Improving HIV Self-Testing Social Network Interventions: The Role of Sexual Behavior Disclosure Among Chinese Men Who Have Sex with Men

We assessed if same-sex sexual behavior disclosure of index men who have sex with men (MSM) was related to number of HIV self-testing (HIVST) kits requested by index participants, and number of test results successfully uploaded by alters in a network-based HIVST intervention. Index participants are men who accessed and distributed HIVST kits and alters are index's social contacts who received kits. We analyzed treatment arm data [N = 106, mean age = 27 (SD = 5.3)] of an intervention conducted among MSM in Guangzhou, China, May 2019-December 2019. Index MSM who disclosed sexual behavior to their family tended to request more kits [adjusted incidence rate ratio (aIRR) 1.42, 95% CI 1.06, 1.90, p < .05]. Index men who disclosed sexual behavior to their family (aIRR 2.47, 95% CI 1.17, 5.24, p < .05) tended to yield an increase in number of alter test results uploaded. Findings have implications for the development of network-based interventions for key populations.

Effect of community-based interventions targeting female sex workers along the HIV care cascade in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Female sex workers are extremely vulnerable and highly susceptible to being infected with human immunodeficiency virus. As a result, community-based targeted interventions have been recommended as one of the models of care to improve access to HIV services and continued engagement in care. We conducted a systematic review to (1) assess the effect of FSW-targeted community interventions on the improvement of HIV services access along the treatment cascade and (2) describe community-based interventions that positively affect continuation in HIV care across the HIV treatment cascade for FSWs in sub-Saharan Africa.

METHODS

We defined the 5 steps that make up the HIV care cascade and categorized them as outcomes, namely, HIV testing and diagnosis, linkage to care, receipt of ART, and achievement of viral suppression. We conducted a systematic search of randomized controlled trials, cohort, and cross-sectional studies done in sub-Saharan African countries and published from 2004 to 2020. The period was selected based on the time span within which ART was scaled up through widespread roll-out of comprehensive HIV programs in sub-Saharan Africa. We reviewed studies with data on the implementation of community interventions for any of the HIV care cascade stage. The data were analyzed using random effects meta-analysis where possible, and for the rest of the studies, data were synthesized using summary statistics.

RESULTS

The significant impact of the community interventions was observed on HIV testing, HIV diagnosis, and ART use. However, for HIV testing and ART use, the improvement was not sustained for the entire period of implementation. There were minimal interventions that had impact on HIV diagnosis, with only one community service delivery model showing significance. Generally, the interventions that had reasonable impact are those that implemented targeted and comprehensive package of HIV services provided at one location, and with unique strategies specific to each cascade stage.

CONCLUSIONS

The evidence brought forward from this review shows that the effect of community-based interventions varies across the different stages of HIV care cascade. A broad package of interventions including a combination of behavioral, biomedical, and structural, designed with specific strategies, unique to each cascade stage appears to be more effective, although information on long-term treatment outcomes and the extent to which FSWs remain engaged in care is sparse. There is need to conduct a further research to deepen the assessment of the effectiveness of community-based interventions on HIV care cascade for FSWs. This will enhance identification of evidence-based optimal interventions that will guide effective allocation of scarce resources for strategies that would have a significant impact on HIV service delivery.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020157623.

The Changing Landscape of Diverse HIV Treatment and Prevention Interventions: Experiences and Perceptions of Adolescents and Young Adults in Rural KwaZulu-Natal, South Africa

In sub-Saharan Africa, adolescents and young adults aged 15–24 years constitute 36% of an estimated 1. 3 million new HIV infections. Complex biological, social, behavioral and structural factors, as well as cultural norms contribute to whether and how young people perceive, are aware of and experience diverse HIV interventions. This qualitative study explored experiences and perceptions of intervention types among adolescents and young adults, and how different interventions could hinder or facilitate HIV treatment and prevention for adolescents and young adults in rural KwaZulu-Natal, South Africa. Data were collected as part of a DREAMS impact evaluation at the Africa Health Research Institute, KwaZulu-Natal between May 2017–January 2018. We used a combination of rapid community mapping and participant observation in four communities, 58 individual interviews, and 10 group discussions with 61 participants, conducted with both adolescent girls and young women and adolescent boys and young men. Thematic analysis focused on the changing HIV prevention landscape as experienced by adolescents and young adults. Participants reported a mix of new and old biomedical, behavioral, traditional, and locally-developed HIV prevention approaches. The appeal of the newer approaches depended on the extent to which they resonated with existing traditional and longstanding HIV prevention methods and the extent to which they engaged with adolescents and young adults' sexual experiences and with the social and structural factors including gender-related issues. These data demonstrate that in this context, newer methods and approaches can and should synergise with existing methods and beliefs. The HIV prevention landscape is evolving rapidly. Good community links and engagement offer an alternative support structure that could embrace both locally-developed approaches and traditional practices This structure could potentially support feasibility and acceptability of new and old HIV prevention approaches, without creating an impression that new approaches always need to replace the old.

When is Enough, Enough? How the Absence of Dose-Determination Trials Impedes Implementation of HIV Behavioral Interventions

Carefully controlled clinical trials have determined that theory-based behavioral interventions delivered by adherence nurses, professional and paraprofessional counselors, and case managers improve ART adherence and viral suppression. However, there are no studies that empirically inform how much intervention is needed for which patient populations and at what cost. This Editorial raises the issue of how a lack of intervention dosing limits interpretation of trial results and impedes implementation, therefore calling for behavioral intervention dose-finding studies.

Engagement in Maximally-Assisted Therapy and Adherence to Antiretroviral Therapy Among a Cohort of Indigenous People Who Use Illicit Drugs

Throughout the world, Indigenous populations experience a disproportionate burden of HIV infection. Maximally-assisted therapy (MAT) is an interdisciplinary care intervention that includes ART dispensation to support individuals with a history of addiction and homelessness. This study sought to longitudinally evaluate the relationship between engagement in MAT and achieving optimal adherence using data from an ongoing cohort of HIV-positive individuals who use drugs in Vancouver, Canada, where HIV/AIDS treatment is offered at no cost. Between December 2005 and November 2016, 354 HIV-positive Indigenous participants were enrolled and data were analyzed using generalized mixed-effects (GLMM) and marginal structural modeling. In both multivariable analyses, engagement in MAT was independently associated with optimal adherence to ART (GLMM: AOR = 4.92, 95% CI 3.18-7.62; marginal structural model: AOR = 5.76, 95% CI 3.34-9.96). MAT-based programmes could be a part of a renewed evidence-base to elevated levels of preventable HIV/AIDS-associated morbidity, mortality and viral transmission among Indigenous peoples in Canada.

Multi-Site Evaluation of Community-Based Efforts to Improve Engagement in HIV Care Among Populations Disproportionately Affected by HIV in the United States

This study assesses effects of a community-based intervention across seven sites in the United States on HIV care utilization and study retention, among people living with HIV (PLWH). A two-armed study was conducted from 2013 to 2016 in each of seven community-based agencies across the United States. Each site conducted interventions involving community engagement approaches in the form of case management or patient navigation. Control conditions were standard of care involving referral to HIV clinical care. Participants (N = 583) were adults reporting erratic or no HIV care in the past 6 months. Longitudinal survey data on demographics, behavioral risks, and HIV care were collected from participants at baseline, before service delivery, and at 6-month follow-up. Unadjusted and adjusted generalized linear mixed models were used to assess the intervention effects on HIV care utilization and study retention. Participants were majority black (75.5%), cisgender male (55.1%), and heterosexual (55.4%). No significant intervention effect was observed on HIV care utilization, although both groups improved significantly over time [adjusted odds ratio (AOR): 2.09, 95% confidence interval (CI): 1.30-3.37]. Intervention participants were more likely to be retained in the study (AOR: 1.50, 95% CI: 1.03-2.20). Community intervention did not affect HIV care utilization more than standard of care, but intervention participants were more likely to be retained in the study, suggesting that such approaches support relationship building in ways that can facilitate follow-up of socially vulnerable PLWH. More research is needed to understand how such community efforts can support better HIV care utilization in these populations.

Informing Targeted Interventions to Optimize the Cascade of HIV Care Using Cluster Analyses of Health Resource Use Among People Living with HIV/AIDS

Increased awareness of the secondary preventive benefits of antiretroviral treatment (ART) has strengthened the desire to optimize health care systems' response to HIV/AIDS. We identified clusters of health resource utilization (HRU) among people living with HIV (PLHIV) to inform targeted interventions aimed to optimize the cascade of HIV care. Using linked population-level health databases in British Columbia, Canada, we selected two analytic samples of PLHIV with 3 years of follow-up between 2006-2011 that were classified as intermittently retained in care or intermittently engaged in ART, and executed a probabilistic model-based clustering analysis for each sample with 5 and 9 quarterly HRU variables, respectively. We found clear HRU profile differences among both samples with similar HIV-related care: one featured active involvement in non-HIV care, the other little or no health care interaction following linkage to care. Differential reengagement intervention strategies capitalizing on missed opportunities in non-HIV care and further engaging physicians delivering HIV care are needed to optimize the response to the HIV epidemic.

Evidence of injection drug use in Kisumu, Kenya: Implications for HIV prevention

BACKGROUND

Injection drug use is increasingly contributing to the HIV epidemic across sub-Saharan Africa. This paper provides the first descriptive analysis of injection drug use in western Kenya, where HIV prevalence is already highest in the nation at 15.1%.

METHODS

We draw on quantitative data from a study of injection drug use in Kisumu, Kenya. We generated descriptive statistics on socio-demographics, sexual characteristics, and drug-related behaviors. Logistic regression models were adjusted for sex to identify correlates of self-reported HIV positive status.

RESULTS

Of 151 participants, mean age was 28.8 years, 84% (n = 127) were male, and overall self-reported HIV prevalence reached 19.4%. Women had greater than four times the odds of being HIV positive relative to men (Odds Ratio [OR] 4.5, CI: 1.7, 11.8, p = .003). Controlling for sex, ever experiencing STI symptoms (Adjusted Odds ratio [AOR] 4.6, 95% CI 1.7, 12.0, p = .002) and sharing needles or syringes due to lack of access (AOR 3.6, 95% CI 1.2, 10.5, p = .02) were significantly associated with HIV positive status. Lower education (AOR 2.3, 95% CI 0.9, 5.6, p=.08), trading sex for drugs (AOR 2.8, 95% CI 0.9, 8.8, p = .08), being injected by a peddler (AOR 2.9, 95% CI 1.0, 8.5, p = .05), and injecting heroin (AOR 2.3, 95% CI 1.0, 5.7, p = .06), were marginally associated with HIV.

CONCLUSIONS

This exploratory study identified patterns of unsafe drug injection and concurrent sexual risk in western Kenya, yet few resources are currently available to address addiction or injection-related harm. Expanded research, surveillance, and gender sensitive programming are needed.