5, 6, and 7, respectively; p = 0.019). Within IeDEA, greater site-level comprehensiveness of services was associated with improved individual RIC. Much work remains in exploring this relationship, which may inform HIV clinical practice and health systems planning.
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Affiliation(s)
- Paul Y. Wada
- Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Ahra Kim
- Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Karu Jayathilake
- Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Stephany N. Duda
- Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Yao Abo
- Centre Médical de Suivi des Donneurs de Sang (CMSDS), Centre National de Transfusion Sanguine, Abidjan, Côte d'Ivoire
| | - Keri N. Althoff
- Division of Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Morna Cornell
- Center for Infectious Disease Epidemiology & Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Beverly Musick
- Division of Biostatistics and Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Steve Brown
- Division of Biostatistics and Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Annette H. Sohn
- Division of Pediatrics, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Yu Jiun Chan
- Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kara K. Wools-Kaloustian
- Division of Biostatistics and Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Denis Nash
- Division of Epidemiology and Biostatistics, City University of New York, Institute for Implementation Science in Population Health, New York, New York, USA
| | - Constantin T. Yiannoutsos
- Division of Biostatistics, Indiana University Fairbanks School of Public Health, Indianapolis, Indiana, USA
| | | | - Catherine C. McGowan
- Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Peter F. Rebeiro
- Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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14
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Hubbard JA, Mphande M, Phiri K, Balakasi K, Hoffman RM, Daniels J, Choko A, Coates TJ, Dovel K. Improving ART initiation among men who use HIV self-testing in Malawi: a qualitative study. J Int AIDS Soc 2022; 25:e25950. [PMID: 35700027 PMCID: PMC9196890 DOI: 10.1002/jia2.25950] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 05/24/2022] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION HIV self-testing (HIVST) increases HIV testing uptake among men; however, the linkage to antiretroviral therapy (ART) among HIVST users is low. Innovative strategies for ART initiation are needed, yet little is known about the unique barriers to care experienced by male HIVST users, and what ART-related interventions men desire. METHODS We conducted semi-structured in-depth interviews with cisgender men (≥15 years) in Malawi who tested HIV positive using HIVST between 2018 and 2020, as well as interviews with their female partners (≥15 years) who distributed the HIVST kits. Medical records from seven facilities were used to identify respondents. We included men who received HIVST from a health facility (primary distribution) and from sexual partners (secondary distribution). Interview guides focused on unique barriers to ART initiation following HIVST and desired interventions to improve linkage and initiation. Interviews were audio recorded, translated and transcribed to English, and analysed using constant comparison methods in Atlas.ti v.8.4. Themes were compared by HIVST distribution strategy. Data were collected between 2019 and 2020. RESULTS Twenty-seven respondents were interviewed: eight male/female dyads (16 respondents), eight men without a female partner and three women who represented men who did not participate in the study. Among the 19 men represented (16 men interviewed in person, three represented by secondary report from female partners), seven received HIVST through primary distribution, 12 through secondary distribution. Six men never initiated ART (all secondary HIVST distribution). Barriers to ART initiation centred on the absence of healthcare workers at the time of diagnosis and included lack of external motivation for linkage to care (men had to motivate themselves) and lack of counselling before and after testing (leaving ART-related fears and misconceptions unaddressed)--the latter was especially true for secondary HIVST distribution. Desired interventions were similar across distribution strategies and included ongoing peer mentorship for normalizing treatment adherence, counselling messages tailored to men, outside-facility services for convenience and privacy, and facility navigation to help men understand how to navigate ART clinics. CONCLUSIONS Male HIVST users face unique challenges to ART initiation, especially those receiving HIVST through secondary distribution. Male-tailored interventions are desired by men and may help overcome barriers to care.
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Affiliation(s)
- Julie A Hubbard
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.,Partners in Hope Medical Center, Lilongwe, Malawi
| | | | - Khumbo Phiri
- Partners in Hope Medical Center, Lilongwe, Malawi
| | | | - Risa M Hoffman
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Joseph Daniels
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA
| | - Augustine Choko
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, TB/HIV, Blantyre, Malawi
| | - Thomas J Coates
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.,University of California Global Health Institute, San Francisco, California, USA
| | - Kathryn Dovel
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.,Partners in Hope Medical Center, Lilongwe, Malawi
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15
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Nichols BE, van der Valk M. Barriers to eliminating HIV transmission in England by 2030. LANCET PUBLIC HEALTH 2021; 6:e699-e700. [PMID: 34563279 DOI: 10.1016/s2468-2667(21)00161-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 06/23/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Brooke E Nichols
- Department of Global Health, Boston University School of Public Health, Boston, MA; Health Economics and Epidemiology Research Office (HE(2)RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Medical Microbiology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands.
| | - Marc van der Valk
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity, University of Amsterdam, Amsterdam, Netherlands; Stichting HIV Monitoring, Amsterdam, Netherlands
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