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Rucinski K, Knight J, Willis K, Wang L, Rao A, Roach MA, Phaswana-Mafuya R, Bao L, Thiam S, Arimi P, Mishra S, Baral S. Challenges and Opportunities in Big Data Science to Address Health Inequities and Focus the HIV Response. Curr HIV/AIDS Rep 2024:10.1007/s11904-024-00702-3. [PMID: 38916675 DOI: 10.1007/s11904-024-00702-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2024] [Indexed: 06/26/2024]
Abstract
PURPOSE OF REVIEW Big Data Science can be used to pragmatically guide the allocation of resources within the context of national HIV programs and inform priorities for intervention. In this review, we discuss the importance of grounding Big Data Science in the principles of equity and social justice to optimize the efficiency and effectiveness of the global HIV response. RECENT FINDINGS Social, ethical, and legal considerations of Big Data Science have been identified in the context of HIV research. However, efforts to mitigate these challenges have been limited. Consequences include disciplinary silos within the field of HIV, a lack of meaningful engagement and ownership with and by communities, and potential misinterpretation or misappropriation of analyses that could further exacerbate health inequities. Big Data Science can support the HIV response by helping to identify gaps in previously undiscovered or understudied pathways to HIV acquisition and onward transmission, including the consequences for health outcomes and associated comorbidities. However, in the absence of a guiding framework for equity, alongside meaningful collaboration with communities through balanced partnerships, a reliance on big data could continue to reinforce inequities within and across marginalized populations.
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Affiliation(s)
- Katherine Rucinski
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, MD, USA.
| | - Jesse Knight
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Kalai Willis
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Linwei Wang
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, ON, Canada
| | - Amrita Rao
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Mary Anne Roach
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Refilwe Phaswana-Mafuya
- South African Medical Research Council/University of Johannesburg Pan African Centre for Epidemics Research (PACER) Extramural Unit, Johannesburg, South Africa
- Department of Environmental Health, Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
| | - Le Bao
- Department of Statistics, Pennsylvania State University, University Park, PA, USA
| | - Safiatou Thiam
- Conseil National de Lutte Contre Le Sida, Dakar, Senegal
| | - Peter Arimi
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - Sharmistha Mishra
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation & Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
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Tuyishime E, Remera E, Kayitesi C, Malamba S, Sangwayire B, Habimana Kabano I, Ruisenor-Escudero H, Oluoch T, Unna Chukwu A. Estimation of the Population Size of Street- and Venue-Based Female Sex Workers and Sexually Exploited Minors in Rwanda in 2022: 3-Source Capture-Recapture. JMIR Public Health Surveill 2024; 10:e50743. [PMID: 38488847 PMCID: PMC10980986 DOI: 10.2196/50743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 11/25/2023] [Accepted: 01/10/2024] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND HIV surveillance among key populations is a priority in all epidemic settings. Female sex workers (FSWs) globally as well as in Rwanda are disproportionately affected by the HIV epidemic; hence, the Rwanda HIV and AIDS National Strategic Plan (2018-2024) has adopted regular surveillance of population size estimation (PSE) of FSWs every 2-3 years. OBJECTIVE We aimed at estimating, for the fourth time, the population size of street- and venue-based FSWs and sexually exploited minors aged ≥15 years in Rwanda. METHODS In August 2022, the 3-source capture-recapture method was used to estimate the population size of FSWs and sexually exploited minors in Rwanda. The field work took 3 weeks to complete, with each capture occasion lasting for a week. The sample size for each capture was calculated using shinyrecap with inputs drawn from previously conducted estimation exercises. In each capture round, a stratified multistage sampling process was used, with administrative provinces as strata and FSW hotspots as the primary sampling unit. Different unique objects were distributed to FSWs in each capture round; acceptance of the unique object was marked as successful capture. Sampled FSWs for the subsequent capture occasions were asked if they had received the previously distributed unique object in order to determine recaptures. Statistical analysis was performed in R (version 4.0.5), and Bayesian Model Averaging was performed to produce the final PSE with a 95% credibility set (CS). RESULTS We sampled 1766, 1848, and 1865 FSWs and sexually exploited minors in each capture round. There were 169 recaptures strictly between captures 1 and 2, 210 recaptures exclusively between captures 2 and 3, and 65 recaptures between captures 1 and 3 only. In all 3 captures, 61 FSWs were captured. The median PSE of street- and venue-based FSWs and sexually exploited minors in Rwanda was 37,647 (95% CS 31,873-43,354), corresponding to 1.1% (95% CI 0.9%-1.3%) of the total adult females in the general population. Relative to the adult females in the general population, the western and northern provinces ranked first and second with a higher concentration of FSWs, respectively. The cities of Kigali and eastern province ranked third and fourth, respectively. The southern province was identified as having a low concentration of FSWs. CONCLUSIONS We provide, for the first time, both the national and provincial level population size estimate of street- and venue-based FSWs in Rwanda. Compared with the previous 2 rounds of FSW PSEs at the national level, we observed differences in the street- and venue-based FSW population size in Rwanda. Our study might not have considered FSWs who do not want anyone to know they are FSWs due to several reasons, leading to a possible underestimation of the true PSE.
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Affiliation(s)
- Elysee Tuyishime
- African Center of Excellence in Data Science, University of Rwanda, Kigali, Rwanda
- Division of Global HIV and TB, Global Health Center, US Centers for Disease Control and Prevention, Kigali, Rwanda
| | - Eric Remera
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Rwanda Ministry of Health, Kigali, Rwanda
| | - Catherine Kayitesi
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Rwanda Ministry of Health, Kigali, Rwanda
| | - Samuel Malamba
- Division of Global HIV and TB, Global Health Center, US Centers for Disease Control and Prevention, Kigali, Rwanda
| | - Beata Sangwayire
- Division of Global HIV and TB, Global Health Center, US Centers for Disease Control and Prevention, Kigali, Rwanda
| | | | - Horacio Ruisenor-Escudero
- Key Population Surveillance Team, Epidemiology and Surveillance Branch, Division of Global HIV/TB, Global Health Center, US Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Tom Oluoch
- Division of Global HIV and TB, Global Health Center, US Centers for Disease Control and Prevention, Kigali, Rwanda
| | - Angela Unna Chukwu
- African Center of Excellence in Data Science, University of Rwanda, Kigali, Rwanda
- Department of Statistics, University of Ibadan, Ibadan, Nigeria
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Ugwendum D, Fernando A, Arrey Agbor DB, Ndemazie NB, Forsah SF, Okorie IJ, Villanueva K, Grigos A, Nfonoyim J. An Atypical Presentation of Burkitt Lymphoma Presenting As Large Intra-abdominal Masses Compressing Multiple Organs With Peri-Pericardial Involvement in an HIV Patient: A Case Report and Literature Review. Cureus 2024; 16:e54088. [PMID: 38487136 PMCID: PMC10937252 DOI: 10.7759/cureus.54088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2024] [Indexed: 03/17/2024] Open
Abstract
Many types of malignancies have been associated with immunodeficiency states, especially patients who are HIV positive. Burkitt lymphoma (BL) is one of those malignancies associated with HIV and it presents in three varieties. The endemic form is primarily seen in children, and it is associated with the Epstein-Barr virus (EBV). In this form, patients with Burkitt's present with a large jaw mass. The second variety is seen in older adults. These patients usually present with abdominal and pelvic masses. This subtype is more prominent in the United States. The third variety of BL is seen in patients who are HIV positive. In this case report, we present an atypical presentation of BL secondary to undiagnosed HIV/AIDS with a very large tumor burden causing compressive symptoms. This case will further guide healthcare professionals in diagnosing BL, which presents uniquely in high-risk populations. This report will also serve as a review of the diagnosis and treatment options of BL.
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Affiliation(s)
- Derek Ugwendum
- Internal Medicine, Richmond University Medical Center, Staten Island, USA
| | - Annmarie Fernando
- Internal Medicine, Richmond University Medical Center, Staten Island, USA
| | | | | | - Sabastain F Forsah
- Internal Medicine, Richmond University Medical Center, Staten Island, USA
| | | | - Kevin Villanueva
- Radiology, Richmond University Medical Center, Staten Island, USA
| | - Angela Grigos
- Internal Medicine, Richmond University Medical Center, Staten Island, USA
| | - Jay Nfonoyim
- Pulmonary and Critical Care, Richmond University Medical Center, Staten Island, USA
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Stevens O, Anderson R, Stover J, Teng Y, Stannah J, Silhol R, Jones H, Booton RD, Martin-Hughes R, Johnson L, Maheu-Giroux M, Mishra S, Stone J, Bershteyn A, Kim HY, Sabin K, Mitchell KM, Dimitrov D, Baral S, Donnell D, Korenromp E, Rice B, Hargreaves JR, Vickerman P, Boily MC, Imai-Eaton JW. Comparison of Empirically Derived and Model-Based Estimates of Key Population HIV Incidence and the Distribution of New Infections by Population Group in Sub-Saharan Africa. J Acquir Immune Defic Syndr 2024; 95:e46-e58. [PMID: 38180738 PMCID: PMC10769165 DOI: 10.1097/qai.0000000000003321] [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: 01/06/2024]
Abstract
BACKGROUND The distribution of new HIV infections among key populations, including female sex workers (FSWs), gay men and other men who have sex with men (MSM), and people who inject drugs (PWID) are essential information to guide an HIV response, but data are limited in sub-Saharan Africa (SSA). We analyzed empirically derived and mathematical model-based estimates of HIV incidence among key populations and compared with the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates. METHODS We estimated HIV incidence among FSW and MSM in SSA by combining meta-analyses of empirical key population HIV incidence relative to the total population incidence with key population size estimates (KPSE) and HIV prevalence. Dynamic HIV transmission model estimates of HIV incidence and percentage of new infections among key populations were extracted from 94 country applications of 9 mathematical models. We compared these with UNAIDS-reported distribution of new infections, implied key population HIV incidence and incidence-to-prevalence ratios. RESULTS Across SSA, empirical FSW HIV incidence was 8.6-fold (95% confidence interval: 5.7 to 12.9) higher than total population female 15-39 year incidence, and MSM HIV incidence was 41.8-fold (95% confidence interval: 21.9 to 79.6) male 15-29 year incidence. Combined with KPSE, these implied 12% of new HIV infections in 2021 were among FSW and MSM (5% and 7% respectively). In sensitivity analysis varying KPSE proportions within 95% uncertainty range, the proportion of new infections among FSW and MSM was between 9% and 19%. Insufficient data were available to estimate PWID incidence rate ratios. Across 94 models, median proportion of new infections among FSW, MSM, and PWID was 6.4% (interquartile range 3.2%-11.7%), both much lower than the 25% reported by UNAIDS. CONCLUSION Empirically derived and model-based estimates of HIV incidence confirm dramatically higher HIV risk among key populations in SSA. Estimated proportions of new infections among key populations in 2021 were sensitive to population size assumptions and were substantially lower than estimates reported by UNAIDS.
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Affiliation(s)
- Oliver Stevens
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Rebecca Anderson
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - John Stover
- Center for Modeling, Planning and Policy Analysis, Avenir Health, Glastonbury, CT
| | - Yu Teng
- Center for Modeling, Planning and Policy Analysis, Avenir Health, Glastonbury, CT
| | - James Stannah
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, Canada
| | - Romain Silhol
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
- HIV Prevention Trials Network Modelling Centre, Imperial College London, London, United Kingdom
| | - Harriet Jones
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ross D. Booton
- United Kingdom Heath Security Agency, London, United Kingdom
| | - Rowan Martin-Hughes
- Macfarlane Burnet Institute for Medical Research and Public Health, Melbourne, Australia
| | - Leigh Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Mathieu Maheu-Giroux
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, Canada
| | - Sharmistha Mishra
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Canada
| | - Jack Stone
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Anna Bershteyn
- Department of Population Health, New York University Grossman School of Medicine, New York, NY
| | - Hae-Young Kim
- Department of Population Health, New York University Grossman School of Medicine, New York, NY
| | - Keith Sabin
- Data for Impact, The Joint United Nations Program on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - Kate M. Mitchell
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
- Department of Nursing and Community Health, Glasgow Caledonian University London, London, United Kingdom
| | - Dobromir Dimitrov
- HIV Prevention Trials Network Modelling Centre, Imperial College London, London, United Kingdom
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Deborah Donnell
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Eline Korenromp
- Data for Impact, The Joint United Nations Program on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - Brian Rice
- School of Health and Related Research (SchARR), University of Sheffield, Sheffield, United Kingdom; and
| | - James R. Hargreaves
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Peter Vickerman
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Marie-Claude Boily
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
- HIV Prevention Trials Network Modelling Centre, Imperial College London, London, United Kingdom
| | - Jeffrey W. Imai-Eaton
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA
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5
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Mishra S, Silhol R, Knight J, Phaswana‐Mafuya R, Diouf D, Wang L, Schwartz S, Boily M, Baral S. Estimating the epidemic consequences of HIV prevention gaps among key populations. J Int AIDS Soc 2021; 24 Suppl 3:e25739. [PMID: 34189863 PMCID: PMC8242976 DOI: 10.1002/jia2.25739] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 04/22/2021] [Accepted: 04/28/2021] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION HIV epidemic appraisals are used to characterize heterogeneity and inequities in the context of the HIV pandemic and the response. However, classic measures used in appraisals have been shown to underestimate disproportionate risks of onward transmission, particularly among key populations. In response, a growing number of modelling studies have quantified the consequences of unmet prevention and treatment needs (prevention gaps) among key populations as a transmission population attributable fraction over time (tPAFt ). To aid its interpretation and use by programme implementers and policy makers, we outline and discuss a conceptual framework for understanding and estimating the tPAFt via transmission modelling as a measure of onward transmission risk from HIV prevention gaps; and discuss properties of the tPAFt . DISCUSSION The distribution of onward transmission risks may be defined by who is at disproportionate risk of onward transmission, and under which conditions. The latter reflects prevention gaps, including secondary prevention via treatment: the epidemic consequences of which may be quantified by the tPAFt . Steps to estimating the tPAFt include parameterizing the acquisition and onward transmission risks experienced by the subgroup of interest, defining the most relevant counterfactual scenario, and articulating the time-horizon of analyses and population among whom to estimate the relative difference in cumulative transmissions; such steps could reflect programme-relevant questions about onward transmission risks. Key properties of the tPAFt include larger onward transmission risks over longer time-horizons; seemingly mutually exclusive tPAFt measures summing to greater than 100%; an opportunity to quantify the magnitude of disproportionate onward transmission risks with a per-capita tPAFt ; and that estimates are conditional on what has been achieved so far in reducing prevention gaps and maintaining those conditions moving forward as the status quo. CONCLUSIONS The next generation of HIV epidemic appraisals has the potential to support a more specific HIV response by characterizing heterogeneity in disproportionate risks of onward transmission which are defined and conditioned on the past, current and future prevention gaps across subsets of the population.
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Affiliation(s)
- Sharmistha Mishra
- Department of MedicineUniversity of TorontoTorontoONCanada
- Institute of Medical SciencesUniversity of TorontoTorontoONCanada
- Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoOnCanada
- Li Ka Shing Knowledge InstituteSt. Michael’s HospitalUnity Health TorontoTorontoONCanada
| | - Romain Silhol
- MRC Centre for Global Infectious Disease AnalysisSchool of Public HealthImperial College LondonLondonUnited Kingdom
| | - Jesse Knight
- Institute of Medical SciencesUniversity of TorontoTorontoONCanada
- Li Ka Shing Knowledge InstituteSt. Michael’s HospitalUnity Health TorontoTorontoONCanada
| | | | | | - Linwei Wang
- Li Ka Shing Knowledge InstituteSt. Michael’s HospitalUnity Health TorontoTorontoONCanada
| | - Sheree Schwartz
- Department of EpidemiologyJohns Hopkins School of Public HealthBaltimoreMDUSA
| | - Marie‐Claude Boily
- MRC Centre for Global Infectious Disease AnalysisSchool of Public HealthImperial College LondonLondonUnited Kingdom
| | - Stefan Baral
- Department of EpidemiologyJohns Hopkins School of Public HealthBaltimoreMDUSA
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Stone J, Mukandavire C, Boily M, Fraser H, Mishra S, Schwartz S, Rao A, Looker KJ, Quaife M, Terris‐Prestholt F, Marr A, Lane T, Coetzee J, Gray G, Otwombe K, Milovanovic M, Hausler H, Young K, Mcingana M, Ncedani M, Puren A, Hunt G, Kose Z, Phaswana‐Mafuya N, Baral S, Vickerman P. Estimating the contribution of key populations towards HIV transmission in South Africa. J Int AIDS Soc 2021; 24:e25650. [PMID: 33533115 PMCID: PMC7855076 DOI: 10.1002/jia2.25650] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 10/26/2020] [Accepted: 11/12/2020] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION In generalized epidemic settings, there is insufficient understanding of how the unmet HIV prevention and treatment needs of key populations (KPs), such as female sex workers (FSWs) and men who have sex with men (MSM), contribute to HIV transmission. In such settings, it is typically assumed that HIV transmission is driven by the general population. We estimated the contribution of commercial sex, sex between men, and other heterosexual partnerships to HIV transmission in South Africa (SA). METHODS We developed the "Key-Pop Model"; a dynamic transmission model of HIV among FSWs, their clients, MSM, and the broader population in SA. The model was parameterized and calibrated using demographic, behavioural and epidemiological data from national household surveys and KP surveys. We estimated the contribution of commercial sex, sex between men and sex among heterosexual partnerships of different sub-groups to HIV transmission over 2010 to 2019. We also estimated the efficiency (HIV infections averted per person-year of intervention) and prevented fraction (% IA) over 10-years from scaling-up ART (to 81% coverage) in different sub-populations from 2020. RESULTS Sex between FSWs and their paying clients, and between clients with their non-paying partners contributed 6.9% (95% credibility interval 4.5% to 9.3%) and 41.9% (35.1% to 53.2%) of new HIV infections in SA over 2010 to 2019 respectively. Sex between low-risk groups contributed 59.7% (47.6% to 68.5%), sex between men contributed 5.3% (2.3% to 14.1%) and sex between MSM and their female partners contributed 3.7% (1.6% to 9.8%). Going forward, the largest population-level impact on HIV transmission can be achieved from scaling up ART to clients of FSWs (% IA = 18.2% (14.0% to 24.4%) or low-risk individuals (% IA = 20.6% (14.7 to 27.5) over 2020 to 2030), with ART scale-up among KPs being most efficient. CONCLUSIONS Clients of FSWs play a fundamental role in HIV transmission in SA. Addressing the HIV prevention and treatment needs of KPs in generalized HIV epidemics is central to a comprehensive HIV response.
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Affiliation(s)
- Jack Stone
- Population Health SciencesUniversity of BristolBristolUnited Kingdom
| | - Christinah Mukandavire
- Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Marie‐Claude Boily
- Department of Infectious Disease EpidemiologyImperial CollegeLondonUnited Kingdom
| | - Hannah Fraser
- Population Health SciencesUniversity of BristolBristolUnited Kingdom
| | | | - Sheree Schwartz
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Amrita Rao
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | | | - Matthew Quaife
- London School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | | | - Alexander Marr
- University of California San FranciscoSan FranciscoCAUSA
| | - Tim Lane
- Equal InternationalWashingtonDCUSA
| | - Jenny Coetzee
- Perinatal HIV Research UnitFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- South African Medical Research CouncilCape TownSouth Africa
| | - Glenda Gray
- South African Medical Research CouncilCape TownSouth Africa
| | - Kennedy Otwombe
- Perinatal HIV Research UnitFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Minja Milovanovic
- Perinatal HIV Research UnitFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | | | | | | | | | - Adrian Puren
- National Institute of Communicable DiseasesJohannesburgSouth Africa
| | - Gillian Hunt
- National Institute of Communicable DiseasesJohannesburgSouth Africa
| | - Zamakayise Kose
- Research and Innovation OfficeNorth West UniversityPotchefstroomSouth Africa
| | | | - Stefan Baral
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Peter Vickerman
- Population Health SciencesUniversity of BristolBristolUnited Kingdom
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Knight J, Baral SD, Schwartz S, Wang L, Ma H, Young K, Hausler H, Mishra S. Contribution of high risk groups' unmet needs may be underestimated in epidemic models without risk turnover: A mechanistic modelling analysis. Infect Dis Model 2020; 5:549-562. [PMID: 32913937 PMCID: PMC7452422 DOI: 10.1016/j.idm.2020.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/13/2020] [Accepted: 07/17/2020] [Indexed: 12/24/2022] Open
Abstract
Background Epidemic models of sexually transmitted infections (STIs) are often used to characterize the contribution of risk groups to overall transmission by projecting the transmission population attributable fraction (tPAF) of unmet prevention and treatment needs within risk groups. However, evidence suggests that STI risk is dynamic over an individual’s sexual life course, which manifests as turnover between risk groups. We sought to examine the mechanisms by which turnover influences modelled projections of the tPAF of high risk groups. Methods We developed a unifying, data-guided framework to simulate risk group turnover in deterministic, compartmental transmission models. We applied the framework to an illustrative model of an STI and examined the mechanisms by which risk group turnover influenced equilibrium prevalence across risk groups. We then fit a model with and without turnover to the same risk-stratified STI prevalence targets and compared the inferred level of risk heterogeneity and tPAF of the highest risk group projected by the two models. Results The influence of turnover on group-specific prevalence was mediated by three main phenomena: movement of previously high risk individuals with the infection into lower risk groups; changes to herd effect in the highest risk group; and changes in the number of partnerships where transmission can occur. Faster turnover led to a smaller ratio of STI prevalence between the highest and lowest risk groups. Compared to the fitted model without turnover, the fitted model with turnover inferred greater risk heterogeneity and consistently projected a larger tPAF of the highest risk group over time. Implications If turnover is not captured in epidemic models, the projected contribution of high risk groups, and thus, the potential impact of prioritizing interventions to address their needs, could be underestimated. To aid the next generation of tPAF models, data collection efforts to parameterize risk group turnover should be prioritized. A new framework for parameterizing turnover in risk groups is developed. Mechanisms by which turnover influences sexually transmitted infection (STI), prevalence in risk groups are examined. Turnover reduces the ratio of equilibrium STI prevalence in high vs low risk groups. Inferred risk heterogeneity is higher when fitting transmission models with turnover. Ignoring turnover in risk could underestimate the transmission population attributable fraction (tPAF), of high risk groups to the overall epidemic.
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Affiliation(s)
- Jesse Knight
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Canada
| | - Stefan D Baral
- Deptartment of Epidemiology, Johns Hopkins Bloomberg School of Public Health, USA
| | - Sheree Schwartz
- Deptartment of Epidemiology, Johns Hopkins Bloomberg School of Public Health, USA
| | - Linwei Wang
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Canada
| | - Huiting Ma
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Canada
| | | | | | - Sharmistha Mishra
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Canada.,Division of Infectious Disease, Department of Medicine, University of Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Canada.,Institute of Medical Sciences, University of Toronto, Canada
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Abstract
Purpose of review To explore the comparative importance of HIV infections among key populations and their intimate partners as HIV epidemics evolve, and to review implications for guiding responses. Recent findings Even as concentrated epidemics evolve, new infections among current and former key population members and their intimate partners dominate new infections. Prevalent infections in the general population grow primarily because of key population turnover and infections among their intimate partners. In generalized epidemic settings, data and analysis on key populations are often inadequate to assess the impact of key population-focused responses, so they remain limited in coverage and under resourced. Models must incorporate downstream infections in comparing impacts of alternative responses. Summary Recognize that every epidemic is unique, moving beyond the overly simplistic concentrated/generalized epidemic paradigm that can misdirect resources. Guide HIV responses by gathering and using locally relevant data, understanding risk heterogeneity, and applying modeling at both national and sub-national levels to optimize resource allocations among different populations for greatest impact. Translate this improved understanding into clear, unequivocal advice for policymakers on where to focus for impact, breaking them free of the generalized/concentrated paradigm limiting their thinking and affecting their decisions.
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The Spectrum-STI Groups model: syphilis prevalence trends across high-risk and lower-risk populations in Yunnan, China. Sci Rep 2020; 10:5472. [PMID: 32214152 PMCID: PMC7096386 DOI: 10.1038/s41598-020-62208-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 03/09/2020] [Indexed: 11/08/2022] Open
Abstract
The Spectrum-STI model, structured by sub-groups within a population, was used in a workshop in Yunnan, China, to estimate provincial trends in active syphilis in 15 to 49-year-old adults. Syphilis prevalence data from female sex workers (FSW), men who have sex with men (MSM), and lower-risk women and men in Yunnan were identified through literature searches and local experts. Sources included antenatal care clinic screening, blood donor screening, HIV/STI bio-behavioural surveys, sentinel surveillance, and epidemiology studies. The 2017 provincial syphilis prevalence estimates were 0.26% (95% confidence interval 0.17-0.34%) in women and 0.28% (0.20-0.36%) in men. Estimated prevalence was 6.8-fold higher in FSW (1.69% (0.68-3.97%) than in lower-risk women (0.25% (0.18-0.35%)), and 22.7-fold higher in MSM (5.35% (2.74-12.47%) than in lower-risk men (0.24% (0.17-0.31%). For all populations, the 2017 estimates were below the 2005 estimates, but differences were not significant. In 2017 FSW and MSM together accounted for 9.3% of prevalent cases. These estimates suggest Yunnan's STI programs have kept the overall prevalence of syphilis low, but prevalence remains high in FSW and MSM. Strengthening efforts targeting FSW and MSM, and identification of other risk populations e.g. among heterosexual men, are critical to reduce syphilis.
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Evaluation of Selected Outcomes of Combination Antiretroviral Therapy: Yemen Cohort Retrospective Descriptive Studies. Sci Rep 2019; 9:19923. [PMID: 31882645 PMCID: PMC6934668 DOI: 10.1038/s41598-019-56314-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 12/10/2019] [Indexed: 11/12/2022] Open
Abstract
In 2007, HIV treatment services were established in five main governorates out of twenty-two which resulted in low access to services and poor treatment outcomes. The main goal of this study was to evaluate and analyse the selected treatment outcomes of eight cohorts of PLHIV who were treated with cART during 2007–2014. The method used was a retrospective descriptive study of 1,703 PLHIV who initiated cART at five public health facilities. The results: Retention rate was less than 80%, male: female ratio 1.661, with a mean age of 35 years (±9.2 SD), 85% had been infected with HIV via heterosexual contact. 65% of patients presented with clinical stages 3 and 4, and 52% of them were initiated cART at a CD4 T-cell count ≤200 cells/mm. 61% of cART included Tenofovir and Efavirenz. TB treatment started for 5% of PLHIV, and 22% developed HIV-related clinical manifestations after cART initiation. 67% of PLHIV had experienced cART substitution. The mean AIDS-mortality rate was 15% and the mean LTFU rate was 16%. Conclusion: Although cART showed effectiveness in public health, mobilization of resources and formulation of better health policies are important steps toward improving access to cART and achieving the desired treatment outcomes.
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Rao A, Ewing W, Ketende S, Wirtz AL, Jumbe V, Trapence G, Kamba D, Umar E, Beyrer C, Muula AS, Baral S. Correlates of Water-Based Lubricant Use Among Men Who Have Sex with Men in Blantyre, Malawi. AIDS Res Hum Retroviruses 2019; 35:833-841. [PMID: 31204861 DOI: 10.1089/aid.2018.0287] [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: 11/12/2022] Open
Abstract
Condom compatible lubricants (CCLs), including water-based lubricants (WBL) represent one strategy to prevent the breakage of latex condoms and thus decrease the risk of HIV transmission during anal intercourse. The analyses presented here characterize the correlates of WBL use during anal sex among men who have sex with men (MSM) in Blantyre, Malawi enrolled from April 2011 to March 2012 using respondent-driven sampling (RDS). Bivariate and multivariable logistic regression analyses with RDS-weighting were conducted on a total sample of 338 MSM. With RDS-weighting, 25.4% [95% confidence interval (CI): 20.3-31.4] of MSM (106/329) reported primarily using WBL during anal sex. In multivariable analysis, higher income [adjusted odds ratio (aOR): 5.9; 95% CI: 2.48-14.19], family being aware of their sexual practices (aOR: 2.52; 95% CI: 1.29-4.92), and reporting consistent condom use in the last 6 months (aOR: 1.27; 95% CI: 1.06-1.52) were positively associated with WBL use. Increasing age (per 1 year increase in age; aOR: 0.89; 95% CI: 0.83-0.95) was negatively associated with WBL. Taken together, these data highlight the limited uptake of WBL among MSM in Blantyre, Malawi, especially among older men and those belonging with lower income. Older MSM in Malawi are known to have a higher prevalence of HIV and lower reported use of WBL, suggesting significant risks of onward HIV transmission. Separately, the limited use among those with lower incomes suggests the need for free or subsidized distribution of CCL together with condoms and counseling about their use specifically for MSM in Malawi.
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Affiliation(s)
- Amrita Rao
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Whitney Ewing
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sosthenes Ketende
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Andrea L. Wirtz
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Vincent Jumbe
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
- Centre for Global Health, Trinity College, Dublin, Ireland
| | - Gift Trapence
- Centre for the Development of People, Blantyre, Malawi
| | - Dunker Kamba
- Centre for the Development of People, Blantyre, Malawi
| | - Eric Umar
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Chris Beyrer
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Adamson S. Muula
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Stefan Baral
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
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Leveraging Geospatial Approaches to Characterize the HIV Prevention and Treatment Needs of Out-of-School Adolescent Girls and Young Women in Ethiopia. AIDS Behav 2019; 23:183-193. [PMID: 31134462 PMCID: PMC6773675 DOI: 10.1007/s10461-019-02537-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Adolescent girls and young women (AGYW) remain underserved and at risk for HIV acquisition in Ethiopia. However, there is significant risk heterogeneity among AGYW with limited consensus on optimal strategies of identifying vulnerable AGYW. This study assessed the utility of venue-based sampling approaches to identify AGYW at increased risk for HIV infection. Venue mapping and time-location-sampling (TLS) methods were used to recruit AGYW from three sub-cities of Addis Ababa, February–June 2018. Interviewer-administered surveys captured socio-demographic and behavioral characteristics. Measures of AGYW vulnerability were assessed geographically and described by venue type. A total of 2468 unique venues were identified, of which 802 (32%) were systematically selected for validation and 371 (46%) were eligible including many sites that would traditionally not be included as venues in need of HIV prevention services. Overall, 800 AGYW were enrolled across 81 sampled venues. AGYW reached were largely out-of-school (n = 599, 75%) with high proportions of AGYW reporting transactional sex (n = 101, 12.6%), food insecurity (n = 165, 20.7%) and migration (n = 565, 70.6%). Taken together, these data suggest the utility of TLS methods in reaching vulnerable, out-of-school AGYW in Addis Ababa, Ethiopia.
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Timba-Emmanuel T, Kroll T, Renfrew MJ, MacGillivray S. Understanding the experiences of married Southern African women in protecting themselves from HIV/AIDS: a systematic review and meta-synthesis. ETHNICITY & HEALTH 2019; 24:623-644. [PMID: 28748704 DOI: 10.1080/13557858.2017.1357067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 06/30/2017] [Indexed: 06/07/2023]
Abstract
Background: Whilst marriage has been repeatedly identified in the literature as an HIV risk factor amongst Southern African women, not much is known about women's perception of their role, experiences and strategies used to address HIV risks in the context of a marriage. Aims: The aim of the study was to synthesise perceptions, experiences and strategies of married Southern African women in the prevention of HIV. Methods: A systematic review of qualitative studies was conducted. Three electronic databases (Medline, Cinahl and PsycINFO) were systematically searched to identify relevant literature. The meta-synthesis process followed Sandelowski and Barroso's [2007. Handbook for Synthesizing Qualitative Research. Springer Publishing Company] recommendations. Results: Of 7 609 papers, 15 were included in the review. The quality of the included studies was variable. In the final synthesis stage, three broad analytic themes emerged: contextual background, cues to preventive behaviour, and HIV prevention strategies. Implications: Findings were used to develop a conceptual framework for studying HIV/AIDS prevention experiences of married Southern African women.
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Affiliation(s)
| | - Thilo Kroll
- b School of Nursing, Midwifery and Health Systems , University College Dublin , Dublin , Ireland
| | - Mary J Renfrew
- a School of Nursing and Health Sciences , University of Dundee , Dundee , Scotland
| | - Steve MacGillivray
- a School of Nursing and Health Sciences , University of Dundee , Dundee , Scotland
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Abstract
PURPOSE OF REVIEW This review summarizes the use of genetic similarity clusters to understand HIV transmission and inform prevention efforts. RECENT FINDINGS Recent emphases include the development of real-time cluster identification in order to interrupt transmission chains, the use of clusters to estimate rates of transmission along the HIV care cascade, and the extension of cluster analyses to understand transmission in the generalized epidemics of sub-Saharan Africa. Importantly, this recent empirical work has been accompanied by theoretical work that elucidates the processes that underlie HIV genetic similarity clusters; multiple studies suggest that clusters are not necessarily enriched with individuals with high transmission rates, but rather can reflect variation in sampling times within a population, with individuals sampled early in infection more likely to cluster. Analyses of genetic similarity clusters have great promise to inform HIV epidemiology and prevention. Future emphases should include the collection of additional sequence data from underrepresented populations, such as those in sub-Saharan Africa, and further development and evaluation of clustering methods.
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Affiliation(s)
- Mary Kate Grabowski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Rakai Health Sciences Program, Baltimore, MD, USA
| | - Joshua T Herbeck
- International Clinical Research Center, Department of Global Health, University of Washington, Seattle, WA, USA.
| | - Art F Y Poon
- Department of Pathology and Laboratory Medicine, Western University, London, ON, Canada
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Hill AL, Rosenbloom DIS, Nowak MA, Siliciano RF. Insight into treatment of HIV infection from viral dynamics models. Immunol Rev 2018; 285:9-25. [PMID: 30129208 PMCID: PMC6155466 DOI: 10.1111/imr.12698] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The odds of living a long and healthy life with HIV infection have dramatically improved with the advent of combination antiretroviral therapy. Along with the early development and clinical trials of these drugs, and new field of research emerged called viral dynamics, which uses mathematical models to interpret and predict the time-course of viral levels during infection and how they are altered by treatment. In this review, we summarize the contributions that virus dynamics models have made to understanding the pathophysiology of infection and to designing effective therapies. This includes studies of the multiphasic decay of viral load when antiretroviral therapy is given, the evolution of drug resistance, the long-term persistence latently infected cells, and the rebound of viremia when drugs are stopped. We additionally discuss new work applying viral dynamics models to new classes of investigational treatment for HIV, including latency-reversing agents and immunotherapy.
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Affiliation(s)
- Alison L. Hill
- Program for Evolutionary DynamicsHarvard UniversityCambridgeMassachusetts
| | - Daniel I. S. Rosenbloom
- Department of PharmacokineticsPharmacodynamics, & Drug MetabolismMerck Research LaboratoriesKenilworthNew Jersey
| | - Martin A. Nowak
- Program for Evolutionary DynamicsHarvard UniversityCambridgeMassachusetts
| | - Robert F. Siliciano
- Department of MedicineJohns Hopkins University School of MedicineBaltimoreMaryland
- Howard Hughes Medical InstituteBaltimoreMaryland
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Mukandavire C, Walker J, Schwartz S, Boily M, Danon L, Lyons C, Diouf D, Liestman B, Diouf NL, Drame F, Coly K, Muhire RSM, Thiam S, Diallo PAN, Kane CT, Ndour C, Volz E, Mishra S, Baral S, Vickerman P. Estimating the contribution of key populations towards the spread of HIV in Dakar, Senegal. J Int AIDS Soc 2018; 21 Suppl 5:e25126. [PMID: 30033604 PMCID: PMC6055131 DOI: 10.1002/jia2.25126] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 05/16/2018] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Key populations including female sex workers (FSW) and men who have sex with men (MSM) bear a disproportionate burden of HIV. However, the role of focusing prevention efforts on these groups for reducing a country's HIV epidemic is debated. We estimate the extent to which HIV transmission among FSW and MSM contributes to overall HIV transmission in Dakar, Senegal, using a dynamic assessment of the population attributable fraction (PAF). METHODS A dynamic transmission model of HIV among FSW, their clients, MSM and the lower-risk adult population was parameterized and calibrated within a Bayesian framework using setting-specific demographic, behavioural, HIV epidemiological and antiretroviral treatment (ART) coverage data for 1985 to 2015. We used the model to estimate the 10-year PAF of commercial sex between FSW and their clients, and sex between men, to overall HIV transmission (defined as the percentage of new infections prevented when these modes of transmission are removed). In addition, we estimated the prevention benefits associated with historical increases in condom use and ART uptake, and impact of further increases in prevention and treatment. RESULTS The model projections suggest that unprotected sex between men contributed to 42% (2.5 to 97.5th percentile range 24 to 59%) of transmissions between 1995 and 2005, increasing to 64% (37 to 79%) from 2015 to 2025. The 10-year PAF of commercial sex is smaller, diminishing from 21% (7 to 39%) in 1995 to 14% (5 to 35%) in 2015. Without ART, 49% (32 to 71%) more HIV infections would have occurred since 2000, when ART was initiated, whereas without condom use since 1985, 67% (27 to 179%) more HIV infections would have occurred, and the overall HIV prevalence would have been 60% (29 to 211%) greater than what it is now. Further large decreases in HIV incidence (68%) can be achieved by scaling up ART in MSM to 74% coverage and reducing their susceptibility to HIV by two-thirds through any prevention modality. CONCLUSIONS Unprotected sex between men may be an important contributor to HIV transmission in Dakar, due to suboptimal coverage of evidence-informed interventions. Although existing interventions have effectively reduced HIV transmission among adults, it is crucial that further strategies address the unmet need among MSM.
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Affiliation(s)
| | - Josephine Walker
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Sheree Schwartz
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | | | - Leon Danon
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
- College of Engineering, Mathematics and Physical SciencesUniversity of ExeterExeterUK
| | - Carrie Lyons
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | | | - Ben Liestman
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Nafissatou Leye Diouf
- Institut de Recherche en Santéde Surveillance Epidemiologique et de FormationsDakarSenegal
| | | | - Karleen Coly
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | | | - Safiatou Thiam
- Department of HealthNational AIDS Council of SenegalDakarSenegal
| | | | - Coumba Toure Kane
- Institut de Recherche en Santéde Surveillance Epidemiologique et de FormationsDakarSenegal
| | - Cheikh Ndour
- Division de La Lutte Contre Le Sida et Les ISTMinistry of HealthDakarSenegal
| | - Erik Volz
- Department of Infectious Disease EpidemiologyImperial CollegeLondonUK
| | | | - Stefan Baral
- Department of Infectious Disease EpidemiologyImperial CollegeLondonUK
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
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Belus JM, Kline T, Carney T, Myers B, Wechsberg WM. Measuring Relationship Functioning in South African Couples: A Strategy for Improving HIV Prevention Efforts. SEXUAL AND RELATIONSHIP THERAPY 2018; 35:2-14. [PMID: 32728347 PMCID: PMC7388832 DOI: 10.1080/14681994.2017.1419559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 11/15/2017] [Indexed: 10/18/2022]
Abstract
Over the past decade there has been increased focus on targeting couples in HIV prevention efforts, particularly in sub-Saharan Africa where HIV transmission primarily occurs through heterosexual contact, in the context of intersecting alcohol use and intimate partner violence (IPV). However, little is known about couples' general relationship functioning. This understanding is needed to augment couple-based HIV prevention programs and address risk for IPV. This paper presents data on domains of relationship functioning with 300 South African couples who were recruited for an HIV prevention study. Exploratory and confirmatory factor analyses were conducted to determine the relevance of 17 individual items, as well as the overall factor structure of the questions. Results revealed three independent factors of relationship functioning: relationship satisfaction, arguing, and open communication; an overarching construct of relationship functioning for these three domains was not observed in the data. Results provide insight into the structure of relationship functioning questions and subscales that can be used to assess South African adult romantic relationships. This may allow for a greater focus on aspects of relationships within couple-based HIV prevention programs going forward.
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Affiliation(s)
- Jennifer M. Belus
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Davie Hall CB # 3270, Chapel Hill, NC, 27599, USA
| | - Tracy Kline
- Statistics and Epidemiology, RTI International, 3040 Cornwallis Rd., Research Triangle Park, NC, 27709, USA
| | - Tara Carney
- Alcohol Tobacco and Other Drug Research Unit, South African Medical Research Council, Francie van Zijl Drive, Cape Town, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, J-Block, Groote Schurr Hospital, Observatory, Cape Town, South Africa
| | - Bronwyn Myers
- Alcohol Tobacco and Other Drug Research Unit, South African Medical Research Council, Francie van Zijl Drive, Cape Town, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, J-Block, Groote Schurr Hospital, Observatory, Cape Town, South Africa
| | - Wendee M. Wechsberg
- Substance Use, Gender and Applied Research, RTI International, 3040 Cornwallis Rd., Research Triangle Park, NC, 27709, USA
- Health Policy and Management, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
- Psychology in the Public Interest, North Carolina State University, 640 Poe Hall, CB#7650, Raleigh, NC, 27695, USA
- Psychiatry and Behavioral Sciences, Duke University, 4584 White Zone, Duke South, CB#3950, Durham, NC, USA
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Rao A, Stahlman S, Hargreaves J, Weir S, Edwards J, Rice B, Kochelani D, Mavimbela M, Baral S. Sampling Key Populations for HIV Surveillance: Results From Eight Cross-Sectional Studies Using Respondent-Driven Sampling and Venue-Based Snowball Sampling. JMIR Public Health Surveill 2017; 3:e72. [PMID: 29054832 PMCID: PMC5670312 DOI: 10.2196/publichealth.8116] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/15/2017] [Accepted: 08/31/2017] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND In using regularly collected or existing surveillance data to characterize engagement in human immunodeficiency virus (HIV) services among marginalized populations, differences in sampling methods may produce different pictures of the target population and may therefore result in different priorities for response. OBJECTIVE The objective of this study was to use existing data to evaluate the sample distribution of eight studies of female sex workers (FSW) and men who have sex with men (MSM), who were recruited using different sampling approaches in two locations within Sub-Saharan Africa: Manzini, Swaziland and Yaoundé, Cameroon. METHODS MSM and FSW participants were recruited using either respondent-driven sampling (RDS) or venue-based snowball sampling. Recruitment took place between 2011 and 2016. Participants at each study site were administered a face-to-face survey to assess sociodemographics, along with the prevalence of self-reported HIV status, frequency of HIV testing, stigma, and other HIV-related characteristics. Crude and RDS-adjusted prevalence estimates were calculated. Crude prevalence estimates from the venue-based snowball samples were compared with the overlap of the RDS-adjusted prevalence estimates, between both FSW and MSM in Cameroon and Swaziland. RESULTS RDS samples tended to be younger (MSM aged 18-21 years in Swaziland: 47.6% [139/310] in RDS vs 24.3% [42/173] in Snowball, in Cameroon: 47.9% [99/306] in RDS vs 20.1% [52/259] in Snowball; FSW aged 18-21 years in Swaziland 42.5% [82/325] in RDS vs 8.0% [20/249] in Snowball; in Cameroon 15.6% [75/576] in RDS vs 8.1% [25/306] in Snowball). They were less educated (MSM: primary school completed or less in Swaziland 42.6% [109/310] in RDS vs 4.0% [7/173] in Snowball, in Cameroon 46.2% [138/306] in RDS vs 14.3% [37/259] in Snowball; FSW: primary school completed or less in Swaziland 86.6% [281/325] in RDS vs 23.9% [59/247] in Snowball, in Cameroon 87.4% [520/576] in RDS vs 77.5% [238/307] in Snowball) than the snowball samples. In addition, RDS samples indicated lower exposure to HIV prevention information, less knowledge about HIV prevention, limited access to HIV prevention tools such as condoms, and less-reported frequency of sexually transmitted infections (STI) and HIV testing as compared with the venue-based samples. Findings pertaining to the level of disclosure of sexual practices and sexual practice-related stigma were mixed. CONCLUSIONS Samples generated by RDS and venue-based snowball sampling produced significantly different prevalence estimates of several important characteristics. These findings are tempered by limitations to the application of both approaches in practice. Ultimately, these findings provide further context for understanding existing surveillance data and how differences in methods of sampling can influence both the type of individuals captured and whether or not these individuals are representative of the larger target population. These data highlight the need to consider how program coverage estimates of marginalized populations are determined when characterizing the level of unmet need.
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Affiliation(s)
- Amrita Rao
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Shauna Stahlman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - James Hargreaves
- Measurement and Surveillance of HIV Epidemics Consortium, Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sharon Weir
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, United States
| | - Jessie Edwards
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, United States
| | - Brian Rice
- Measurement and Surveillance of HIV Epidemics Consortium, Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Duncan Kochelani
- Center for Communication Programs, Johns Hopkins University, Mbabane, Swaziland
| | | | - Stefan Baral
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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Changing Dynamics of HIV Transmission in Côte d'Ivoire: Modeling Who Acquired and Transmitted Infections and Estimating the Impact of Past HIV Interventions (1976-2015). J Acquir Immune Defic Syndr 2017; 75:517-527. [PMID: 28471837 DOI: 10.1097/qai.0000000000001434] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Understanding the impact of past interventions and how it affected transmission dynamics is key to guiding prevention efforts. We estimated the population-level impact of condom, antiretroviral therapy (ART), and prevention of mother-to-child transmission activities on HIV transmission and the contribution of key risk factors on HIV acquisition and transmission. METHODS An age-stratified dynamical model of sexual and vertical HIV transmission among the general population, female sex workers (FSW), and men who have sex with men was calibrated to detailed prevalence and intervention data. We estimated the fraction of HIV infections averted by the interventions, and the fraction of incident infections acquired and transmitted by different populations over successive 10-year periods (1976-2015). RESULTS Overall, condom use averted 61% (95% credible intervals: 56%-66%) of all adult infections during 1987-2015 mainly because of increased use by FSW (46% of infections averted). In comparison, ART prevented 15% (10%-19%) of adult infections during 2010-2015. As a result, FSW initially (1976-1985) contributed 95% (91%-97%) of all new infections, declining to 19% (11%-27%) during 2005-2015. Older men and clients mixing with non-FSW are currently the highest contributors to transmission. Men who have sex with men contributed ≤4% transmissions throughout. Young women (15-24 years; excluding FSW) do not transmit more infections than they acquired. CONCLUSIONS Early increases in condom use, mainly by FSW, have substantially reduced HIV transmission. Clients of FSWs and older men have become the main source of transmission, whereas young women remain at increased risk. Strengthening prevention and scaling-up of ART, particularly to FSW and clients of female sex workers, is important.
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Morar MM, Pitman JP, McFarland W, Bloch EM. The contribution of unsafe blood transfusion to human immunodeficiency virus incidence in sub-Saharan Africa: reexamination of the 5% to 10% convention. Transfusion 2016; 56:3121-3132. [PMID: 27663172 DOI: 10.1111/trf.13816] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 06/21/2016] [Accepted: 07/28/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND Historical estimates have attributed 5% to 10% of new human immunodeficiency virus (HIV) infections in sub-Saharan Africa (SSA) to unsafe blood transfusions. Although frequently cited, the validity of this statistic is uncertain or outdated. Recent estimates suggest blood transfusion's contribution to new HIV infections in the region may be much lower. STUDY DESIGN AND METHODS We searched the peer-reviewed and gray literature for quantitative estimates of the specific contribution of unsafe blood transfusion to the proportion of new HIV infections occurring in SSA. The sources and methods used to generate attribution estimates were evaluated against published country-specific HIV prevalence data. RESULTS Despite multiple secondary citations, a primary published source attributing 5% to 10% of new HIV infections to blood transfusions in SSA could not be established for the current era. The United Nations Programme on HIV and AIDS (UNAIDS) modes of transmission (MOT) reports representing 15 countries suggest that between 0 and 1.1% of new HIV infections per year (median, 0.2% or approx. two out of 1000 new infections each year) may be attributable to blood transfusions. CONCLUSION Recent modeled estimates suggest that blood transfusions account for a very low proportion of new HIV infections in SSA, likely an order of magnitude lower than 5% to 10%. Direct quantification of risk is challenging given the paucity of data on the variables that impact transfusion-associated HIV. Specifically, data on HIV incidence in blood donors, blood bank laboratory test performance, and posttransfusion surveillance are lacking. Findings suggest an urgent need for improved surveillance and modeling of transfusion-associated HIV transmission in the region.
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Affiliation(s)
- Malika M Morar
- University of California at San Francisco, San Francisco, California
| | - John P Pitman
- Institute of Science in Healthy Aging & health caRE (SHARE), University of Groningen, University Medical Center Groningen (UMCG), Groningen, The Netherlands
| | - Willi McFarland
- University of California at San Francisco, San Francisco, California
| | - Evan M Bloch
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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Bórquez A, Cori A, Pufall EL, Kasule J, Slaymaker E, Price A, Elmes J, Zaba B, Crampin AC, Kagaayi J, Lutalo T, Urassa M, Gregson S, Hallett TB. The Incidence Patterns Model to Estimate the Distribution of New HIV Infections in Sub-Saharan Africa: Development and Validation of a Mathematical Model. PLoS Med 2016; 13:e1002121. [PMID: 27622516 PMCID: PMC5021265 DOI: 10.1371/journal.pmed.1002121] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 08/03/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Programmatic planning in HIV requires estimates of the distribution of new HIV infections according to identifiable characteristics of individuals. In sub-Saharan Africa, robust routine data sources and historical epidemiological observations are available to inform and validate such estimates. METHODS AND FINDINGS We developed a predictive model, the Incidence Patterns Model (IPM), representing populations according to factors that have been demonstrated to be strongly associated with HIV acquisition risk: gender, marital/sexual activity status, geographic location, "key populations" based on risk behaviours (sex work, injecting drug use, and male-to-male sex), HIV and ART status within married or cohabiting unions, and circumcision status. The IPM estimates the distribution of new infections acquired by group based on these factors within a Bayesian framework accounting for regional prior information on demographic and epidemiological characteristics from trials or observational studies. We validated and trained the model against direct observations of HIV incidence by group in seven rounds of cohort data from four studies ("sites") conducted in Manicaland, Zimbabwe; Rakai, Uganda; Karonga, Malawi; and Kisesa, Tanzania. The IPM performed well, with the projections' credible intervals for the proportion of new infections per group overlapping the data's confidence intervals for all groups in all rounds of data. In terms of geographical distribution, the projections' credible intervals overlapped the confidence intervals for four out of seven rounds, which were used as proxies for administrative divisions in a country. We assessed model performance after internal training (within one site) and external training (between sites) by comparing mean posterior log-likelihoods and used the best model to estimate the distribution of HIV incidence in six countries (Gabon, Kenya, Malawi, Rwanda, Swaziland, and Zambia) in the region. We subsequently inferred the potential contribution of each group to transmission using a simple model that builds on the results from the IPM and makes further assumptions about sexual mixing patterns and transmission rates. In all countries except Swaziland, individuals in unions were the single group contributing to the largest proportion of new infections acquired (39%-77%), followed by never married women and men. Female sex workers accounted for a large proportion of new infections (5%-16%) compared to their population size. Individuals in unions were also the single largest contributor to the proportion of infections transmitted (35%-62%), followed by key populations and previously married men and women. Swaziland exhibited different incidence patterns, with never married men and women accounting for over 65% of new infections acquired and also contributing to a large proportion of infections transmitted (up to 56%). Between- and within-country variations indicated different incidence patterns in specific settings. CONCLUSIONS It is possible to reliably predict the distribution of new HIV infections acquired using data routinely available in many countries in the sub-Saharan African region with a single relatively simple mathematical model. This tool would complement more specific analyses to guide resource allocation, data collection, and programme planning.
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Affiliation(s)
- Annick Bórquez
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
- Division of Global Public Health, University of California San Diego, San Diego, California, United States of America
- * E-mail:
| | - Anne Cori
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Erica L. Pufall
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | | | - Emma Slaymaker
- Department of Population Health, London School of Hygiene &Tropical Medicine, London, United Kingdom
| | - Alison Price
- Department of Population Health, London School of Hygiene &Tropical Medicine, London, United Kingdom
| | - Jocelyn Elmes
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Basia Zaba
- Department of Population Health, London School of Hygiene &Tropical Medicine, London, United Kingdom
| | - Amelia C. Crampin
- Department of Population Health, London School of Hygiene &Tropical Medicine, London, United Kingdom
| | | | - Tom Lutalo
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Mark Urassa
- Mwanza Research Centre, National Institute for Medical Research, Mwanza, Tanzania
| | - Simon Gregson
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Timothy B. Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
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HIV epidemics among transgender populations: the importance of a trans-inclusive response. J Int AIDS Soc 2016. [DOI: 10.7448/ias.19.3.21259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Silva-Santisteban A, Eng S, de la Iglesia G, Falistocco C, Mazin R. HIV prevention among transgender women in Latin America: implementation, gaps and challenges. J Int AIDS Soc 2016; 19:20799. [PMID: 27431470 PMCID: PMC4949309 DOI: 10.7448/ias.19.3.20799] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 04/21/2016] [Accepted: 04/26/2016] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Transgender women are the population most vulnerable to HIV in Latin America, with prevalence between 18 and 38%. Although the region has improved antiretroviral coverage, there is an urgent need to strengthen HIV prevention for key populations to meet regional targets set by governments. We conducted an assessment on the state of HIV prevention among transgender women in Latin America. METHODS We conducted a desk review of Global AIDS Response Progress Reports, national strategic plans, technical reports and peer-reviewed articles from 17 Latin American countries published through January 2015. The review was preceded by 12 semi-structured interviews with UNAIDS and Pan American Health Organization officers and a discussion group with transgender women regional leaders, to guide the identification of documents. We assessed access to, implementation and coverage of programmes; legal frameworks; community participation; inclusion of new strategies; and alignment with international recommendations. RESULTS AND DISCUSSION Overall, prevention activities in the region focus on condom distribution, diagnosis of sexually transmitted infections and peer education, mostly delivered at health facilities, with limited community involvement. Argentina and Uruguay have implemented structural interventions to address social inclusion. Argentina, Brazil and Mexico have adopted early initiation of antiretroviral therapy and treatment as prevention strategies. The other countries do not have substantial tailored interventions and consider the trans population a sub-population of men who have sex with men in data collection and programme implementation. Limited coverage of services, discrimination and a deep-seated mistrust of the health system among transgender women are the main barriers to accessing HIV prevention services. Promising interventions include health services adapted to transgender women in Mexico; LGBT-friendly clinics in Argentina that incorporate community and health workers in mixed teams; task-shifting to community-based organizations; mobile HIV testing; and gender identity laws. CONCLUSIONS Transgender women in Latin America continue to have limited access to HIV prevention services, which presents a bottleneck for reaching prevention goals and incorporating new prevention interventions. Prevention programmes should be rights-based; offer tailored, holistic interventions; and involve transgender women in their design and implementation.
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Affiliation(s)
- Alfonso Silva-Santisteban
- Center for Interdisciplinary Research on Sexuality, AIDS and Society, Cayetano Heredia University, Lima, Peru;
| | - Shirley Eng
- Regional Support Team for Latin America, UNAIDS, Panama City, Panama
| | - Gabriela de la Iglesia
- Horizontal Cooperation Technical Group for Latin America and the Caribbean, Buenos Aires, Argentina
| | - Carlos Falistocco
- Horizontal Cooperation Technical Group for Latin America and the Caribbean, Buenos Aires, Argentina
| | - Rafael Mazin
- HIV and Sexually Transmitted Infections, Pan American Health Organization, Washington, DC, USA
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Mishra S, Boily MC, Schwartz S, Beyrer C, Blanchard JF, Moses S, Castor D, Phaswana-Mafuya N, Vickerman P, Drame F, Alary M, Baral SD. Data and methods to characterize the role of sex work and to inform sex work programs in generalized HIV epidemics: evidence to challenge assumptions. Ann Epidemiol 2016; 26:557-569. [PMID: 27421700 DOI: 10.1016/j.annepidem.2016.06.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 05/06/2016] [Accepted: 06/03/2016] [Indexed: 01/15/2023]
Abstract
In the context of generalized human immunodeficiency virus (HIV) epidemics, there has been limited recent investment in HIV surveillance and prevention programming for key populations including female sex workers. Often implicit in the decision to limit investment in these epidemic settings are assumptions including that commercial sex is not significant to the sustained transmission of HIV, and HIV interventions designed to reach "all segments of society" will reach female sex workers and clients. Emerging empiric and model-based evidence is challenging these assumptions. This article highlights the frameworks and estimates used to characterize the role of sex work in HIV epidemics as well as the relevant empiric data landscape on sex work in generalized HIV epidemics and their strengths and limitations. Traditional approaches to estimate the contribution of sex work to HIV epidemics do not capture the potential for upstream and downstream sexual and vertical HIV transmission. Emerging approaches such as the transmission population attributable fraction from dynamic mathematical models can address this gap. To move forward, the HIV scientific community must begin by replacing assumptions about the epidemiology of generalized HIV epidemics with data and more appropriate methods of estimating the contribution of unprotected sex in the context of sex work.
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Affiliation(s)
- Sharmistha Mishra
- Division of Infectious Diseases, Department of Medicine, St. Michael's Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada; Department of Infectious Disease Epidemiology, Imperial College, London, UK
| | - Marie-Claude Boily
- Department of Infectious Disease Epidemiology, Imperial College, London, UK
| | - Sheree Schwartz
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Chris Beyrer
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - James F Blanchard
- Centre for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Stephen Moses
- Centre for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Delivette Castor
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC
| | - Nancy Phaswana-Mafuya
- HIV/AIDS, STI, and Tuberculosis Department, Human Sciences Research Council, Port Elizabeth, South Africa
| | - Peter Vickerman
- School of Social and Community Medicine, Bristol University, Bristol, UK
| | - Fatou Drame
- Department of Geography, Université Gaston-Berger, St. Louis, Senegal
| | - Michel Alary
- Département de médecine sociale et préventive, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
| | - Stefan D Baral
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD.
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Morris BJ, Barboza G, Wamai RG, Krieger JN. Circumcision is a primary preventive against HIV infection: Critique of a contrary meta-regression analysis by Van Howe. Glob Public Health 2016; 13:1889-1899. [PMID: 27043484 DOI: 10.1080/17441692.2016.1164737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
A meta-analysis by Van Howe of 109 populations confirms the well-known association of male circumcision (MC) with reduced HIV prevalence. He then performed meta-regression adjusting for location, risk and MC prevalence. When one or two of these adjustments in combination were applied MC appeared protective, but when all three were introduced the association remained significant in high-risk populations, but not in general populations within Africa with a hypothetical MC prevalence of <25% or elsewhere with hypothetical MC prevalence of <75%. However, many MC prevalence values given differed from those reported in references cited (including all US studies). This and other problems invalidate his adjustments for MC prevalence, undermining most of his meta-regression results. Meta-regression is a highly sophisticated statistical tool and is prone to error if not applied correctly. The study contained a high risk of bias arising from confounding. We also question his use of crude, rather than adjusted, odds ratios and his inclusion of unpublished data, so precluding replication by others. Flawed statistics, opaque presentation of results and inclusion of previously repudiated arguments downplaying a role for MC in HIV prevention programmes should lead readers to be sceptical of the findings and conclusions of Van Howe's study.
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Affiliation(s)
- Brian J Morris
- a School of Medical Sciences and Bosch Institute , University of Sydney , Sydney , Australia
| | - Gia Barboza
- b Department of African-American Studies , Northeastern University , Boston , MA , USA.,c School of Criminology and Criminal Justice , Northeastern University , Boston , MA , USA
| | - Richard G Wamai
- b Department of African-American Studies , Northeastern University , Boston , MA , USA
| | - John N Krieger
- d University of Washington School of Medicine and VA Puget Sound Health Care System, Section of Urology , Seattle , WA , USA
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Phanuphak N, Lo YR, Shao Y, Solomon SS, O'Connell RJ, Tovanabutra S, Chang D, Kim JH, Excler JL. HIV Epidemic in Asia: Implications for HIV Vaccine and Other Prevention Trials. AIDS Res Hum Retroviruses 2015; 31:1060-76. [PMID: 26107771 DOI: 10.1089/aid.2015.0049] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
An overall decrease of HIV prevalence is now observed in several key Asian countries due to effective prevention programs. The decrease in HIV prevalence and incidence may further improve with the scale-up of combination prevention interventions. The implementation of future prevention trials then faces important challenges. The opportunity to identify heterosexual populations at high risk such as female sex workers may rapidly wane. With unabating HIV epidemics among men who have sex with men (MSM) and transgender (TG) populations, an effective vaccine would likely be the only option to turn the epidemic. It is more likely that efficacy trials will occur among MSM and TG because their higher HIV incidence permits smaller and less costly trials. The constantly evolving patterns of HIV-1 diversity in the region suggest close monitoring of the molecular HIV epidemic in potential target populations for HIV vaccine efficacy trials. CRF01_AE remains predominant in southeast Asian countries and MSM populations in China. This relatively steady pattern is conducive to regional efficacy trials, and as efficacy warrants, to regional licensure. While vaccines inducing nonneutralizing antibodies have promise against HIV acquisition, vaccines designed to induce broadly neutralizing antibodies and cell-mediated immune responses of greater breadth and depth in the mucosal compartments should be considered for testing in MSM and TG. The rationale and design of efficacy trials of combination prevention modalities such as HIV vaccine and preexposure prophylaxis (PrEP) remain hypothetical, require high adherence to PrEP, are more costly, and present new regulatory challenges. The prioritization of prevention interventions should be driven by the HIV epidemic and decided by the country-specific health and regulatory authorities. Modeling the impact and cost-benefit may help this decision process.
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Affiliation(s)
| | - Ying-Ru Lo
- HIV, Hepatitis, and STI Unit, WHO Regional Office for the Western Pacific, Manila, Philippines
| | - Yiming Shao
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Sunil Suhas Solomon
- Johns Hopkins University School of Medicine, Baltimore, Maryland
- Y.R. Gaitonde Centre for AIDS Research and Education (YRG CARE), Chennai, India
| | - Robert J. O'Connell
- Department of Retrovirology, U.S. Army Medical Component, Armed Forces Institute of Medical Sciences (AFRIMS), Bangkok, Thailand
| | - Sodsai Tovanabutra
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - David Chang
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Jerome H. Kim
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Jean Louis Excler
- U.S. Military HIV Research Program, Bethesda, Maryland
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
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Mishra S, Pickles M, Blanchard JF, Moses S, Shubber Z, Boily MC. Validation of the modes of transmission model as a tool to prioritize HIV prevention targets: a comparative modelling analysis. PLoS One 2014; 9:e101690. [PMID: 25014543 PMCID: PMC4090151 DOI: 10.1371/journal.pone.0101690] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 06/10/2014] [Indexed: 01/22/2023] Open
Abstract
Background The static Modes of Transmission (MOT) model predicts the annual fraction of new HIV infections acquired across subgroups (MOT metric), and is used to focus HIV prevention. Using synthetic epidemics via a dynamical model, we assessed the validity of the MOT metric for identifying epidemic drivers (behaviours or subgroups that are sufficient and necessary for HIV to establish and persist), and the potential consequence of MOT-guided policies. Methods and Findings To generate benchmark MOT metrics for comparison, we simulated three synthetic epidemics (concentrated, mixed, and generalized) with different epidemic drivers using a dynamical model of heterosexual HIV transmission. MOT metrics from generic and complex MOT models were compared against the benchmark, and to the contribution of epidemic drivers to overall HIV transmission (cumulative population attributable fraction over t years, PAFt). The complex MOT metric was similar to the benchmark, but the generic MOT underestimated the fraction of infections in epidemic drivers. The benchmark MOT metric identified epidemic drivers early in the epidemics. Over time, the MOT metric did not identify epidemic drivers. This was not due to simplified MOT models or biased parameters but occurred because the MOT metric (irrespective of the model used to generate it) underestimates the contribution of epidemic drivers to HIV transmission over time (PAF5–30). MOT-directed policies that fail to reach epidemic drivers could undermine long-term impact on HIV incidence, and achieve a similar impact as random allocation of additional resources. Conclusions Irrespective of how it is obtained, the MOT metric is not a valid stand-alone tool to identify epidemic drivers, and has limited additional value in guiding the prioritization of HIV prevention targets. Policy-makers should use the MOT model judiciously, in combination with other approaches, to identify epidemic drivers.
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Affiliation(s)
- Sharmistha Mishra
- Department of Infectious Disease Epidemiology, Imperial College, London, United Kingdom
- St. Michael's Hospital, Department of Medicine, University of Toronto, Toronto, Canada
- * E-mail:
| | - Michael Pickles
- Department of Infectious Disease Epidemiology, Imperial College, London, United Kingdom
| | - James F. Blanchard
- Centre for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Stephen Moses
- Centre for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Zara Shubber
- Department of Infectious Disease Epidemiology, Imperial College, London, United Kingdom
| | - Marie-Claude Boily
- Department of Infectious Disease Epidemiology, Imperial College, London, United Kingdom
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