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Hendrickx DM, Delva W, Hens N. Influence of sexual risk behaviour and STI co-infection dynamics on the evolution of HIV set point viral load in MSM. Epidemics 2021; 36:100474. [PMID: 34153622 DOI: 10.1016/j.epidem.2021.100474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 03/17/2021] [Accepted: 06/07/2021] [Indexed: 11/27/2022] Open
Abstract
HIV viral load (VL) is an important predictor of HIV progression and transmission. Anti-retroviral therapy (ART) has been reported to reduce HIV transmission by lowering VL. However, apart from this beneficial effect, increased levels of population mean set-point viral load (SPVL), an estimator for HIV virulence, have been observed in men who have sex with men (MSM) in the decade following the introduction of ART in The Netherlands. Several studies have been devoted to explain these counter-intuitive trends in SPVL. However, to our knowledge, none of these studies has investigated an explanation in which it arises as the result of a sexually transmitted infection (STI) co-factor in detail. In this study, we adapted an event-based, individual-based model to investigate how STI co-infection and sexual risk behaviour affect the evolution of HIV SPVL in MSM before and after the introduction of ART. The results suggest that sexual risk behaviour has an effect on SPVL and indicate that more data are needed to test the effect of STI co-factors on SPVL. Furthermore, the observed trends in SPVL cannot be explained by sexual risk behaviour and STI co-factors only. We recommend to develop mathematical models including also factors related to viral evolution as reported earlier in the literature. However, this requires more complex models, and the collection of more data for parameter estimation than what is currently available.
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Affiliation(s)
- Diana M Hendrickx
- I-BioStat, Data Science Institute, Hasselt University, Hasselt, Belgium.
| | - Wim Delva
- I-BioStat, Data Science Institute, Hasselt University, Hasselt, Belgium; The South African Department of Science and Technology-National Research Foundation (DST-NRF) Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa; Department of Global Health, Faculty of Medicine and Health, Stellenbosch University, Stellenbosch, South Africa; International Centre for Reproductive Health, Ghent University, Ghent, Belgium; Rega Institute for Medical Research, KU Leuven, Leuven, Belgium; School for Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
| | - Niel Hens
- I-BioStat, Data Science Institute, Hasselt University, Hasselt, Belgium; Centre for Health Economics Research and Modelling Infectious Diseases, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
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2
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Khan S, Spiegelman D, Walsh F, Mazibuko S, Pasipamire M, Chai B, Reis R, Mlambo K, Delva W, Khumalo G, Zwane M, Fleming Y, Mafara E, Hettema A, Lejeune C, Chao A, Bärnighausen T, Okello V. Early access to antiretroviral therapy versus standard of care among HIV-positive participants in Eswatini in the public health sector: the MaxART stepped-wedge randomized controlled trial. J Int AIDS Soc 2021; 23:e25610. [PMID: 32949103 PMCID: PMC7507004 DOI: 10.1002/jia2.25610] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 06/10/2020] [Accepted: 07/15/2020] [Indexed: 12/18/2022] Open
Abstract
Introduction The WHO recommends antiretroviral treatment (ART) for all HIV‐positive patients regardless of CD4 count or disease stage, referred to as “Early Access to ART for All” (EAAA). The health systems effects of EAAA implementation are unknown. This trial was implemented in a government‐managed public health system with the aim to examine the “real world” impact of EAAA on care retention and viral suppression. Methods In this stepped‐wedge randomized controlled trial, 14 public sector health facilities in Eswatini were paired and randomly assigned to stepwise transition from standard of care (SoC) to EAAA. ART‐naïve participants ≥18 years who were not pregnant or breastfeeding were eligible for enrolment. We used Cox proportional hazard models with censoring at clinic transition to estimate the effects of EAAA on retention in care and retention and viral suppression combined. Results Between September 2014 and August 2017, 3405 participants were enrolled. In SoC and EAAA respectively, 12‐month HIV care retention rates were 80% (95% CI: 77 to 83) and 86% (95% CI: 83 to 88). The 12‐month combined retention and viral suppression endpoint rates were 44% (95% CI: 40 to 48) under SoC compared to 80% (95% CI: 77 to 83) under EAAA. EAAA increased both retention (HR: 1·60, 95% CI: 1·15 to 2·21, p = 0.005) and retention and viral suppression combined (HR: 4.88, 95% CI: 2.96 to 8.05, p < 0.001). We also identified significant gaps in current health systems ability to provide viral load (VL) monitoring with 80% participants in SoC and 66% in EAAA having a missing VL at last contact. Conclusions The observed improvement in retention in care and on the combined retention and viral suppression provides an important co‐benefit of EAAA to HIV‐positive adults themselves, at least in the short term. Our results from this “real world” health systems trial strongly support EAAA for Eswatini and countries with similar HIV epidemics and health systems. VL monitoring needs to be scaled up for appropriate care management.
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Affiliation(s)
- Shaukat Khan
- Clinton Health Access Initiative (CHAI), Mbabane, Swaziland
| | - Donna Spiegelman
- Center on Methods for Implementation and Prevention Science and Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA.,Departments of Epidemiology, Biostatistics, Nutrition and Global Health, Harvard T.H Chan School of Public Health, Boston, MA, USA
| | - Fiona Walsh
- Clinton Health Access Initiative (CHAI), Boston, MA, USA
| | - Sikhatele Mazibuko
- Eswatini National ART program (SNAP), Ministry of Health, Mbabane, Swaziland
| | | | - Boyang Chai
- Department of Nutrition, Harvard T.H Chan School of Public Health, Boston, MA, USA
| | - Ria Reis
- Leiden University Medical Center, Leiden University, Leiden, the Netherlands.,Amsterdam Institute for Social Science, University of Amsterdam, Amsterdam, the Netherlands.,Children's Institute, University of Cape Town, Cape Town, South Africa
| | - Khudzie Mlambo
- Clinton Health Access Initiative (CHAI), Mbabane, Swaziland
| | - Wim Delva
- The South African Department of Science and Technology - National Research Foundation (DST-NRF) Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa.,Center for Statistics, Hasselt University, Diepenbeek, Belgium.,International Centre for Reproductive Health, Ghent University, Gent, Belgium.,KU Leuven, Rega Institute for Medical Research, Leuven, Belgium.,Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Gavin Khumalo
- Eswatini National Network of People Living with HIV (SWANNEPHA), Mbabane, Swaziland
| | | | | | - Emma Mafara
- Clinton Health Access Initiative (CHAI), Mbabane, Swaziland
| | - Anita Hettema
- Clinton Health Access Initiative (CHAI), Mbabane, Swaziland
| | | | - Ariel Chao
- Center on Methods for Implementation and Prevention Science and Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Till Bärnighausen
- Heidelberg Institute of Public Health, University of Heidelberg, Heidelberg, Germany.,Department of Global Health and Population, Harvard T.H Chan School of Public Health, Boston, MA, USA
| | - Velephi Okello
- Directorate Office, Ministry of Health, Mbabane, Swaziland
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3
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Niyukuri D, Nyasulu P, Delva W. Assessing the uncertainty around age-mixing patterns in HIV transmission inferred from phylogenetic trees. PLoS One 2021; 16:e0249013. [PMID: 33765091 PMCID: PMC7993798 DOI: 10.1371/journal.pone.0249013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 03/10/2021] [Indexed: 11/18/2022] Open
Abstract
Understanding age-mixing patterns in Human Immunodeficiency Virus (HIV) transmission networks can enhance the design and implementation of HIV prevention strategies in sub-Saharan Africa. Due to ethical consideration, it is less likely possible to conduct a benchmark study to assess which sampling strategy, and sub-optimal sampling coverage which can yield best estimates for these patterns. We conducted a simulation study, using phylogenetic trees to infer estimates of age-mixing patterns in HIV transmission, through the computation of proportions of pairings between men and women, who were phylogenetically linked across different age groups (15-24 years, 25-39 years, and 40-49 years); and the means, and standard deviations of their age difference. We investigated also the uncertainty around these estimates as a function of the sampling coverage in four sampling strategies: when missing sequence data were missing completely at random (MCAR), and missing at random (MAR) with at most 30%-50%-70% of women in different age groups being in the sample. The results suggested that age-mixing patterns in HIV transmission can be unveiled from proportions of phylogenetic pairings between men and women across age groups; and the mean, and standard deviation of their age difference. A 55% sampling coverage was sufficient to provide the best values of estimates of age-mixing patterns in HIV transmission with MCAR scenario. But we should be cautious in interpreting proportions of men phylogenetically linked to women because they may be overestimated or underestimated, even at higher sampling coverage. The findings showed that, MCAR was the best sampling strategy. This means, it is advisable not to use sequence data collected in settings where we can find a systematic imbalance of age and gender to investigate age-mixing in HIV transmission. If not possible, ensure to take into consideration the imbalance in interpreting the results.
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Affiliation(s)
- David Niyukuri
- Division of Epidemiology & Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- The South African Department of Science and Technology–National Research Foundation (DST-NRF) Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Cape Town, South Africa
- * E-mail:
| | - Peter Nyasulu
- Division of Epidemiology & Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health, Faculty of Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Wim Delva
- Division of Epidemiology & Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- The South African Department of Science and Technology–National Research Foundation (DST-NRF) Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Cape Town, South Africa
- Center for Statistics, I-BioStat, Hasselt University, Diepenbeek, Belgium
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium
- Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
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4
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Chao A, Spiegelman D, Khan S, Walsh F, Mazibuko S, Pasipamire M, Chai B, Reis R, Mlambo K, Delva W, Khumalo G, Zwane M, Fleming Y, Mafara E, Hettema A, Lejeune C, Bärnighausen T, Okello V. Mortality under early access to antiretroviral therapy vs. Eswatini's national standard of care: the MaxART clustered randomized stepped-wedge trial. HIV Med 2020; 21:429-440. [PMID: 32458567 DOI: 10.1111/hiv.12876] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 03/18/2020] [Accepted: 04/13/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Current WHO guidelines recommend the treatment of all HIV-infected individuals with antiretroviral therapy (ART) to improve survival and quality of life, and decrease infection of others. MaxART is the first implementation trial of this strategy embedded within a government-managed health system, and assesses mortality as a secondary outcome. Because primary findings strongly supported scale-up of the 'treat all' strategy (hereafter Treat All), this analysis examines mortality as an additional indicator of its impact. METHODS MaxART was conducted in 14 Eswatinian health clinics through a clinic-based stepped-wedge design, by transitioning clinics from then-national standard of care (SoC) to the Treat All intervention. All-cause, disease-related, and HIV-related mortality were analysed using the Cox proportional hazards model, censoring SoC participants at clinic transition. Median follow-up time among study participants was 292 days. There were 36/2034 deaths in SoC (1.77%) and 49/1371 deaths in Treat All (3.57%). RESULTS Between September 2014 and August 2017, 3405 participants were enrolled. In SoC and Treat All interventions, respectively, the multivariable-adjusted 12-month all-cause mortality rates were 1.42% [95% confidence interval (CI): 0.66-2.17] and 1.60% (95% CI: 0.78-2.40), disease-related mortality rates were 1.02% (95% CI: 0.40-1.64) and 1.10% (95% CI: 0.46-1.73), and HIV-related mortality rates were 1.03% (95% CI: 0.40-1.65) and 0.99% (95% CI: 0.40-1.58). Treat All had no impact on all-cause [hazard ratio (HR) = 1.12, 95% CI: 0.58-2.18, P = 0.73], disease-related (HR = 1.04, 95% CI: 0.52-2.11, P = 0.90), or HIV-related mortality (HR = 0.93, 95% CI: 0.46-1.87, P = 0.83). CONCLUSION There was no immediate benefit of the Treat All strategy on mortality, nor evidence of harm. Longer follow-up of participants is needed to establish long-term consequences.
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Affiliation(s)
- A Chao
- Department of Biostatistics, Yale School of Public Health, Center for Methods in Implementation and Prevention Science (CMIPS), New Haven, CT, USA
| | - D Spiegelman
- Department of Biostatistics, Yale School of Public Health, Center for Methods in Implementation and Prevention Science (CMIPS), New Haven, CT, USA
| | - S Khan
- Clinton Health Access Initiative (CHAI), Mbabane, Eswatini
| | - F Walsh
- Clinton Health Access Initiative (CHAI), Boston, MA, USA
| | - S Mazibuko
- Eswatini National ART program (SNAP), Ministry of Health, Mbabane, Eswatini
| | - M Pasipamire
- Eswatini National ART program (SNAP), Ministry of Health, Mbabane, Eswatini
| | - B Chai
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - R Reis
- Leiden University Medical Center, Leiden University, Leiden, Netherlands.,Amsterdam Institute for Social Science, University of Amsterdam, Amsterdam, Netherlands.,Children's Institute, University of Cape Town, Cape Town, South Africa
| | - K Mlambo
- Clinton Health Access Initiative (CHAI), Mbabane, Eswatini
| | - W Delva
- The South African Department of Science and Technology - National Research Foundation (DST-NRF) Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa.,Center for Statistics, Hasselt University, Diepenbeek, Belgium.,International Centre for Reproductive Health, Ghent University, Gent, Belgium.,Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
| | - G Khumalo
- Eswatini National Network of People Living with HIV (SWANNEPHA), Mbabane, Eswatini
| | | | | | - E Mafara
- Clinton Health Access Initiative (CHAI), Mbabane, Eswatini
| | - A Hettema
- Clinton Health Access Initiative (CHAI), Mbabane, Eswatini
| | - C Lejeune
- Clinton Health Access Initiative (CHAI), Mbabane, Eswatini
| | - T Bärnighausen
- Heidelberg Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - V Okello
- Directorate Office, Ministry of Health, Mbabane, Eswatini
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5
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Hazelbag CM, Dushoff J, Dominic EM, Mthombothi ZE, Delva W. Calibration of individual-based models to epidemiological data: A systematic review. PLoS Comput Biol 2020; 16:e1007893. [PMID: 32392252 PMCID: PMC7241852 DOI: 10.1371/journal.pcbi.1007893] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 05/21/2020] [Accepted: 04/21/2020] [Indexed: 01/24/2023] Open
Abstract
Individual-based models (IBMs) informing public health policy should be calibrated to data and provide estimates of uncertainty. Two main components of model-calibration methods are the parameter-search strategy and the goodness-of-fit (GOF) measure; many options exist for each of these. This review provides an overview of calibration methods used in IBMs modelling infectious disease spread. We identified articles on PubMed employing simulation-based methods to calibrate IBMs informing public health policy in HIV, tuberculosis, and malaria epidemiology published between 1 January 2013 and 31 December 2018. Articles were included if models stored individual-specific information, and calibration involved comparing model output to population-level targets. We extracted information on parameter-search strategies, GOF measures, and model validation. The PubMed search identified 653 candidate articles, of which 84 met the review criteria. Of the included articles, 40 (48%) combined a quantitative GOF measure with an algorithmic parameter-search strategy–either an optimisation algorithm (14/40) or a sampling algorithm (26/40). These 40 articles varied widely in their choices of parameter-search strategies and GOF measures. For the remaining 44 (52%) articles, the parameter-search strategy could either not be identified (32/44) or was described as an informal, non-reproducible method (12/44). Of these 44 articles, the majority (25/44) were unclear about the GOF measure used; of the rest, only five quantitatively evaluated GOF. Only a minority of the included articles, 14 (17%) provided a rationale for their choice of model-calibration method. Model validation was reported in 31 (37%) articles. Reporting on calibration methods is far from optimal in epidemiological modelling studies of HIV, malaria and TB transmission dynamics. The adoption of better documented, algorithmic calibration methods could improve both reproducibility and the quality of inference in model-based epidemiology. There is a need for research comparing the performance of calibration methods to inform decisions about the parameter-search strategies and GOF measures. Calibration—that is, “fitting” the model to data—is a crucial part of using mathematical models to better forecast and control the population-level spread of infectious diseases. Evidence that the mathematical model is well-calibrated improves confidence that the model provides a realistic picture of the consequences of health policy decisions. To make informed decisions, Policymakers need information about uncertainty: i.e., what is the range of likely outcomes (rather than just a single prediction). Thus, modellers should also strive to provide accurate measurements of uncertainty, both for their model parameters and for their predictions. This systematic review provides an overview of the methods used to calibrate individual-based models (IBMs) of the spread of HIV, malaria, and tuberculosis. We found that less than half of the reviewed articles used reproducible, non-subjective calibration methods. For the remaining articles, the method could either not be identified or was described as an informal, non-reproducible method. Only one-third of the articles obtained estimates of parameter uncertainty. We conclude that the adoption of better-documented, algorithmic calibration methods could improve both reproducibility and the quality of inference in model-based epidemiology.
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Affiliation(s)
- C. Marijn Hazelbag
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- * E-mail:
| | - Jonathan Dushoff
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- Department of Biology, Department of Mathematics and Statistics, Institute for Infectious Disease Research, McMaster University, Hamilton, Ontario, Canada
| | - Emanuel M. Dominic
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Zinhle E. Mthombothi
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Wim Delva
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- School for Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
- Center for Statistics, I-BioStat, Hasselt University, Diepenbeek, Belgium
- Department of Global Health, Faculty of Medicine and Health, Stellenbosch University, Stellenbosch, South Africa
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium
- Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
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6
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Liesenborgs J, Hendrickx DM, Kuylen E, Niyukuri D, Hens N, Delva W. SimpactCyan 1.0: An Open-source Simulator for Individual-Based Models in HIV Epidemiology with R and Python Interfaces. Sci Rep 2019; 9:19289. [PMID: 31848434 PMCID: PMC6917719 DOI: 10.1038/s41598-019-55689-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 11/29/2019] [Indexed: 01/21/2023] Open
Abstract
SimpactCyan is an open-source simulator for individual-based models in HIV epidemiology. Its core algorithm is written in C++ for computational efficiency, while the R and Python interfaces aim to make the tool accessible to the fast-growing community of R and Python users. Transmission, treatment and prevention of HIV infections in dynamic sexual networks are simulated by discrete events. A generic “intervention” event allows model parameters to be changed over time, and can be used to model medical and behavioural HIV prevention programmes. First, we describe a more efficient variant of the modified Next Reaction Method that drives our continuous-time simulator. Next, we outline key built-in features and assumptions of individual-based models formulated in SimpactCyan, and provide code snippets for how to formulate, execute and analyse models in SimpactCyan through its R and Python interfaces. Lastly, we give two examples of applications in HIV epidemiology: the first demonstrates how the software can be used to estimate the impact of progressive changes to the eligibility criteria for HIV treatment on HIV incidence. The second example illustrates the use of SimpactCyan as a data-generating tool for assessing the performance of a phylodynamic inference framework.
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Affiliation(s)
- Jori Liesenborgs
- Expertise Centre for Digital Media, Hasselt University - tUL, Diepenbeek, Belgium
| | - Diana M Hendrickx
- Center for Statistics, I-BioStat, Hasselt University, Diepenbeek, Belgium
| | - Elise Kuylen
- IDLab, University of Antwerp, Antwerp, Belgium.,Centre for Health Economics Research and Modelling Infectious Diseases and Centre for the Evaluation of Vaccination, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - David Niyukuri
- The South African Department of Science and Technology-National Research Foundation (DST-NRF) Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa.,Department of Global Health, Faculty of Medicine and Health, Stellenbosch University, Stellenbosch, South Africa
| | - Niel Hens
- Center for Statistics, I-BioStat, Hasselt University, Diepenbeek, Belgium.,Centre for Health Economics Research and Modelling Infectious Diseases and Centre for the Evaluation of Vaccination, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Wim Delva
- Center for Statistics, I-BioStat, Hasselt University, Diepenbeek, Belgium. .,The South African Department of Science and Technology-National Research Foundation (DST-NRF) Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa. .,Department of Global Health, Faculty of Medicine and Health, Stellenbosch University, Stellenbosch, South Africa. .,International Centre for Reproductive Health, Ghent University, Ghent, Belgium. .,Rega Institute for Medical Research, KU Leuven, Leuven, Belgium. .,School for Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa.
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7
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Verelst F, Kessels R, Delva W, Beutels P, Willem L. Drivers of vaccine decision-making in South Africa: A discrete choice experiment. Vaccine 2019; 37:2079-2089. [PMID: 30857931 DOI: 10.1016/j.vaccine.2019.02.056] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 02/21/2019] [Accepted: 02/24/2019] [Indexed: 01/22/2023]
Abstract
To increase vaccination coverage, it is essential to understand the vaccine decision-making process. High population coverage is required to obtain herd immunity and to protect vulnerable groups in terms of age (e.g. the very young) or health (e.g. immunodeficiency). Vaccine confidence and coverage in South Africa are relatively low, opening the window for sustained outbreaks of vaccine-preventable diseases in a country facing one of the most severe HIV epidemics in the world. To capture the vaccine-related decision-making process in South Africa, we performed a discrete choice experiment with 1200 participants in December 2017. We asked for their preferences with respect to (1) vaccine effectiveness, (2) vaccine-preventable burden of disease, (3) accessibility of the vaccine in terms of co-payment and prescription requirements, (4) frequency of mild vaccine-related side-effects, (5) population vaccination coverage and (6) local vaccination coverage. We distinguished between decision-making for vaccines administered to the participant, and for vaccines administered to their youngest child. We analyzed the data for each of these groups using a panel mixed logit model and found similar results for decisions to vaccinate oneself or one's child. Vaccine effectiveness was the most important attribute followed by population coverage and burden of disease. Local coverage and accessibility were also important determinants of vaccination behavior, but to a lesser extent. Regarding population and local coverage, we observed a positive effect on vaccine utility indicating the potential of peer influence. As such, social normative influence could be exploited to increase vaccination confidence and coverage. With respect to vaccine-preventable burden of the disease, the marginal utilities showed disease severity to be more important than frequency of disease. Policymakers and health care workers should stress the effectiveness of vaccines together with the severity of vaccine-preventable diseases.
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Affiliation(s)
- Frederik Verelst
- Centre for Health Economics Research and Modelling Infectious Diseases, Vaccine and Infectious Disease Institute, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk (Antwerp), Belgium.
| | - Roselinde Kessels
- Department of Economics & Flemish Research Foundation (FWO), University of Antwerp, Prinsstraat 13, 2000 Antwerp, Belgium; School of Economics, University of Amsterdam, PO Box 15867, 1001 NJ Amsterdam, the Netherlands
| | - Wim Delva
- International Centre for Reproductive Health, Ghent University, C. Heymanslaan 10, 9000 Ghent, Belgium; The South African Department of Science and Technology-National Research Foundation (DST-NRF) Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Matieland, Stellenbosch 7602, South Africa; Center for Statistics, Hasselt University, Martelarenlaan 42, 3500 Hasselt, Belgium; Rega Institute for Medical Research, KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Global Health Faculty of Medicine and Health Sciences, Stellenbosch University, Matieland, Stellenbosch 7602, South Africa
| | - Philippe Beutels
- Centre for Health Economics Research and Modelling Infectious Diseases, Vaccine and Infectious Disease Institute, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk (Antwerp), Belgium; School of Public Health and Community Medicine, The University of New South Wales, UNSW Medicine, NSW 2052, Australia
| | - Lander Willem
- Centre for Health Economics Research and Modelling Infectious Diseases, Vaccine and Infectious Disease Institute, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk (Antwerp), Belgium
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8
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Kenyon CR, Delva W, Brotman RM. Differential sexual network connectivity offers a parsimonious explanation for population-level variations in the prevalence of bacterial vaginosis: a data-driven, model-supported hypothesis. BMC Womens Health 2019; 19:8. [PMID: 30630481 PMCID: PMC6327541 DOI: 10.1186/s12905-018-0703-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 12/20/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The prevalence of bacterial vaginosis (BV) and vaginal microbiota types varies dramatically between different populations around the world. Understanding what underpins these differences is important, as high-diversity microbiotas associated with BV are implicated in adverse pregnancy outcomes and enhanced susceptibility to and transmission of sexually transmitted infections. MAIN TEXT We hypothesize that these variations in the vaginal microbiota can, in part, be explained by variations in the connectivity of sexual networks. We argue: 1) Couple-level data suggest that BV-associated bacteria can be sexually transmitted and hence high sexual network connectivity would be expected to promote the spread of BV-associated bacteria. Epidemiological studies have found positive associations between indicators of network connectivity and the prevalence of BV; 2) The relationship between BV prevalence and STI incidence/prevalence can be parsimoniously explained by differential network connectivity; 3) Studies from other mammals are generally supportive of the association between network connectivity and high-diversity vaginal microbiota. CONCLUSION To test this hypothesis, we propose a combination of empirical and simulation-based study designs.
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Affiliation(s)
- Chris R. Kenyon
- STI Unit, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium
| | - Wim Delva
- The South African DST-NRF Centre of Excellence in Epidemiological, Modelling and Analysis (SACEMA), Stellenbosch, South Africa
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium
- Center for Statistics, Hasselt University, Diepenbeek, Belgium
- Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
| | - Rebecca M. Brotman
- Department of Epidemiology and Public Health, Institute for Genome Sciences, University of Maryland School of Medicine, Ghent, Belgium
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9
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Abstract
There is little consensus as to why sexually transmitted infections (STIs), including HIV and bacterial vaginosis (BV) are more prevalent in some populations than others. Using a broad definition of sexual network connectivity that includes both structural and conductivity-related factors, we argue that the available evidence suggests that high prevalence of traditional STIs, HIV and BV can be parsimoniously explained by these populations having more connected sexual networks. Positive feedback, whereby BV and various STIs enhance the spread of other STIs, then further accentuates the spread of BV, HIV and other STIs. We review evidence that support this hypothesis and end by suggesting study designs that could further evaluate the hypothesis, as well as implications of this hypothesis for the prevention and management of STIs.
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Affiliation(s)
- Chris R. Kenyon
- Institute of Tropical Medicine, Antwerp, Antwerp, 2000, Belgium
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Wim Delva
- Department of Global Health, University of Stellenbosch, Stellenbosch, South Africa
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium
- South African Centre for Epidemiological Modelling and Analysis, University of Stellenbosch, Stellenbosch, South Africa
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10
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Abstract
There is little consensus as to why sexually transmitted infections (STIs), including HIV and bacterial vaginosis (BV) are more prevalent in some populations than others. Using a broad definition of sexual network connectivity that includes both structural and conductivity-related factors, we argue that the available evidence suggests that high prevalence of traditional STIs, HIV and BV can be parsimoniously explained by these populations having more connected sexual networks. Positive feedback, whereby BV and various STIs enhance the spread of other STIs, then further accentuates the spread of BV, HIV and other STIs. We review evidence that support this hypothesis and end by suggesting study designs that could further evaluate the hypothesis, as well as implications of this hypothesis for the prevention and management of STIs.
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Affiliation(s)
- Chris R. Kenyon
- Institute of Tropical Medicine, Antwerp, Antwerp, 2000, Belgium
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Wim Delva
- Department of Global Health, University of Stellenbosch, Stellenbosch, South Africa
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium
- South African Centre for Epidemiological Modelling and Analysis, University of Stellenbosch, Stellenbosch, South Africa
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Lafort Y, Greener L, Lessitala F, Chabeda S, Greener R, Beksinska M, Gichangi P, Griffin S, Smit JA, Chersich M, Delva W. Effect of a 'diagonal' intervention on uptake of HIV and reproductive health services by female sex workers in three sub-Saharan African cities. Trop Med Int Health 2018; 23:774-784. [PMID: 29752836 DOI: 10.1111/tmi.13072] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To enhance uptake of sexual and reproductive health (SRH) services by female sex workers (FSWs), we conducted an implementation study in which we piloted and tested context-specific 'diagonal' interventions, combining vertical, targeted interventions with horizontally improved access to the general health services, in three cities in sub-Saharan Africa. METHODS We collected indicators of SRH service uptake through face-to-face interviews with approximately 400 FSWs, pre- and post-intervention, in Durban, South Africa; Tete, Mozambique; and Mombasa, Kenya, recruited by respondent-driven sampling. Changes in uptake were tested for their statistical significance using multivariate logistic regression models. RESULTS In all cities, overall uptake of services increased. Having used all services for contraception, STI care, HIV testing, HIV care, cervical cancer screening and sexual violence, if needed, increased from 12.5% to 41.5% in Durban, 25.0% to 40.1% in Tete and 44.9% to 69.1% in Mombasa. Across cities, the effect was greatest in having been tested for HIV in the past six months which increased from 40.9% to 83.2% in Durban, 56.0% to 76.6% in Tete and 70.9% to 87.6% in Mombasa. In Tete and Mombasa, rise in SRH service use was almost entirely due to a greater uptake of targeted services. Only in Durban was there additionally an increase in the utilisation of general health services. CONCLUSION SRH service utilisation improved in the short-term in three different sub-Saharan African contexts, primarily through vertical, targeted components. The long-term effectiveness of diagonal approaches, in particular on the use of general, horizontal health services, needs further investigation.
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Affiliation(s)
- Yves Lafort
- International Centre for Reproductive Health, Ghent University, Gent, Belgium
| | - Letitia Greener
- Maternal, Adolescent and Child Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Faustino Lessitala
- International Centre for Reproductive Health-Mozambique, Maputo, Mozambique
| | - Sophie Chabeda
- International Centre for Reproductive Health-Kenya, Mombasa, Kenya
| | - Ross Greener
- Maternal, Adolescent and Child Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Mags Beksinska
- Maternal, Adolescent and Child Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Peter Gichangi
- International Centre for Reproductive Health, Ghent University, Gent, Belgium.,International Centre for Reproductive Health-Kenya, Mombasa, Kenya.,University of Nairobi, Nairobi, Kenya
| | - Sally Griffin
- International Centre for Reproductive Health-Mozambique, Maputo, Mozambique
| | - Jenni A Smit
- Maternal, Adolescent and Child Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Matthew Chersich
- International Centre for Reproductive Health, Ghent University, Gent, Belgium.,Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Wim Delva
- International Centre for Reproductive Health, Ghent University, Gent, Belgium.,The South African DST-NRF Centre of Excellence in Epidemiological Modelling and Analysis, Stellenbosch University, Stellenbosch, South Africa.,Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa.,Center for Statistics, Hasselt University, Diepenbeek, Belgium
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Beauclair R, Hens N, Delva W. The role of age-mixing patterns in HIV transmission dynamics: Novel hypotheses from a field study in Cape Town, South Africa. Epidemics 2018; 25:61-71. [PMID: 29866422 DOI: 10.1016/j.epidem.2018.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 02/15/2018] [Accepted: 05/17/2018] [Indexed: 10/16/2022] Open
Abstract
BACKGROUND Age-disparate relationships are thought to put young women at increased risk of HIV, though current evidence is inconclusive. Studying population-level age-mixing patterns as well as individual-level measures of age difference variation may provide insight into the persistence and magnitude of the epidemic in South Africa. METHODS We used data from a survey in Cape Town (n = 506) to describe age-mixing dynamics in the four population strata of HIV negative and HIV positive male and female participants. Mixed-effects models were used to calculate the average increase in partner age for each year increase in age of participant, the average partner age for 15 year olds, and the between-subject and the within-subject standard deviation of partner ages. We conducted 2000 bootstrap replications of the models. Using negative binomial models, we also explored whether HIV status was associated with participants having a larger range in partner ages. RESULTS HIV positive women had large variability in partner ages at the population level, and at the individual level had nearly three times the expected range of partner ages compared to HIV negative women. This pattern may increase the potential for HIV transmission across birth cohorts and may partially explain the persistence of the epidemic in South Africa. Young men, who have been previously absent from the age-disparity discourse, also choose older partners who may be putting them at increased risk of HIV infection due to the high HIV prevalence among older age categories of women.
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Affiliation(s)
- Roxanne Beauclair
- International Centre for Reproductive Health, Ghent University, Gent, Belgium; The South African Department of Science and Technology-National Research Foundation (DST-NRF) Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa.
| | - Niel Hens
- Center for Statistics, I-BioStat, Hasselt University, Martelarenlaan 42, BE3500 Hasselt, Belgium; Centre for Health Economics Research and Modelling Infectious Diseases and Centre for the Evaluation of Vaccination, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Wim Delva
- International Centre for Reproductive Health, Ghent University, Gent, Belgium; The South African Department of Science and Technology-National Research Foundation (DST-NRF) Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa; Center for Statistics, I-BioStat, Hasselt University, Martelarenlaan 42, BE3500 Hasselt, Belgium; Rega Institute for Medical Research, KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Global Health Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
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13
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Lafort Y, Lessitala F, Ismael de Melo MS, Griffin S, Chersich M, Delva W. Impact of a "Diagonal" Intervention on Uptake of Sexual and Reproductive Health Services by Female Sex Workers in Mozambique: A Mixed-Methods Implementation Study. Front Public Health 2018; 6:109. [PMID: 29721490 PMCID: PMC5915464 DOI: 10.3389/fpubh.2018.00109] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 04/03/2018] [Indexed: 12/31/2022] Open
Abstract
Background Female sex workers (FSWs) have high risks for adverse sexual and reproductive health (SRH) outcomes, yet low access to services. Within an implementation research project enhancing uptake of SRH services by FSWs, we piloted a “diagonal” intervention, which combined strengthening of FSW-targeted services (vertical) with making public health facilities more FSW-friendly (horizontal), and tested its effect. Methods The study applied a convergent parallel mixed-methods design to assess changes in access to SRH services. Results of structured interviews with FSWs pre-intervention (N = 311) and thereafter (N = 404) were compared with the findings of eight post-intervention focus group discussions (FGDs) with FSWs and two with FSW-peer educators (PEs). Results Marked and statistically significant rises occurred in consistent condom use with all partners (55.3–67.7%), ever use of female condoms (37.9–54.5%), being tested for HIV in the past 6 months (56.0–76.6%), using contraception (84.5–95.4%), ever screened for cervical cancer (0.0–16.9%) and having ≥10 contacts with a PE in the past year (0.5–24.45%). Increases mostly resulted from FSW-targeted outreach, with no rise detected in utilization of public health facilities. FGD participants reported that some facilities had become more FSW-friendly, but barriers such as stock-outs, being asked for bribes and disrespectful treatment persisted. Conclusion The combination of expanding FSW-targeted SRH services with improving access to the public health services resulted in an overall increased uptake of services, but almost exclusively because of the strengthened targeted (vertical) outreach services. Utilization of public SRH services had not yet increased and many barriers to access remained. Our diagonal approach was thus only successful in its vertical component. Improving access to the general health services remains nevertheless important and further research is needed how to reduce barriers. Ideally, the combination approach should be maintained and more successful approaches to increase utilization of public services should be explored.
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Affiliation(s)
- Yves Lafort
- International Centre for Reproductive Health, Ghent University, Gent, Belgium
| | - Faustino Lessitala
- International Centre for Reproductive Health-Mozambique, Maputo, Mozambique
| | | | - Sally Griffin
- International Centre for Reproductive Health-Mozambique, Maputo, Mozambique
| | - Matthew Chersich
- International Centre for Reproductive Health, Ghent University, Gent, Belgium.,Faculty of Health Sciences, Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Wim Delva
- International Centre for Reproductive Health, Ghent University, Gent, Belgium.,The South African DST-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), University of Stellenbosch, Stellenbosch, South Africa.,Center for Statistics, Hasselt University, Diepenbeek, Belgium.,Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
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14
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Delva W, Hens N, Vandamme AM. A8 Improving the accuracy and precision of estimated temporal trends in HIV incidence among MSM populations by calibrating agent-based simulation models to phylogenetic tree data. Virus Evol 2018. [PMCID: PMC5905378 DOI: 10.1093/ve/vey010.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- W Delva
- South Africa Centre of Epidemiological Modelling and Analysis, Stellenbosch University, South Africa
- Department of Microbiology and Immunology, Rega Institute for Medical Research, Clinical and Epidemiological Virology, KU Leuven—University of Leuven, Belgium
- Center for Statistics, I-BioStat, Hasselt University, Belgium
- International Centre for Reproductive Health, Ghent University, Belgium
| | - N Hens
- Center for Statistics, I-BioStat, Hasselt University, Belgium
- Centre for Health Economic Research and Modelling Infectious Diseases, Vaxinfectio, University of Antwerp, Belgium
- Epidemiology and Social Medicine, University of Antwerp, Belgium
| | - A-M Vandamme
- Department of Microbiology and Immunology, Rega Institute for Medical Research, Clinical and Epidemiological Virology, KU Leuven—University of Leuven, Belgium
- Center for Global Health and Tropical Medicine, Unidade de Microbiologia, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Portugal
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15
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Niyukuri D, Delva W. A7 The effect of the mechanism and amount of missingness on phylodynamic inference of heterosexual HIV transmission networks. Virus Evol 2018. [PMCID: PMC5905480 DOI: 10.1093/ve/vey010.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- David Niyukuri
- South Africa Centre of Epidemiological Modelling and Analysis, Stellenbosch University, South Africa
| | - Wim Delva
- South Africa Centre of Epidemiological Modelling and Analysis, Stellenbosch University, South Africa
- Department of Microbiology and Immunology, Rega Institute for Medical Research, Clinical and Epidemiological Virology, KU Leuven, Belgium
- Center for Statistics, I-BioStat, Hasselt University, Belgium
- International Centre for Reproductive Health, Ghent University, Belgium
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16
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Beauclair R, Dushoff J, Delva W. Partner age differences and associated sexual risk behaviours among adolescent girls and young women in a cash transfer programme for schooling in Malawi. BMC Public Health 2018; 18:403. [PMID: 29587710 PMCID: PMC5872581 DOI: 10.1186/s12889-018-5327-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 03/16/2018] [Indexed: 11/23/2022] Open
Abstract
Background Age disparities in sexual relationships have been proposed as a key risk factor for HIV transmission in Sub-Saharan Africa, but evidence remains inconclusive. The SIHR study, a cluster randomised trial of a cash transfer programme in Malawi, found that young women in the intervention groups were less likely to have had a sexual partner aged 25 or older, and less likely to test positive for HIV and HSV-2 at follow-up compared to control groups. We examined the hypotheses that girls in the intervention groups had smaller age differences than control groups and that large age differences were associated with relationship-level HIV transmission risk factors: inconsistent condom use, sex frequency, and relationship duration. Methods We conducted an analysis of schoolgirls in the Schooling, Income, and Health Risk (SIHR) study aged 13-22 at baseline (n = 2907). We investigated the effects of study arm, trial stage and participant age on age differences in sexual relationships using a linear mixed-effects model. Cumulative-link mixed-effects models were used to estimate the effect of relationship age difference on condom use and sex frequency, and a Cox proportional hazard model was used to estimate the effect of relationship age difference on relationship duration. We controlled for the girl’s age, number of partners, study group and study round. Results Girls receiving cash transfers, on average, had smaller age differences in relationships compared to controls, though the estimated difference was not statistically significant (− 0.43 years; 95% CI: -1.03, 0.17). The older the participant was, the smaller her age differences (− 0.67 per 4-year increase in age; 95% CI: -0.99, − 0.35). Among controls, after the cash transfers had ended the average age difference was 0.82 years larger than during the intervention (95% CI: 0.43, 1.21), suggesting a possible indirect effect of the study on behaviour in the community as a whole. Across treatment groups, larger age differences in relationships were associated with lower levels of condom use, more frequent sex, and longer relationship durations. Conclusions Cash-transfer programmes may prevent HIV transmission in part by encouraging young women to form age-similar relationships, which are characterised by increased condom use and reduced sex frequency. The benefits of these programmes may extend to those who are not directly receiving the cash. Electronic supplementary material The online version of this article (10.1186/s12889-018-5327-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Roxanne Beauclair
- International Centre for Reproductive Health, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium. .,The South African Department of Science and Technology-National Research Foundation (DST-NRF) Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, 19 Jonkershoek Road, Stellenbosch, 7600, South Africa.
| | - Jonathan Dushoff
- Department of Biology, McMaster University, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada
| | - Wim Delva
- International Centre for Reproductive Health, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium.,The South African Department of Science and Technology-National Research Foundation (DST-NRF) Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, 19 Jonkershoek Road, Stellenbosch, 7600, South Africa.,Center for Statistics, Hasselt University, Campus Diepenbeek, Agoralaan Building D, 3590, Diepenbeek, Belgium.,Rega Institute for Medical Research, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
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17
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Walsh FJ, Bärnighausen T, Delva W, Fleming Y, Khumalo G, Lejeune CL, Mazibuko S, Mlambo CK, Reis R, Spiegelman D, Zwane M, Okello V. Impact of early initiation versus national standard of care of antiretroviral therapy in Swaziland's public sector health system: study protocol for a stepped-wedge randomized trial. Trials 2017; 18:383. [PMID: 28821264 PMCID: PMC5563033 DOI: 10.1186/s13063-017-2128-8] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 07/27/2017] [Indexed: 01/27/2023] Open
Abstract
Background There is robust clinical evidence to support offering early access to antiretroviral treatment (ART) to all HIV-positive individuals, irrespective of disease stage, to both improve patient health outcomes and reduce HIV incidence. However, as the global treatment guidelines shift to meet this evidence, it is still largely unknown if early access to ART for all (also referred to as “treatment as prevention” or “universal test and treat”) is a feasible intervention in the resource-limited countries where this approach could have the biggest impact on the course of the HIV epidemics. The MaxART Early Access to ART for All (EAAA) implementation study was designed to determine the feasibility, acceptability, clinical outcomes, affordability, and scalability of offering early antiretroviral treatment to all HIV-positive individuals in Swaziland’s public sector health system. Methods This is a three-year stepped-wedge randomized design with open enrollment for all adults aged 18 years and older across 14 government-managed health facilities in Swaziland’s Hhohho Region. Primary endpoints are retention and viral suppression. Secondary endpoints include ART initiation, adherence, drug resistance, tuberculosis, HIV disease progression, patient satisfaction, and cost per patient per year. Sites are grouped to transition two at a time from the control (standard of care) to intervention (EAAA) stage at each four-month step. This design will result in approximately one half of the total observation time to accrue in the intervention arm and the other half in the control arm. Our estimated enrolment number, which is supported by conservative power calculations, is 4501 patients over the course of the 36-month study period. A multidisciplinary, mixed-methods approach will be adopted to supplement the randomized controlled trial and meet the study aims. Additional study components include implementation science, social science, economic evaluation, and predictive HIV incidence modeling. Discussion A stepped-wedge randomized design is a causally strong and robust approach to determine if providing antiretroviral treatment for all HIV-positive individuals is a feasible intervention in a resource-limited, public sector health system. We expect our study results to contribute to health policy decisions related to the HIV response in Swaziland and other countries in sub-Saharan Africa. Trial registration ClinicalTrials.gov, NCT02909218. Registered on 10 July 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2128-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Till Bärnighausen
- Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Africa Health Research Institute (AHRI), Mtubatuba, South Africa.,Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - Wim Delva
- The South African Department of Science and Technology - National Research Foundation (DST-NRF) Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa.,Hasselt University, Center for Statistics, Diepenbeek, Belgium.,Ghent University, International Centre for Reproductive Health, Gent, Belgium.,KU Leuven, Rega Institute for Medical Research, Leuven, Belgium
| | | | - Gavin Khumalo
- Swaziland National Network of People Living with HIV/AIDS (SWANNEPHA), Mbabane, Swaziland
| | | | | | | | - Ria Reis
- University of Amsterdam, Amsterdam, The Netherlands.,Leiden University Medical Center, Leiden, The Netherlands.,Children's Institute, University of Cape Town, Cape Town, South Africa
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Affiliation(s)
- Wim Delva
- Wim Delva is a postdoc at the University of Leuven and Hasselt University and an assistant professor at Ghent University in Belgium. He is also the deputy director for research at the South African Centre for Epidemiological Modelling and Analysis at Stellenbosch University. Send your career story to
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19
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Lafort Y, Greener R, Roy A, Greener L, Ombidi W, Lessitala F, Skordis-Worrall J, Beksinska M, Gichangi P, Reza-Paul S, Smit JA, Chersich M, Delva W. Sexual and reproductive health services utilization by female sex workers is context-specific: results from a cross-sectional survey in India, Kenya, Mozambique and South Africa. Reprod Health 2017; 14:13. [PMID: 28103896 PMCID: PMC5247811 DOI: 10.1186/s12978-017-0277-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 01/04/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Female sex workers (FSWs) are extremely vulnerable to adverse sexual and reproductive health (SRH) outcomes. To mitigate these risks, they require access to services covering not only HIV prevention but also contraception, cervical cancer screening and sexual violence. To develop context-specific intervention packages to improve uptake, we identified gaps in service utilization in four different cities. METHODS A cross-sectional survey was conducted, as part of the baseline assessment of an implementation research project. FWSs were recruited in Durban, South Africa (n = 400), Mombasa, Kenya (n = 400), Mysore, India (n = 458) and Tete, Mozambique (n = 308), using respondent-driven sampling (RDS) and starting with 8-16 'seeds' identified by the peer educators. FSWs responded to a standardised interviewer-administered questionnaire about the use of contraceptive methods and services for cervical cancer screening, sexual violence and unwanted pregnancies. RDS-adjusted proportions and surrounding 95% confidence intervals were estimated by non-parametric bootstrapping, and compared across cities using post-hoc pairwise comparison tests with Dunn-Šidák correction. RESULTS Current use of any modern contraception ranged from 86.2% in Tete to 98.4% in Mombasa (p = 0.001), while non-barrier contraception (hormonal, IUD or sterilisation) varied from 33.4% in Durban to 85.1% in Mysore (p < 0.001). Ever having used emergency contraception ranged from 2.4% in Mysore to 38.1% in Mombasa (p < 0.001), ever having been screened for cervical cancer from 0.0% in Tete to 29.0% in Durban (p < 0.001), and having gone to a health facility for a termination of an unwanted pregnancy from 15.0% in Durban to 93.7% in Mysore (p < 0.001). Having sought medical care after forced sex varied from 34.4% in Mombasa to 51.9% in Mysore (p = 0.860). Many of the differences between cities remained statistically significant after adjusting for variations in FSWs' sociodemographic characteristics. CONCLUSION The use of SRH commodities and services by FSWs is often low and is highly context-specific. Reasons for variation across cities need to be further explored. The differences are unlikely caused by differences in socio-demographic characteristics and more probably stem from differences in the availability and accessibility of SRH services. Intervention packages to improve use of contraceptives and SRH services should be tailored to the particular gaps in each city.
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Affiliation(s)
- Yves Lafort
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium.
| | - Ross Greener
- MatCH Research Unit (Maternal, Adolescent and Child Health Research Unit), Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | | | - Letitia Greener
- MatCH Research Unit (Maternal, Adolescent and Child Health Research Unit), Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Wilkister Ombidi
- International Centre for Reproductive Health-Kenya, Mombasa, Kenya
| | - Faustino Lessitala
- International Centre for Reproductive Health-Mozambique, Maputo, Mozambique
| | | | - Mags Beksinska
- MatCH Research Unit (Maternal, Adolescent and Child Health Research Unit), Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Peter Gichangi
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium.,International Centre for Reproductive Health-Kenya, Mombasa, Kenya.,University of Nairobi, Nairobi, Kenya
| | | | - Jenni A Smit
- MatCH Research Unit (Maternal, Adolescent and Child Health Research Unit), Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Matthew Chersich
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium.,Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Wim Delva
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium.,The South African DST-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), University of Stellenbosch, Stellenbosch, South Africa.,Center for Statistics, Hasselt University, Diepenbeek, Belgium
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Delva W, Helleringer S. Beyond Risk Compensation: Clusters of Antiretroviral Treatment (ART) Users in Sexual Networks Can Modify the Impact of ART on HIV Incidence. PLoS One 2016; 11:e0163159. [PMID: 27657492 PMCID: PMC5033240 DOI: 10.1371/journal.pone.0163159] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 09/02/2016] [Indexed: 11/19/2022] Open
Abstract
Introduction Concerns about risk compensation—increased risk behaviours in response to a perception of reduced HIV transmission risk—after the initiation of ART have largely been dispelled in empirical studies, but other changes in sexual networking patterns may still modify the effects of ART on HIV incidence. Methods We developed an exploratory mathematical model of HIV transmission that incorporates the possibility of ART clusters, i.e. subsets of the sexual network in which the density of ART patients is much higher than in the rest of the network. Such clusters may emerge as a result of ART homophily—a tendency for ART patients to preferentially form and maintain relationships with other ART patients. We assessed whether ART clusters may affect the impact of ART on HIV incidence, and how the influence of this effect-modifying variable depends on contextual variables such as HIV prevalence, HIV serosorting, coverage of HIV testing and ART, and adherence to ART. Results ART homophily can modify the impact of ART on HIV incidence in both directions. In concentrated epidemics and generalized epidemics with moderate HIV prevalence (≈ 10%), ART clusters can enhance the impact of ART on HIV incidence, especially when adherence to ART is poor. In hyperendemic settings (≈ 35% HIV prevalence), ART clusters can reduce the impact of ART on HIV incidence when adherence to ART is high but few people living with HIV (PLWH) have been diagnosed. In all contexts, the effects of ART clusters on HIV epidemic dynamics are distinct from those of HIV serosorting. Conclusions Depending on the programmatic and epidemiological context, ART clusters may enhance or reduce the impact of ART on HIV incidence, in contrast to serosorting, which always leads to a lower impact of ART on HIV incidence. ART homophily and the emergence of ART clusters should be measured empirically and incorporated into more refined models used to plan and evaluate ART programmes.
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Affiliation(s)
- Wim Delva
- The South African Department of Science and Technology-National Research Foundation (DST-NRF) Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium
- Center for Statistics, Hasselt University, Diepenbeek, Belgium
- Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
- Institute of Integrative Biology, ETH Zurich, Zurich, Switzerland
- * E-mail:
| | - Stéphane Helleringer
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
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Lafort Y, Greener R, Roy A, Greener L, Ombidi W, Lessitala F, Haghparast-Bidgoli H, Beksinska M, Gichangi P, Reza-Paul S, Smit JA, Chersich M, Delva W. HIV prevention and care-seeking behaviour among female sex workers in four cities in India, Kenya, Mozambique and South Africa. Trop Med Int Health 2016; 21:1293-1303. [PMID: 27479236 DOI: 10.1111/tmi.12761] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To identify gaps in the use of HIV prevention and care services and commodities for female sex workers, we conducted a baseline cross-sectional survey in four cities, in the context of an implementation research project aiming to improve use of sexual and reproductive health services. METHODS Using respondent-driven sampling, 400 sex workers were recruited in Durban, 308 in Tete, 400 in Mombasa and 458 in Mysore and interviewed face-to-face. RDS-adjusted proportions were estimated by nonparametric bootstrapping and compared across cities using post hoc pairwise comparison. RESULTS Condom use with last client ranged from 88.3% to 96.8%, ever female condom use from 1.6% to 37.9%, HIV testing within the past 6 months from 40.5% to 70.9%, receiving HIV treatment and care from 35.5% to 92.7%, care seeking for last STI from 74.4% to 87.6% and having had at least 10 contacts with a peer educator in the past year from 5.7% to 98.1%. Many of the differences between cities remained statistically significant (P < 0.05) after adjusting for differences in FSWs' socio-demographic characteristics. CONCLUSION The use of HIV prevention and care by FSWs is often insufficient and differed greatly between cities. Differences could not be explained by variations in socio-demographic sex worker characteristics. Models to improve use of condoms and HIV prevention and care services should be tailored to the specific context of each site. Programmes at each site must focus on improving availability and uptake of those services that are currently least used.
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Affiliation(s)
- Yves Lafort
- International Centre for Reproductive Health, Ghent University, Gent, Belgium.
| | - Ross Greener
- MatCH Research Unit, University of the Witwatersrand, Durban, South Africa
| | | | - Letitia Greener
- MatCH Research Unit, University of the Witwatersrand, Durban, South Africa
| | - Wilkister Ombidi
- International Centre for Reproductive Health-Kenya, Mombasa, Kenya
| | - Faustino Lessitala
- International Centre for Reproductive Health-Mozambique, Maputo, Mozambique
| | | | - Mags Beksinska
- MatCH Research Unit, University of the Witwatersrand, Durban, South Africa
| | - Peter Gichangi
- International Centre for Reproductive Health, Ghent University, Gent, Belgium.,International Centre for Reproductive Health-Kenya, Mombasa, Kenya.,University of Nairobi, Nairobi, Kenya
| | | | - Jenni A Smit
- MatCH Research Unit, University of the Witwatersrand, Durban, South Africa.,Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Matthew Chersich
- International Centre for Reproductive Health, Ghent University, Gent, Belgium.,Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Wim Delva
- International Centre for Reproductive Health, Ghent University, Gent, Belgium.,The South African DST/NRF Centre of Excellence in Epidemiological Modelling and Analysis, University of Stellenbosch, Stellenbosch, South Africa.,Center for Statistics, Hasselt University, Diepenbeek, Belgium
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Lafort Y, Greener R, Roy A, Greener L, Ombidi W, Lessitala F, Haghparast-Bidgoli H, Beksinska M, Gichangi P, Reza-Paul S, Smit JA, Chersich M, Delva W. Where Do Female Sex Workers Seek HIV and Reproductive Health Care and What Motivates These Choices? A Survey in 4 Cities in India, Kenya, Mozambique and South Africa. PLoS One 2016; 11:e0160730. [PMID: 27494412 PMCID: PMC4975460 DOI: 10.1371/journal.pone.0160730] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 07/25/2016] [Indexed: 11/18/2022] Open
Abstract
Background A baseline cross-sectional survey among female sex workers (FSWs) was conducted in four cities within the context of an implementation research project aiming to improve FSWs’ access to HIV, and sexual and reproductive health (SRH) services. The survey measured where FSWs seek HIV/SRH care and what motivates their choice. Methods Using respondent-driven sampling (RDS), FWSs were recruited in Durban, South Africa (n = 400), Tete, Mozambique (n = 308), Mombasa, Kenya (n = 400) and Mysore, India (n = 458) and interviewed. RDS-adjusted proportions were estimated by non-parametric bootstrapping, and compared across cities using post-hoc pairwise comparison tests. Results Across cities, FSWs most commonly sought care for the majority of HIV/SRH services at public health facilities, most especially in Durban (ranging from 65% for condoms to 97% for HIV care). Services specifically targeting FSWs only had a high coverage in Mysore for STI care (89%) and HIV testing (79%). Private-for-profit clinics were important providers in Mombasa (ranging from 17% for STI care and HIV testing to 43% for HIV care), but not in the other cities. The most important reason for the choice of care provider in Durban and Mombasa was proximity, in Tete ‘where they always go’, and in Mysore cost of care. Where available, clinics specifically targeting FSWs were more often chosen because of shorter waiting times, perceived higher quality of care, more privacy and friendlier personnel. Conclusion The place where care is sought for HIV/SRH services differs substantially between cities. Targeted services have limited coverage in the African cities compared to Mysore. Convenience appears more important for choosing the place of care than aspects of quality of care. The best model to improve access, linking targeted interventions with general health services, will need to be tailored to the specific context of each city.
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Affiliation(s)
- Yves Lafort
- International Centre for Reproductive Health, Ghent University, Gent, Belgium
- * E-mail:
| | - Ross Greener
- MatCH Research (Maternal, Adolescent and Child Health Research) Unit, University of the Witwatersrand, Durban, South Africa
| | | | - Letitia Greener
- MatCH Research (Maternal, Adolescent and Child Health Research) Unit, University of the Witwatersrand, Durban, South Africa
| | - Wilkister Ombidi
- International Centre for Reproductive Health-Kenya, Mombasa, Kenya
| | - Faustino Lessitala
- International Centre for Reproductive Health-Mozambique, Maputo, Mozambique
| | | | - Mags Beksinska
- MatCH Research (Maternal, Adolescent and Child Health Research) Unit, University of the Witwatersrand, Durban, South Africa
| | - Peter Gichangi
- International Centre for Reproductive Health, Ghent University, Gent, Belgium
- International Centre for Reproductive Health-Kenya, Mombasa, Kenya
- University of Nairobi, Nairobi, Kenya
| | - Sushena Reza-Paul
- Ashodaya Samithi, Mysore, India
- University of Manitoba, Winnipeg, Canada
| | - Jenni A. Smit
- MatCH Research (Maternal, Adolescent and Child Health Research) Unit, University of the Witwatersrand, Durban, South Africa
- Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Matthew Chersich
- International Centre for Reproductive Health, Ghent University, Gent, Belgium
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Wim Delva
- International Centre for Reproductive Health, Ghent University, Gent, Belgium
- The South African DST/NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), University of Stellenbosch, Stellenbosch, South Africa
- Center for Statistics, Hasselt University, Diepenbeek, Belgium
- Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
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Lafort Y, Jocitala O, Candrinho B, Greener L, Beksinska M, Smit JA, Chersich M, Delva W. Are HIV and reproductive health services adapted to the needs of female sex workers? Results of a policy and situational analysis in Tete, Mozambique. BMC Health Serv Res 2016; 16:301. [PMID: 27456516 PMCID: PMC4960856 DOI: 10.1186/s12913-016-1551-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 07/12/2016] [Indexed: 11/23/2022] Open
Abstract
Background In the context of an implementation research project aiming at improving use of HIV and sexual and reproductive health (SRH) services for female sex workers (FSWs), a broad situational analysis was conducted in Tete, Mozambique, assessing if services are adapted to the needs of FSWs. Methods Methods comprised (1) a policy analysis including a review of national guidelines and interviews with policy makers, and (2) health facility assessments at 6 public and 1 private health facilities, and 1 clinic specifically targeting FSWs, consisting of an audit checklist, interviews with 18 HIV/SRH care providers and interviews of 99 HIV/SRH care users. Results There exist national guidelines for most HIV/SRH care services, but none provides guidance for care adapted to the needs of high-risk women such as FSWs. The Ministry of Health recently initiated the process of establishing guidelines for attendance of key populations, including FSWs, at public health facilities. Policy makers have different views on the best approach for providing services to FSWs—integrated in the general health services or through parallel services for key populations—and there exists no national strategy. The most important provider of HIV/SRH services in the study area is the government. Most basic services are widely available, with the exception of certain family planning methods, cervical cancer screening, services for victims of sexual and gender-based violence, and termination of pregnancy (TOP). The public facilities face serious limitations in term of space, staff, equipment, regular supplies and adequate provider practices. A stand-alone clinic targeting key populations offers a limited range of services to the FSW population in part of the area. Private clinics offer only a few services, at commercial prices. Conclusion There is a need to improve the availability of quality HIV/SRH services in general and to FSWs specifically, and to develop guidelines for care adapted to the needs of FSWs. Access for FSWs can be improved by either expanding the range of services and the coverage of the targeted clinic and/or by improving access to adapted care at the public health services and ensure a minimum standard of quality. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1551-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yves Lafort
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium.
| | - Osvaldo Jocitala
- International Centre for Reproductive Health-Mozambique, Maputo, Mozambique
| | | | - Letitia Greener
- MatCH Research Unit (Maternal, Adolescent and Child Health Research Unit), University of the Witwatersrand, Durban, South Africa
| | - Mags Beksinska
- MatCH Research Unit (Maternal, Adolescent and Child Health Research Unit), University of the Witwatersrand, Durban, South Africa
| | - Jenni A Smit
- MatCH Research Unit (Maternal, Adolescent and Child Health Research Unit), University of the Witwatersrand, Durban, South Africa.,Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Matthew Chersich
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium.,Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Wim Delva
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium.,The South African DST/NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), University of Stellenbosch, Stellenbosch, South Africa.,Center for Statistics, Hasselt University, Diepenbeek, Belgium
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Lafort Y, Lessitala F, Candrinho B, Greener L, Greener R, Beksinska M, Smit JA, Chersich M, Delva W. Barriers to HIV and sexual and reproductive health care for female sex workers in Tete, Mozambique: results from a cross-sectional survey and focus group discussions. BMC Public Health 2016; 16:608. [PMID: 27440108 PMCID: PMC4955167 DOI: 10.1186/s12889-016-3305-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 07/14/2016] [Indexed: 11/10/2022] Open
Abstract
Background In the context of an operational research project in Tete, Mozambique, use of, and barriers to, HIV and sexual and reproductive health (HIV/SRH) commodities and services for female sex workers (FSWs) were assessed as part of a baseline situational analysis. Methods In a cross-sectional survey 311 FSWs were recruited using respondent driven sampling and interviewed face-to-face, and three focus group discussions were held with respectively 6 full-time Mozambican, 7 occasional Mozambican and 9 full-time Zimbabwean FSWs, to investigate use of, and barriers to, HIV/SRH care. Results The cross-sectional survey showed that 71 % of FSWs used non-barrier contraception, 78 % sought care for their last sexually transmitted infection episode, 51 % of HIV-negative FSWs was tested for HIV in the last 6 months, 83 % of HIV-positive FSWs were in HIV care, 55 % sought help at a health facility for their last unwanted pregnancy and 48 % after sexual assault, and none was ever screened for cervical cancer. Local public health facilities were by far the most common place where care was sought, followed by an NGO-operated clinic targeting FSWs, and places outside the Tete area. In the focus group discussions, FSWs expressed dissatisfaction with the public health services, as a result of being asked for bribes, being badly attended by some care providers, stigmatisation and breaches of confidentiality. The service most lacking was said to be termination of unwanted pregnancies. Conclusions The use of most HIV and SRH services is insufficient in this FSW population. The public health sector is the main provider, but access is hampered by several barriers. The reach of a FSW-specific NGO clinic is limited. Access to, and use of, HIV and SRH services should be improved by reducing barriers at public health facilities, broadening the range of services and expanding the reach of the targeted NGO clinic.
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Affiliation(s)
- Yves Lafort
- International Centre for Reproductive Health, Ghent University, Gent, Belgium.
| | - Faustino Lessitala
- International Centre for Reproductive Health-Mozambique, Maputo, Mozambique
| | | | - Letitia Greener
- MatCH Research Unit (Maternal, Adolescent and Child Health Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Ross Greener
- MatCH Research Unit (Maternal, Adolescent and Child Health Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Mags Beksinska
- MatCH Research Unit (Maternal, Adolescent and Child Health Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Jenni A Smit
- MatCH Research Unit (Maternal, Adolescent and Child Health Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa.,Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Matthew Chersich
- International Centre for Reproductive Health, Ghent University, Gent, Belgium.,Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Wim Delva
- International Centre for Reproductive Health, Ghent University, Gent, Belgium.,The South African DST/NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), University of Stellenbosch, Stellenbosch, South Africa.,Center for Statistics, Hasselt University, Diepenbeek, Belgium
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Beauclair R, Hens N, Delva W. P14.06 A characterisation of concurrent partnerships in cape town, south africa. Br J Vener Dis 2015. [DOI: 10.1136/sextrans-2015-052270.518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Beauclair R, Delva W. Is younger really safer? A qualitative study of perceived risks and benefits of age-disparate relationships among women in Cape Town, South Africa. PLoS One 2013; 8:e81748. [PMID: 24260585 PMCID: PMC3829971 DOI: 10.1371/journal.pone.0081748] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 10/16/2013] [Indexed: 11/18/2022] Open
Abstract
Young women in age-asymmetric relationships may be at an elevated risk for acquisition of HIV, since relationships with older men are also correlated with other risk behaviors like less condom use. Qualitative studies have shown that women are motivated to participate in these relationships for money and emotional support. However, there is a paucity of research on women’s perceived risks of these relationships, particularly in South Africa. To this end, we conducted in-depth interviews with 23 women recruited from three urban communities in Cape Town. A thematic question guide was used to direct the interviews. Thematic content analysis was used to explore women’s perceived risks of age-disparate and non-age-disparate relationships, the benefits of dating older men, and risk perceptions that influence decisions around beginning or ending a relationship. A plurality of women thought that dating an older man does not bring any adverse consequences, although some thought that older men do not use condoms and may be involved in concurrent partnerships. Many women were less inclined to date same-age or younger men, because they were viewed as being disrespectful and abusive. This study points to the need for more awareness raising about the risks of age-disparate relationships. In addition to these initiatives, there is an urgent need to implement holistic approaches to relationship health, in order to curb intimate partner violence, improve gender equity and make non-age-disparate relationships more attractive.
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Affiliation(s)
- Roxanne Beauclair
- The South African Department of Science and Technology/National Research Foundation (DST/NRF) Centre of Excellence in Epidemiological Modeling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- * E-mail:
| | - Wim Delva
- The South African Department of Science and Technology/National Research Foundation (DST/NRF) Centre of Excellence in Epidemiological Modeling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- International Centre for Reproductive Health, Ghent University, Gent, Belgium
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Beauclair R, Meng F, Deprez N, Temmerman M, Welte A, Hens N, Delva W. Evaluating audio computer assisted self-interviews in urban South African communities: evidence for good suitability and reduced social desirability bias of a cross-sectional survey on sexual behaviour. BMC Med Res Methodol 2013; 13:11. [PMID: 23368888 PMCID: PMC3568408 DOI: 10.1186/1471-2288-13-11] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 01/25/2013] [Indexed: 11/24/2022] Open
Abstract
Background Efficient HIV prevention requires accurate identification of individuals with risky sexual behaviour. However, self-reported data from sexual behaviour surveys are prone to social desirability bias (SDB). Audio Computer-Assisted Self-Interviewing (ACASI) has been suggested as an alternative to face-to-face interviewing (FTFI), because it may promote interview privacy and reduce SDB. However, little is known about the suitability and accuracy of ACASI in urban communities with high HIV prevalence in South Africa. To test this, we conducted a sexual behaviour survey in Cape Town, South Africa, using ACASI methods. Methods Participants (n = 878) answered questions about their sexual relationships on a touch screen computer in a private mobile office. We included questions at the end of the ACASI survey that were used to assess participants’ perceived ease of use, privacy, and truthfulness. Univariate logistic regression models, supported by multivariate models, were applied to identify groups of people who had adverse interviewing experiences. Further, we constructed male–female ratios of self-reported sexual behaviours as indicators of SDB. We used these indicators to compare SDB in our survey and in recent FTFI-based Demographic and Health Surveys (DHSs) from Lesotho, Swaziland, and Zimbabwe. Results Most participants found our methods easy to use (85.9%), perceived privacy (96.3%) and preferred ACASI to other modes of inquiry (82.5%) when reporting on sexual behaviours. Unemployed participants and those in the 40–70 year old age group were the least likely to find our methods easy to use (OR 0.69; 95% CI: 0.47–1.01 and OR 0.37; 95% CI: 0.23–0.58, respectively). In our survey, the male–female ratio for reporting >2 sexual partners in the past year, a concurrent relationship in the past year, and > 2 sexual partners in a lifetime was 3.4, 2.6, and 1.2, respectively— far lower than the ratios observed in the Demographic and Health Surveys. Conclusions Our analysis suggests that most participants in our survey found the ACASI modality to be acceptable, private, and user-friendly. Moreover, our results indicate lower SDB than in FTFI techniques. Targeting older and unemployed participants for ACASI training prior to taking the survey may help to improve their perception of ease and privacy.
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Affiliation(s)
- Roxanne Beauclair
- The South African Department of Science and Technology/National Research Foundation (DST/NRF) Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, 19 Jonkershoek Road, Stellenbosch 7600, South Africa.
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28
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Michielsen K, Beauclair R, Delva W, Roelens K, Van Rossem R, Temmerman M. Effectiveness of a peer-led HIV prevention intervention in secondary schools in Rwanda: results from a non-randomized controlled trial. BMC Public Health 2012; 12:729. [PMID: 22938717 PMCID: PMC3504526 DOI: 10.1186/1471-2458-12-729] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 08/27/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While the HIV epidemic is levelling off in sub-Saharan Africa, it remains at an unacceptably high level. Young people aged 15-24 years remain particularly vulnerable, resulting in a regional HIV prevalence of 1.4% in young men and 3.3% in young women. This study assesses the effectiveness of a peer-led HIV prevention intervention in secondary schools in Rwanda on young people's sexual behavior, HIV knowledge and attitudes. METHODS In a non-randomized longitudinal controlled trial, fourteen schools were selected in two neighboring districts in Rwanda Bugesera (intervention) and Rwamagana (control). Students (n = 1950) in eight intervention and six control schools participated in three surveys (baseline, six and twelve months in the intervention). Analysis was done using linear and logistic regression using generalized estimation equations adjusted for propensity score. RESULTS The overall retention rate was 72%. Time trends in sexual risk behavior (being sexually active, sex in last six months, condom use at last sex) were not significantly different in students from intervention and control schools, nor was the intervention associated with increased knowledge, perceived severity or perceived susceptibility. It did significantly reduce reported stigma. CONCLUSIONS Analyzing this and other interventions, we identified several reasons for the observed limited effectiveness of peer education: 1) intervention activities (spreading information) are not tuned to objectives (changing behavior); 2) young people prefer receiving HIV information from other sources than peers; 3) outcome indicators are not adequate and the context of the relationship in which sex occurs and the context in which sex occurs is ignored. Effectiveness of peer education may increase through integration in holistic interventions and redefining peer educators' role as focal points for sensitization and referral to experts and services. Finally, we argue that a narrow focus on sexual risks will never significantly turn the tide.
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Affiliation(s)
- Kristien Michielsen
- International Centre for Reproductive Health, Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan, 185 6K4, 9000, Gent, Belgium.
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Decat P, Zhang WH, Delva W, Moyer E, Cheng Y, Wang ZJ, Lu CY, Wu SZ, Nadisauskiene RJ, Temmerman M, Degomme O. Promoting contraceptive use among female rural-to-urban migrants in Qingdao, China: a comparative impact study of worksite-based interventions. EUR J CONTRACEP REPR 2012; 17:363-72. [PMID: 22839730 DOI: 10.3109/13625187.2012.696752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND We conducted a comparative study in worksites to assess the impact of sexual health promoting interventions on contraceptive use among female rural-to-urban migrants. STUDY DESIGN In Qingdao ten manufacturing worksites were randomly allocated to a standard package of interventions (SPI) and an intensive package of interventions (IPI). The interventions ran from July 2008 to January 2009. Cross-sectional surveys at baseline and end line assessed the sexual behaviour of young female migrants. To evaluate the impact of the interventions we assessed pre- and post-time trends. RESULTS From the SPI group 721 (baseline) and 615 (end line) respondents were considered. Out of the IPI group we included 684 and 603 migrants. Among childless migrants, self-reported contraceptive use increased significantly after SPI and IPI (adjusted odds ratio [aOR] = 3.23; 95% confidence interval [CI] = 1.52-6.84; p < 0.01 and aOR = 5.81; 95% CI = 2.63-12.80; p < 0.001, respectively). Childless migrants older than 22 years reported a greater use after IPI than after SPI. CONCLUSION Implementing current Chinese sexual health promotion programmes at worksites is likely to have a positive impact on migrant women working in the manufacturing industry of Qingdao. More comprehensive interventions seem to have an added value if they are well targeted to specific groups.
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Affiliation(s)
- Peter Decat
- International Centre for Reproductive Health (ICRH), Ghent University, Belgium.
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30
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Abstract
Until now, decisions about how to allocate ART have largely been based on maximising the therapeutic benefit of ART for patients. Since the results of the HPTN 052 study showed efficacy of antiretroviral therapy (ART) in preventing HIV transmission, there has been increased interest in the benefits of ART not only as treatment, but also in prevention. Resources for expanding ART in the short term may be limited, so the question is how to generate the most prevention benefit from realistic potential increases in the availability of ART. Although not a formal systematic review, here we review different ways in which access to ART could be expanded by prioritising access to particular groups based on clinical or behavioural factors. For each group we consider (i) the clinical and epidemiological benefits, (ii) the potential feasibility, acceptability, and equity, and (iii) the affordability and cost-effectiveness of prioritising ART access for that group. In re-evaluating the allocation of ART in light of the new data about ART preventing transmission, the goal should be to create policies that maximise epidemiological and clinical benefit while still being feasible, affordable, acceptable, and equitable.
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Affiliation(s)
- Wim Delva
- South African Department of Science and Technology/National Research Foundation Centre for Excellence in Epidemiological Modelling and Analysis, University of Stellenbosch, Stellenbosch, South Africa.
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Beauclair R, Kassanjee R, Temmerman M, Welte A, Delva W. Age-disparate relationships and implications for STI transmission among young adults in Cape Town, South Africa. EUR J CONTRACEP REPR 2012; 17:30-9. [PMID: 22239263 DOI: 10.3109/13625187.2011.644841] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To estimate the prevalence of age-disparate (AD) relationships among young black and coloured adults in Cape Town (South Africa) and determine socio-demographic predictors and individual and relationship characteristics of women in these relationships. METHODS A secondary analysis of the Cape Area Panel Study (N = 1960) data was conducted. Descriptive statistics were used to quantify the age-mixing pattern and logistic regression was used to identify significant socio-demographic and behavioural correlates of AD relationships. RESULTS Prevalence of AD relationships was high in both black (36%) and coloured (28%) women. The average age difference between male respondents and their partners increased with age. Young, black women who spent fewer nights under the same roof in one week, had a deceased parent, and were not currently attending classes were more likely to be in an AD relationship. Reports of sexually-transmitted infection (STI) symptoms in the last month and unprotected sex were more common among women in AD relationships. CONCLUSIONS AD relationships are common among young women in Cape Town. Home and family stability is preventative of young women engaging in AD relationships. Therefore, holistic, societal interventions may reduce AD relationships, which are a risk factor for STIs.
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Affiliation(s)
- Roxanne Beauclair
- South African Centre for Epidemiological Modelling & Analysis, Stellenbosch University, South Africa.
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Delva W, Richter M, De Koker P, Chersich M, Temmerman M. Sex work during the 2010 FIFA World Cup: results from a three-wave cross-sectional survey. PLoS One 2011; 6:e28363. [PMID: 22163298 PMCID: PMC3233553 DOI: 10.1371/journal.pone.0028363] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 11/07/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In the months leading up to the 2010 FIFA World Cup in South Africa, international media postulated that at least 40,000 foreign sex workers would enter South Africa, and that an increased HIV incidence would follow. To strengthen the evidence base of future HIV prevention and sexual health programmes during international sporting events, we monitored the supply and demand of female sex work in the weeks before, during and after the 2010 FIFA World Cup. METHODOLOGY/PRINCIPAL FINDINGS We conducted three telephonic surveys of female sex workers advertising online and in local newspapers, in the last week of May, June and July 2010. The overall response rate was 73.4% (718/978). The number of sex workers advertising online was 5.9% higher during the World Cup than before. The client turnover rate did not change significantly during (adjusted rate ratio [aRR] = 1.05; 95%CI: 0.90-1.23) or after (aRR = 1.06; 95%CI: 0.91-1.24) the World Cup. The fraction of non-South African sex workers declined during (adjusted odds ratio [aOR] = 0.50; 95%CI: 0.32-0.79) and after (aOR = 0.56; 95%CI: 0.37-0.86) the World Cup. Relatively more clients were foreign during the World Cup among sex workers advertising in the newspapers (aOR = 2.74; 95%CI: 1.37-5.48) but not among those advertising online (aOR = 1.06; 95%CI: 0.60-1.90). Self-reported condom use was high (99.0%) at baseline, and did not change during (aOR = 1.07; 95% CI: 0.16-7.30) or after (aOR = 1.13; 95% CI: 0.16-8.10) the Word Cup. CONCLUSIONS/SIGNIFICANCE Our findings do not provide evidence for mass-immigration of foreign sex workers advertising online and in local newspapers, nor a spike in sex work or risk of HIV transmission in this subpopulation of sex workers during the World Cup. Public health programmes focusing on sex work and HIV prevention during international sporting events should be based on evidence, not media-driven sensationalism that further heightens discrimination against sex workers and increases their vulnerability.
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Affiliation(s)
- Wim Delva
- South African Centre for Epidemiological Modelling and Analysis, Stellenbosch, South Africa.
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Delva W, Beauclair R, Welte A, Vansteelandt S, Hens N, Aerts M, du Toit E, Beyers N, Temmerman M. Age-disparity, sexual connectedness and HIV infection in disadvantaged communities around Cape Town, South Africa: a study protocol. BMC Public Health 2011; 11:616. [PMID: 21810237 PMCID: PMC3161892 DOI: 10.1186/1471-2458-11-616] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 08/02/2011] [Indexed: 11/12/2022] Open
Abstract
Background Crucial connections between sexual network structure and the distribution of HIV remain inadequately understood, especially in regard to the role of concurrency and age disparity in relationships, and how these network characteristics correlate with each other and other risk factors. Social desirability bias and inaccurate recall are obstacles to obtaining valid, detailed information about sexual behaviour and relationship histories. Therefore, this study aims to use novel research methods in order to determine whether HIV status is associated with age-disparity and sexual connectedness as well as establish the primary behavioural and socio-demographic predictors of the egocentric and community sexual network structures. Method/Design We will conduct a cross-sectional survey that uses a questionnaire exploring one-year sexual histories, with a focus on timing and age disparity of relationships, as well as other risk factors such as unprotected intercourse and the use of alcohol and recreational drugs. The questionnaire will be administered in a safe and confidential mobile interview space, using audio computer-assisted self-interview (ACASI) technology on touch screen computers. The ACASI features a choice of languages and visual feedback of temporal information. The survey will be administered in three peri-urban disadvantaged communities in the greater Cape Town area with a high burden of HIV. The study communities participated in a previous TB/HIV study, from which HIV test results will be anonymously linked to the survey dataset. Statistical analyses of the data will include descriptive statistics, linear mixed-effects models for the inter- and intra-subject variability in the age difference between sexual partners, survival analysis for correlated event times to model concurrency patterns, and logistic regression for association of HIV status with age disparity and sexual connectedness. Discussion This study design is intended to facilitate more accurate recall of sensitive sexual history data and has the potential to provide substantial insights into the relationship between key sexual network attributes and additional risk factors for HIV infection. This will help to inform the design of context-specific HIV prevention programmes.
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Affiliation(s)
- Wim Delva
- South African Centre for Epidemiological Modelling & Analysis, Stellenbosch University, 19 Jonkershoek Road, Stellenbosch 7600, South Africa
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Abstract
Potent antiretroviral therapy (ART) reduces mortality and morbidity in people living with HIV by reducing viral load and allowing their immune systems to recover. The reduction in viral load soon after starting ART has led to the hypothesis that early and widespread ART could prevent onward transmission and therefore eliminate the HIV epidemic in the long term. While several authors have argued that it is feasible to use HIV treatment as prevention (TasP), provided treatment is started sufficiently early, others have reasonably drawn attention to the many operational difficulties that will need to be overcome if the strategy is to succeed in reducing HIV transmission. Furthermore, international public health policy must be based on more than theoretical studies, no matter how appealing. Community randomized controlled trials provide the gold standard for testing the extent to which early treatment reduces incidence, but much still needs to be understood and the immediate need is for operational studies to explore the practical feasibility of this approach. Here, we examine some of the issues to be addressed, the obstacles to be overcome, and strategies that may be necessary if TasP is to be effective. Studies of this kind will provide valuable information for the design of large-scale trials, as well as essential information that will be needed if early treatment is to be incorporated into public health policy.
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Affiliation(s)
- Brian Williams
- South African Centre for Epidemiological Modelling and Analysis (SACEMA), Stellenbosch, South Africa.
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Welte A, Hargrove J, Delva W, Williams B, Stander T. How different are the costs and consequences of delayed versus immediate HIV treatment? S Afr Med J 2011; 101:377-380. [PMID: 21920069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Accepted: 12/17/2010] [Indexed: 05/31/2023] Open
Affiliation(s)
- Alex Welte
- South African Centre for Epidemiological Modelling and Analysis, Stellenbosch University
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Delva W, Michielsen K, Meulders B, Groeninck S, Wasonga E, Ajwang P, Temmerman M, Vanreusel B. HIV prevention through sport: the case of the Mathare Youth Sport Association in Kenya. AIDS Care 2011; 22:1012-20. [PMID: 20552463 DOI: 10.1080/09540121003758606] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Sport has become a popular tool for HIV prevention, based on claims that it can foster life skills that are necessary to translate knowledge, attitudes and behavioural intentions into actual behaviour. Empirical evidence of the effectiveness of sport-based HIV prevention programmes is, however, sorely lacking. We therefore conducted a cross-sectional survey assessing sexual behaviour and the determinants thereof among 454 youth of the Mathare Youth Sport Association (MYSA) in Kenya and a control group of 318 non-MYSA members. Multiple (ordinal) logistic regression models were applied to measure the association between MYSA membership and attitudes, subjective norms and self-efficacy related to condom use as well as sexual experience, age at sexual debut, condom use, history of concurrent relationships and number of partners in the last year. MYSA members were more likely to use condoms during the first sex act (odds ratio (OR)=2.10; 95% CI: 1.10-3.99). Consistent condom use with the current/last partner was 23.2% (36/155) among MYSA members vs. 17.2% (17/99) among the control group. Even after adjusting for media exposure - a factor associated with both MYSA membership and higher frequency of condom use - MYSA members were still found to use condoms more frequently with their current/last partner (adjusted OR=1.64; 95% CI: 1.01-2.68). Nevertheless, levels of condom use remain disturbingly low. More rigorous evaluations of sport programmes for HIV prevention are needed. When possible, programmes should be preceded by baseline assessments, trends in risk behaviour of the intervention group should be compared with those of a control group, and protocols for data collection and analysis should include measuring of and adjusting for potentially confounding factors.
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Affiliation(s)
- Wim Delva
- International Centre for Reproductive Health, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.
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Lafort Y, Geelhoed D, Cumba L, Lázaro CDDM, Delva W, Luchters S, Temmerman M. Reproductive health services for populations at high risk of HIV: Performance of a night clinic in Tete province, Mozambique. BMC Health Serv Res 2010; 10:144. [PMID: 20507644 PMCID: PMC2890643 DOI: 10.1186/1472-6963-10-144] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Accepted: 05/28/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Different models exist to provide HIV/STI services for most-at-risk populations (MARP). Along the Tete traffic corridor in Mozambique, linking Malawi and Zimbabwe, a night clinic opening between 4 and 10 PM was established targeting female sex workers (FSW) and long-distance truck drivers (LDD). The clinic offers free individual education and counselling, condoms, STI care, HIV testing, contraceptive services and outreach peer education. To evaluate this clinic model, we assessed relevance, service utilisation, efficiency and sustainability. METHODS In 2007-2009, mapping and enumeration of FSW and LDD was conducted; 28 key informants were interviewed; 6 focus group discussions (FGD) were held with FSW from Mozambique and Zimbabwe, and LDD from Mozambique and Malawi. Clinic outputs and costs were analysed. RESULTS An estimated 4,415 FSW work in the area, or 9% of women aged 15-49, and on average 66 trucks stay overnight near the clinic. Currently on average, 475 clients/month visit the clinic (43% for contraception, 24% for counselling and testing and 23% for STI care). The average clinic running cost is US$ 1408/month, mostly for human resources. All informants endorsed this clinic concept and the need to expand the services. FGD participants reported high satisfaction with the services and mentioned good reception by the health staff, short waiting times, proximity and free services as most important. Participants were in favour of expanding the range of services, the geographical coverage and the opening times. CONCLUSIONS Size of the target population, satisfaction of clients and endorsement by health policy makers justify maintaining a separate clinic for MARP. Cost-effectiveness may be enhanced by broadening the range of SRHR-HIV/AIDS services, adapting opening times, expanding geographical coverage and targeting additional MARP. Long-term sustainability remains challenging and requires private-public partnerships or continued project-based funding.
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Affiliation(s)
- Yves Lafort
- International Centre for Reproductive Health, University Ghent, Ghent, Belgium.
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Delva W, Yard E, Luchters S, Chersich MF, Muigai E, Oyier V, Temmerman M. A Safe Motherhood project in Kenya: assessment of antenatal attendance, service provision and implications for PMTCT. Trop Med Int Health 2010; 15:584-91. [PMID: 20230571 DOI: 10.1111/j.1365-3156.2010.02499.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To investigate uptake and provision of antenatal care (ANC) services in the Uzazi Bora project: a demonstration-intervention project for Safe Motherhood and prevention of mother-to-child transmission of HIV in Kenya. METHODS Data were extracted from antenatal clinic, laboratory and maternity ward registers of all pregnant women attending ANC from January 2004 until September 2006 at three antenatal clinics in Mombasa and two in rural Kwale district of Coast Province, Kenya (n = 25 364). Multiple logistic and proportional odds logistic regression analyses assessed changes over time, and determinants of the frequency and timing of ANC visits, uptake of HIV testing, and provision of iron sulphate, folate and single-dose nevirapine (sd-NVP). RESULTS About half of women in rural and urban settings (52.2% and 49.2%, respectively) attended antenatal clinics only once. Lower parity, urban setting, older age and having received iron sulphate and folate supplements during the first ANC visit were independent predictors of more frequent visits. The first ANC visit occurred after 28 weeks of pregnancy for 30% (5894/19 432) of women. By mid-2006, provision of nevirapine to HIV-positive women had increased from 32.5% and 11.7% in rural and urban clinics, to 67.0% and 74.6%, respectively. Equally marked improvements were observed in the uptake of HIV testing and the provision of iron sulphate and folate. CONCLUSION Provision of ANC services, including sd-NVP, increased markedly over time. While further improvements in quality are necessary, particular attention is needed to implement evidence-based interventions to alter ANC utilization patterns. Encouragingly, improved provision of basic essential obstetric care may increase attendance.
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Affiliation(s)
- W Delva
- International Centre for Reproductive Health, Department of Obstetrics and Gynaecology, Ghent University, Ghent, Belgium
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Luchters SMF, Broeck DV, Chersich MF, Nel A, Delva W, Mandaliya K, Depuydt CE, Claeys P, Bogers JP, Temmerman M. Association of HIV infection with distribution and viral load of HPV types in Kenya: a survey with 820 female sex workers. BMC Infect Dis 2010; 10:18. [PMID: 20102630 PMCID: PMC2845133 DOI: 10.1186/1471-2334-10-18] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Accepted: 01/26/2010] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Human papillomavirus (HPV) and HIV are each responsible for a considerable burden of disease. Interactions between these infections pose substantial public health challenges, especially where HIV prevalence is high and HPV vaccine coverage low. METHODS Between July 2005 and January 2006, a cross-sectional community-based survey in Mombasa, Kenya, enrolled female sex workers using snowball sampling. After interview and a gynaecological examination, blood and cervical cytology samples were taken. Quantitative real-time PCR detected HPV types and viral load measures. Prevalence of high-risk HPV was compared between HIV-infected and -uninfected women, and in women with abnormal cervical cytology, measured using conventional Pap smears. RESULTS Median age of the 820 participants was 28 years (inter-quartile range [IQR] = 24-36 years). One third of women were HIV infected (283/803; 35.2%) and these women were y more likely to have abnormal cervical cytology than HIV-negative women (27%, 73/269, versus 8%, 42/503; P < 0.001). Of HIV-infected women, 73.3% had high-risk HPV (200/273) and 35.5% had HPV 16 and/or 18 (97/273). Corresponding figures for HIV-negative women were 45.5% (229/503) and 15.7% (79/503). After adjusting for age, number of children and condom use, high-risk HPV was 3.6 fold more common in HIV-infected women (95%CI = 2.6-5.1). Prevalence of all 15 of the high-risk HPV types measured was higher among HIV-infected women, between 1.4 and 5.5 fold. Median total HPV viral load was 881 copies/cell in HIV-infected women (IQR = 33-12,110 copies/cell) and 48 copies/cell in HIV-uninfected women (IQR = 6-756 copies/cell; P < 0.001). HPV 16 and/or HPV 18 were identified in 42.7% of LSIL (32/75) and 42.3% of HSIL (11/26) lesions (P = 0.98). High-risk HPV types other than 16 and 18 were common in LSIL (74.7%; 56/75) and HSIL (84.6%; 22/26); even higher among HIV-infected women. CONCLUSIONS HIV-infected sex workers had almost four-fold higher prevalence of high-risk HPV, raised viral load and more precancerous lesions. HPV 16 and HPV 18, preventable with current vaccines, were associated with cervical disease, though other high-risk types were commoner. HIV-infected sex workers likely contribute disproportionately to HPV transmission dynamics in the general population. Current efforts to prevent HIV and HPV are inadequate. New interventions are required and improved implementation of existing strategies.
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Affiliation(s)
- Stanley MF Luchters
- International Centre for Reproductive Health (ICRH), Mombasa, Kenya
- International Centre for Reproductive Health (ICRH), Ghent University, Belgium
| | - Davy Vanden Broeck
- International Centre for Reproductive Health (ICRH), Mombasa, Kenya
- International Centre for Reproductive Health (ICRH), Ghent University, Belgium
| | - Matthew F Chersich
- International Centre for Reproductive Health (ICRH), Ghent University, Belgium
- Reproductive Health and HIV Research Unit (RHRU), University of Witwatersrand, South Africa
| | - Annalene Nel
- International Partnership for Microbicides (IPM), Paarl, South Africa
| | - Wim Delva
- International Centre for Reproductive Health (ICRH), Ghent University, Belgium
- South African Centre for Epidemiological Modelling and Analysis, Stellenbosch University, South Africa
| | | | - Christophe E Depuydt
- Applied Molecular Biology Research (AMBIOR), University of Antwerp, Belgium
- Laboratory for clinical pathology (Labo Lokeren - Campus Riatol), Antwerp, Belgium
| | - Patricia Claeys
- International Centre for Reproductive Health (ICRH), Ghent University, Belgium
| | - John-Paul Bogers
- Applied Molecular Biology Research (AMBIOR), University of Antwerp, Belgium
- Laboratory for clinical pathology (Labo Lokeren - Campus Riatol), Antwerp, Belgium
| | - Marleen Temmerman
- International Centre for Reproductive Health (ICRH), Ghent University, Belgium
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Delva W, Vercoutere A, Loua C, Lamah J, Vansteelandt S, De Koker P, Claeys P, Temmerman M, Annemans L. Psychological well-being and socio-economic hardship among AIDS orphans and other vulnerable children in Guinea. AIDS Care 2009; 21:1490-8. [DOI: 10.1080/09540120902887235] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Wim Delva
- a International Centre for Reproductive Health , Ghent University , Ghent , Belgium
- b South African Centre for Epidemiological Modelling and Analysis , Stellenbosch , South Africa
| | - An Vercoutere
- c Faculty of Medicine and Health Sciences , Ghent University , Ghent , Belgium
- d Fondation Elizabeth Cathy (FELICA) , Conakry , Guinea
| | | | - Jonas Lamah
- d Fondation Elizabeth Cathy (FELICA) , Conakry , Guinea
| | - Stijn Vansteelandt
- e Department of Applied Mathematics and Computer Science , Ghent University , Ghent , Belgium
| | - Petra De Koker
- a International Centre for Reproductive Health , Ghent University , Ghent , Belgium
| | - Patricia Claeys
- a International Centre for Reproductive Health , Ghent University , Ghent , Belgium
| | - Marleen Temmerman
- a International Centre for Reproductive Health , Ghent University , Ghent , Belgium
| | - Lieven Annemans
- f Department of Public Health , Ghent University , Ghent , Belgium
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Delva W, Pretorius C, Temmerman M. Is scaling up enough to curb the HIV epidemic in southern Africa? S Afr Med J 2009; 99:638-639. [PMID: 20073286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
Affiliation(s)
- Wim Delva
- International Centre for Reproductive Health, Ghent University, Belgium.
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Delva W, Wuillaume F, Vansteelandt S, Claeys P, Verstraelen H, Temmerman M. Sexual behaviour and contraceptive use among youth in the Balkans. EUR J CONTRACEP REPR 2009; 12:309-16. [DOI: 10.1080/13625180701673855] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Verstraelen H, Verhelst R, Nuytinck L, Roelens K, De Meester E, De Vos D, Van Thielen M, Rossau R, Delva W, De Backer E, Vaneechoutte M, Temmerman M. Gene polymorphisms of Toll-like and related recognition receptors in relation to the vaginal carriage of Gardnerella vaginalis and Atopobium vaginae. J Reprod Immunol 2009; 79:163-73. [PMID: 19200604 DOI: 10.1016/j.jri.2008.10.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Revised: 10/14/2008] [Accepted: 10/22/2008] [Indexed: 11/25/2022]
Abstract
Host genetic factors have previously been found to act as determinants of differential susceptibility to major infectious diseases. It is less clear whether such polymorphisms may also impose on pathogen recognition in mucosal overgrowth conditions such as bacterial vaginosis, an anaerobic overgrowth condition characterised by the presence of a vaginal biofilm consisting of the Gram-positive anaerobes Gardnerella vaginalis and Atopobium vaginae. We selected 34 single nucleotide polymorphisms pertaining to 9 genes involved with Toll-like receptor-mediated pathogen recognition and/or regulation (LBP, CD14, TLR1, TLR2, TLR4, TLR6, MD2, CARD15 and SIGIRR) and assessed in a nested case-control study their putative association with bacterial vaginosis, as diagnosed by Gram staining, and with the vaginal carriage of A. vaginae and G. vaginalis, as determined by species-specific PCR, among 144 pregnant women. Carriage of G. vaginalis during early pregnancy was associated with the -1155A>G substitution in the promoter region of the MD2 gene (p=0.041). The presence of A. vaginae during the first half of the pregnancy was significantly associated with the CD14 intron 2 1342G>T (p=0.039), the TLR1 exon 4 743A>G (p=0.038), and the CARD15 exon 4 14772A>T (p=0.012) polymorphisms, and marginally significantly associated with the LBP exon13 26842C>T (p=0.056), the CD14 promoter -260C>T (p=0.052), and the TLR1 promoter -7202A>G (p=0.062) polymorphisms. However, no association between gene polymorphisms and bacterial vaginosis as such could be documented. Our data suggest that some degree of genetic susceptibility involving pathogen recognition may occur with the key bacterial vaginosis organism, A. vaginae.
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Affiliation(s)
- Hans Verstraelen
- Department of Obstetrics & Gynaecology, Faculty of Medicine & Health Sciences, Ghent University, De Pintelaan 185, B-9000 Ghent, Belgium.
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Delva W, Wuillaume F, Vansteelandt S, Claeys P, Verstraelen H, Broeck DV, Temmerman M. HIV testing and sexually transmitted infection care among sexually active youth in the Balkans. AIDS Patient Care STDS 2008; 22:817-21. [PMID: 18847388 DOI: 10.1089/apc.2007.0237] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In light of the imminent threat of a growing HIV epidemic in east and southeast Europe, optimal accessibility of primary and secondary HIV preventative interventions, including HIV testing and sexually transmitted infection (STI) care, are fast becoming public health priorities. We surveyed 2150 high school students in Bosnia and Herzegovina, FYR of Macedonia, Serbia, and Montenegro to examine the uptake of HIV testing and associated predictors. Among sexually active youth (n = 651), 5.9% had already been tested for HIV. In marginal logistic regression, country of origin, type of high school, knowing a friend or relative with HIV, poor self-assessed health status, suspicion of having had an STI, and not having used a condom at first sex were independently associated with HIV testing. Fear of the diagnosis, fear of violation of confidentiality, and not knowing where to go for HIV testing were reported as barriers to HIV testing. Of sexually active adolescents who thought they might have contracted an STI, only 42% had subsequently visited a doctor or health facility. The main reasons for not doing so were spontaneous disappearance of the complaints, fear of the diagnosis and being ashamed of discussing the problem. In conclusion, the uptake of HIV testing among this population of sexually active, urban high school students was found to be low, although a higher prevalence of HIV testing history was observed among students showing evidence of risky sexual behavior. Practical and psychological factors seem to challenge the accessibility of facilities for HIV testing and STI care.
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Affiliation(s)
- Wim Delva
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium
| | - Françoise Wuillaume
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium
| | - Stijn Vansteelandt
- Department of Applied Mathematics and Computer Science, Ghent University, Ghent, Belgium
| | - Patricia Claeys
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium
| | - Hans Verstraelen
- Department of Obstetrics and Gynaecology, Ghent University Hospital, Ghent, Belgium
| | - Davy Vanden Broeck
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium
| | - Marleen Temmerman
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium
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Luján J, de Oñate WA, Delva W, Claeys P, Sambola F, Temmerman M, Fernando J, Folgosa E. Prevalence of sexually transmitted infections in women attending antenatal care in Tete province, Mozambique. S Afr Med J 2008; 98:49-51. [PMID: 18270642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
OBJECTIVE To determine the prevalence of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and syphilis in pregnant women. METHODS A cross-sectional study was conducted among women attending antenatal care clinics (ANCs). Blood samples were tested for syphilis using the rapid plasma reagin (RPR) and treponemal haemagglutination (TPHA) tests; CT and NG were diagnosed using a manual polymerase chain reaction assay on first-void urine samples. A socio-demographic questionnaire was completed. Results were compared with previous published data on sexually transmitted infection (STI) prevalence in Mozambique. RESULTS Blood and urine samples were collected from 1 119 and 835 women, respectively. The prevalence of CT was 4.1%, and that of NG 2.5%. The RPR test was positive in 5.2% of the women, and 7.1% had a positive TPHA test. Active syphilis was found in 4.7%. In univariate analysis, CT was associated with having had any level of education (p<0.05), reactive RPR and TPHA were associated with illiteracy (p<0.05), and TPHA was associated with age >25. Multivariate analysis did not show any significant association. In comparison with published data from 1993, a decline was observed for CT (p<0.05), NG and syphilis (p<0.001). CONCLUSIONS Compared with available data, a decline of STI prevalence was observed in our setting. This might be the result of community-based education programmes focusing on changes to sexual behaviour, as well as the widespread use of the syndromic approach to managing STIs and the expansion of syphilis screening in primary health care settings. However, STI rates are still high, and the problem needs more concrete and sustained efforts for its control.
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Affiliation(s)
- Jhonny Luján
- International Centre for Reproductive Health, Ghent University, Belgium
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Abstract
A recent report from a PMTCT implementation study in Mombasa, Kenya, points at an important gap between the efficacy in clinical trial circumstances and the effectiveness of PMTCT programmes when implemented in real life. Hence, the quality and quantity of antenatal HIV counselling in a routine setting were appraised. The counsellors' social and communicative skills, duration and topics covered during pre- and post-test counselling sessions were assessed by means of the VCT assessment tools published by UNAIDS. A total of 14 group educational sessions, 66 pre-test counselling sessions and 50 post-test counselling sessions were observed and assessed. In general, the frequency and duration of the counselling was low. Crucial topics such as window period and partner involvement and follow-up support were covered haphazardly. The counsellor's social and communicative skills were given high marks, yet information was rarely repeated or summarized. The limited time dedicated to women receiving antenatal VCT contrasts with the heavy and comprehensive load of health information and advice they are supposed to receive. Ample pre- and post-test counselling including follow-up should be pursued for optimal effectiveness of PMTCT. We propose a number of health system interventions preceded and guided by ongoing audit.
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Delva W, Draper B, Temmerman M. Implementation of single-dose nevirapine for prevention of MTCT of HIV--lessons from Cape Town. S Afr Med J 2006; 96:706, 708-9. [PMID: 17019492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023] Open
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Delva W, Vercoutere A, Dehaene I, Willems S, Temmerman M, Annemans L. Thinking ahead--the rising tide of AIDS orphans. S Afr Med J 2005; 95:656-8. [PMID: 16327918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Affiliation(s)
- Wim Delva
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
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Delva W, Temmerman M. The efficacy-effectiveness gap in PMTCT. S Afr Med J 2004; 94:796. [PMID: 15532743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023] Open
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