Potential Impact and Cost-Effectiveness of Condomless-Sex-Concentrated PrEP in KwaZulu-Natal Accounting for Drug Resistance

INTRODUCTION

Oral preexposure prophylaxis (PrEP) in the form of tenofovir-disoproxil-fumarate/emtricitabine is being implemented in selected sites in South Africa. Addressing outstanding questions on PrEP cost-effectiveness can inform further implementation.

METHODS

We calibrated an individual-based model to KwaZulu-Natal to predict the impact and cost-effectiveness of PrEP, with use concentrated in periods of condomless sex, accounting for effects on drug resistance. We consider (1) PrEP availability for adolescent girls and young women aged 15-24 years and female sex workers, and (2) availability for everyone aged 15-64 years. Our primary analysis represents a level of PrEP use hypothesized to be attainable by future PrEP programs.

RESULTS

In the context of PrEP use in adults aged 15-64 years, there was a predicted 33% reduction in incidence and 36% reduction in women aged 15-24 years. PrEP was cost-effective, including in a range of sensitivity analyses, although with substantially reduced (cost) effectiveness under a policy of ART initiation with efavirenz- rather than dolutegravir-based regimens due to PrEP undermining ART effectiveness by increasing HIV drug resistance.

CONCLUSIONS

PrEP use concentrated during time periods of condomless sex has the potential to substantively impact HIV incidence and be cost-effective.

HIV drug resistance profile in South Africa: Findings and implications from the 2017 national HIV household survey

BACKGROUND

HIV drug resistance (HIVDR) testing was included in the 2017 South African national HIV household survey. We describe the prevalence of HIVDR by drug class, age, sex and antiretroviral drugs (ARV) status.

METHODS

Dried blood were spots tested for HIV, with Viral load (VL), exposure to ARVs and HIVDR testing among those HIV positive. HIVDR testing was conducted on samples with VL ≥1000 copies/ml using Next Generation Sequencing. Weighted percentages of HIVDR are reported.

RESULTS

697/1,105 (63%) of HIV positive samples were sequenced. HIVDR was detected in samples from 200 respondents (27.4% (95% confidence interval (CI) 22.8-32.6)). Among these 130 (18.9% (95% CI 14.8-23.8)), had resistance to non-nucleoside reverse transcriptase inhibitors (NNRTIs) only, 63 (7.8% (95% CI 5.6-10.9)) resistance to NNRTIs and nucleoside reverse transcriptase inhibitors, and 3 (0.5% (95% CI 0.1-2.1)) resistance to protease inhibitors. Sixty-five (55.7% (95% CI 42.6-67.9) of ARV-positive samples had HIVDR compared to 112 (22.8% (95% CI 17.7-28.7)), in ARV-negative samples. HIVDR was found in 75.6% (95% CI 59.2-87.3), n = 27, samples from respondents who reported ARV use but tested ARV-negative, and in 15.3% (95% CI 6.3-32.8), n = 7, respondents who reported no ARV use and tested ARV-negative. There were no significant age and sex differences in HIVDR.

CONCLUSION

27% of virally unsuppressed respondents had HIVDR, increasing to 75% among those who had discontinued ARV. Our findings support strengthening first-line ARV regimens by including drugs with a higher resistance barrier and treatment adherence strategies, and close monitoring of HIVDR.

Short Communication: Assessing Estimates of HIV Incidence with a Recent Infection Testing Algorithm That Includes Viral Load Testing and Exposure to Antiretroviral Therapy

A recent infection testing algorithm (RITA) that includes a test for recent HIV infection and a viral load (VL) test is the recommended strategy to estimate national HIV incidence, reducing false-recent misclassification to <1%. The inclusion of information on exposure to antiretroviral therapy (ART), as a supplement to VL testing, could improve RITA performance by further lowering false-recent misclassification of true long-term infection. In 2012, Kenya and South Africa conducted national population-based surveys that collected information on HIV recency (i.e., HIV antibody seroconversion, on average, in the past 130 days) using the Limiting Antigen avidity (LAg-Avidity) enzyme immunoassay, HIV RNA levels, and ART exposure among HIV-infected respondents aged 15-49 years. In Kenya, ART exposure was defined as testing positive for one or more antiretroviral (ARV) drugs using high-performance liquid chromatography coupled with tandem mass spectrometry, and, if not ARV-positive, self-reporting a history of ART exposure. In South Africa, ART exposure was defined as testing ARV-positive. Two RITA strategies were compared: RITA #1 defined recent infection as testing LAg-Avidity-recent with unsuppressed VL (HIV RNA ≥1,000 copies/ml), and RITA #2 defined recent infection as testing LAg-Avidity-recent with unsuppressed VL and, if unsuppressed, having no ART exposure. RITA-derived incidence among persons aged 15-49 years in Kenya was 0.9% on RITA #1 and 0.8% on RITA #2. In South Africa, RITA-derived incidence was 2.2% on RITA #1 and 1.7% on RITA #2. Among specimens testing recent with unsuppressed VL in Kenya and South Africa, 16.0% and 19.7% had evidence of ART exposure, respectively. Although the performance of a VL- and ART-based RITA was encouraging, additional research is needed across HIV-1 subtypes and subpopulations to calibrate and validate this algorithm.

Equity of antiretroviral treatment use in high HIV burden countries: Analyses of data from nationally-representative surveys in Kenya and South Africa

OBJECTIVE

To assess changes and equity in antiretroviral therapy (ART) use in Kenya and South Africa.

METHODS

We analysed national population-based household surveys conducted in Kenya and South Africa between 2007 and 2012 for factors associated with lack of ART use among people living with HIV (PLHIV) aged 15-64 years. We considered ART use to be inequitable if significant differences in use were found between groups of PLHIV (e.g. by sex).

FINDINGS

ART use among PLHIV increased from 29.3% (95% confidence interval [CI]: 22.8-35.8) to 42.5% (95%CI: 37.4-47.7) from 2007 to 2012 in Kenya and 17.4% (95%CI: 14.2-20.9) to 30.3% (95%CI: 27.2-33.6) from 2008 to 2012 in South Africa. In 2012, factors independently associated with lack of ART use among adult Kenyan PLHIV were rural residency (adjusted odds ratio [aOR] 1.98, 95%CI: 1.23-3.18), younger age (15-24 years: aOR 4.25, 95%CI: 1.7-10.63, and 25-34 years: aOR 5.16, 95%CI: 2.73-9.74 versus 50-64 years), nondisclosure of HIV status to most recent sex partner (aOR 2.41, 95%CI: 1.27-4.57) and recent recreational drug use (aOR 2.50, 95%CI: 1.09-5.77). Among South African PLHIV in 2012, lack of ART use was significantly associated with younger age (15-24 years: aOR 4.23, 95%CI: 2.56-6.70, and 25-34 years: aOR 2.84, 95%CI: 1.73-4.67, versus 50-64 years), employment status (aOR 1.61, 95%CI: 1.16-2.23 in students versus unemployed), and recent recreational drug use (aOR 4.56, 95%CI: 1.79-11.57).

CONCLUSION

Although we found substantial increases in ART use in both countries over time, we identified areas needing improvement including among rural Kenyans, students in South Africa, and among young people and drug users in both countries.

Determinants of excellent/good self-rated health among HIV positive individuals in South Africa: evidence from a 2012 nationally representative household survey

BACKGROUND

In South Africa, HIV is increasingly becoming a chronic disease as a result of advances in HIV treatment and prevention in the last three decades. This has changed the perception from a life threating to a potentially manageable disease. However, little is known about self-perceived health status of HIV-infected individuals. Self-rated health (SRH) has been shown to be a sensitive indicator of health-relatedchanges directly linked to HIV, but can also be influenced by differences in social and material conditions. The aim of this paper was to identify determinants of excellent/good SRH among HIV-infected individuals using socio-demographic, life style and health related data.

METHODS

The study used data from the nationally representative 2012 South African population-based household survey on HIV prevalence, incidence and behaviour conducted using multi-stage stratified cluster sampling design. Bivariate and multivariate logistic regression models were used to identify determinants of SRH among HIV-infected individuals.

RESULTS

Out of a total of 2632 HIV positive participants 74.1% (95% CI: 68.4-74.2) reported excellent/good SRH. Increased likelihood of reporting excellent/good SRH was significantly associated with being Black African [OR= 1.97 (95%CI: 1.12-3.46), p = 0.019] and belonging to least poor household [OR= 3.13 (95%CI: 1.26-7.78), p = 0.014]. Decreased likelihood of reporting excellent/good SRH was significantly associated with those aged 25 to 34 years [OR= 0.49 (95% CI: 0.31-0.78), p = 0.003], 35 to 44 years[OR= 0.27 (95% CI: 0.17-0.44), p < 0.001], 45 to 54 years [OR= 0.20 (95% CI: 0.12-0.34), p < 0.001], and those 55 years and older [OR= 0.15 (95% CI: 0.09-0.26), p < 0.001], hospitalization in the past twelve months [OR= 0.40 (95% CI: 0.26-0.60), p < 0.001].

CONCLUSION

To have positive health effects and improve the perceived health status for PLWH social interventions should seek to enhance to support for the elderly HIV-positive individuals, and address the challenge of socio-economic inequalities and underlying comorbid conditions resulting in hospitalization.

Antiretroviral Treatment and Sexual Risk Behavior in South Africa

The sexual behavior of individuals living with HIV determines the onward transmission of HIV. With the understanding that antiretroviral therapy (ART) prevents transmission of HIV, the sexual behaviors of the individuals not on ART with unsuppressed viral loads becomes of the greatest importance in elucidating transmission. We assessed the association between being on ART and sexual risk behavior among those living with HIV in a nationally representative population-based cross-sectional survey of households in South Africa that was conducted in 2012. Of 2237 adults (aged 15-49) who tested HIV-seropositive, 667 (29.8 %) had detectable antiretroviral drugs in their blood specimens. Among males, 77.7 % of those on ART reported having had sex in the past year contrasted with 88.4 % of those not on ART (p = 0.001); among females, 72.2 % of those on ART reported having had sex in the past year while 80.3 % of those not on ART did (p < 0.001). For males and females, the odds of reporting consistent condom use and condom use at last sex were statistically significantly higher for individuals on ART compared to those not on ART (males: consistent condom use aOR 2.8, 95 % CI 1.6-4.9, condom use at last sex aOR 2.6, 95 % CI 1.5-4.6; females: consistent condom use aOR 2.3, 95 % CI 1.7-3.1, condom use at last sex aOR 2.3, 95 % CI 1.7-3.1), while there were no statistically significant differences in odds of reporting multiple sexual partners in the past year. In this nationally representative population-based survey of South African adults, we found evidence of less risky sexual risk behavior among people living with HIV on ART compared to those not on ART.

Predictors of knowledge about tuberculosis: results from SANHANES I, a national, cross-sectional household survey in South Africa

BACKGROUND

South Africa is one of the 22 high tuberculosis burden countries that contribute 80% of the global tuberculosis cases. Tuberculosis is infectious and due to its rapid and easy transmission route poses a threat to population health. Considering the importance of social and psychological factors in influencing health outcomes, appraising knowledge and awareness of tuberculosis, remain vital for effective tuberculosis control. The main aim of this study was to investigate the factors that predict knowledge about tuberculosis among 18-64 year old adults in South Africa.

METHODS

A cross-sectional survey method was used. Multi-stage disproportionate, stratified cluster sampling was used to select households within enumeration areas stratified by province and locality type. Based on the Human Sciences Research Council 2007 master sample, 500 Enumerator Areas representative of the socio-demographic profile of South Africa were identified and a random sample of 20 households was randomly selected from each Enumerator Area, yielding an overall sample of 10,000 households. The tuberculosis module contained in the South African National Health And Nutrition Examination Survey I was the only module that examined the social determinants of an infectious disease. This module was questionnaire-based with no biomarkers obtained to screen for the presence of tuberculosis disease among the participants. Data was collected by administering a researcher developed individual level questionnaire. Simple and multiple linear regression was used to determine the independent variables associated with tuberculosis knowledge.

RESULTS

Half the sample (52.6%) was female and the majority of the respondents were black African (76.5%). More than two thirds (68.0%) resided in urban areas, 56.9% did not complete high school and half were not in formal employment. Significant predictors of tuberculosis knowledge were race, sex, completion of high school, being in employment, having a diagnosis of the disease in ones' life-time and learning about tuberculosis from television, brochures, health workers, and teachers.

CONCLUSIONS

To reduce the burden of tuberculosis in South Africa, media campaigns targeting both rural and urban communities should include conveying accurate information about the disease. Policy makers should also address structural barriers that vulnerable communities face.

Does marital status matter in an HIV hyperendemic country? Findings from the 2012 South African National HIV Prevalence, Incidence and Behaviour Survey

South Africa has experienced declining marriage rates and the increasing practice of cohabitation without marriage. This study aims to improve the understanding of the relationship between marital status and HIV in South Africa, an HIV hyperendemic country, through an analysis of findings from the 2012 South African National HIV Prevalence, Incidence and Behaviour Survey. The nationally representative population-based cross-sectional survey collected data on HIV and socio-demographic and behavioural determinants in South Africa. This analysis considered respondents aged 16 years and older who consented to participate in the survey and provided dried blood spot specimens for HIV testing (N = 17,356). After controlling for age, race, having multiple sexual partners, condom use at last sex, urban/rural dwelling and level of household income, those who were married living with their spouse had significantly reduced odds of being HIV-positive compared to all other marital spouses groups. HIV incidence was 0.27% among respondents who were married living with their spouses; the highest HIV incidence was found in the cohabiting group (2.91%). Later marriage (after age 24) was associated with increased odds of HIV prevalence. Our analysis suggests an association between marital status and HIV prevalence and incidence in contemporary South Africa, where odds of being HIV-positive were found to be lower among married individuals who lived with their spouses compared to all other marital status groups. HIV prevention messages therefore need to be targeted to unmarried populations, especially cohabitating populations. As low socio-economic status, low social cohesion and the resulting destabilization of sexual relationships may explain the increased risk of HIV among unmarried populations, it is necessary to address structural issues including poverty that create an environment unfavourable to stable sexual relationships.

A Comparison of South African National HIV Incidence Estimates: A Critical Appraisal of Different Methods

BACKGROUND

The interpretation of HIV prevalence trends is increasingly difficult as antiretroviral treatment programs expand. Reliable HIV incidence estimates are critical to monitoring transmission trends and guiding an effective national response to the epidemic.

METHODS AND FINDINGS

We used a range of methods to estimate HIV incidence in South Africa: (i) an incidence testing algorithm applying the Limiting-Antigen Avidity Assay (LAg-Avidity EIA) in combination with antiretroviral drug and HIV viral load testing; (ii) a modelling technique based on the synthetic cohort principle; and (iii) two dynamic mathematical models, the EPP/Spectrum model package and the Thembisa model. Overall, the different incidence estimation methods were in broad agreement on HIV incidence estimates among persons aged 15-49 years in 2012. The assay-based method produced slightly higher estimates of incidence, 1.72% (95% CI 1.38 - 2.06), compared with the mathematical models, 1.47% (95% CI 1.23 - 1.72) in Thembisa and 1.52% (95% CI 1.43 - 1.62) in EPP/Spectrum, and slightly lower estimates of incidence compared to the synthetic cohort, 1.9% (95% CI 0.8 - 3.1) over the period from 2008 to 2012. Among youth aged 15-24 years, a declining trend in HIV incidence was estimated by all three mathematical estimation methods.

CONCLUSIONS

The multi-method comparison showed similar levels and trends in HIV incidence and validated the estimates provided by the assay-based incidence testing algorithm. Our results confirm that South Africa is the country with the largest number of new HIV infections in the world, with about 1 000 new infections occurring each day among adults aged 15-49 years in 2012.

Perceptions about the acceptability and prevalence of HIV testing and factors influencing them in different communities in South Africa

HIV counselling and testing (HCT) is considered important because it is an entry point to a comprehensive continuum of care for HIV/AIDS. The South African Department of Health launched an HCT campaign in April 2010, and this reached 13,269,746 people by June 2011, of which 16% tested HIV positive and 400,000 of those were initiated into antiretroviral treatment. The overall objective of this project was to gain insight into the general perceptions about HIV testing in the different South African communities. Factors influencing testing in these communities were also explored. Discussions with twelve focus groups (FG) of 8-12 participants each were conducted with male and female participants recruited from both urban formal and informal communities in Cape Town and Durban. Participants included four racial groups represented by different age groups as follows: adolescents (12-17 years), youth (18-24 years) and adults (25 years and older). Data were analyzed using thematic coding. Among the key themes that emerged from the findings were the inaccurate perception of risk, fear of testing HIV positive, stigma and discrimination. Participants from both African and Indian FGs reported being less likely to do self-initiated HIV testing and counselling, while those from the FG consisting of young whites were more likely to learn about their HIV status through blood donations and campus HIV testing campaigns. Most FGs said they were likely to test if they understood the testing process better and also if the results are kept confidential. The present findings reiterate the importance of spreading positive messages and ensuring confidentiality for HIV testing in a society where there is still some stigma associated with people living with HIV/AIDS. This can partly be accomplished by the continuation of the national HCT campaign, which has been a considerable success in the fight against HIV/AIDS in South Africa during the past two years.

Equity in the use of antiretroviral treatment in the public health care system in urban South Africa

OBJECTIVES

The scaling up of antiretroviral treatment (ART) for HIV-infected adults requires a sizeable investment of resources in the South African public health care system. It is important that these resources are used productively and in ways that reach those in need, irrespective of social status or personal characteristics. In this study we evaluate whether the distribution of ART services in the public system reflects the distribution of need among adults in the urban population.

METHODS

Data from a 2008 national survey were used to estimate the distribution of socioeconomic status (SES) and sex in HIV-positive adults in urban areas. These findings were compared to SES and sex distributions in 635 ART users within 6 urban public ART facilities.

RESULTS

Close to 40% of those with HIV are in the lowest SES quintile, while 67% are women. The distributions in users of ART are similar to these distributions in HIV-positive people.

CONCLUSIONS

Patterns of ART use in study settings correspond to patterns of HIV in the urban population at the national level. This suggests that the South African ART programme is on track to ensure equitable delivery of treatment services in urban settings.

Evaluating the BED capture enzyme immunoassay to estimate HIV incidence among adults in three countries in sub-Saharan Africa

Serological assays for estimating HIV-1 incidence are prone to misclassification, limiting the accuracy of the incidence estimate. Adjustment factors have been developed and recommended for estimating assay-based HIV-1 incidence in cross-sectional settings. We evaluated the performance of the recommended adjustment factors for estimating incidence in national HIV surveys in three countries in sub-Saharan Africa. The BED-capture enzyme immunoassay was applied to stored blood specimens from (1) pregnant women aged 15-49 years attending antenatal clinics in Côte d'Ivoire (1998-2004), (2) adults aged 15-49 years participating in a demographic health survey in Kenya (2003), and (3) adults aged 15-49 years participating in a national household serosurvey in South Africa (2005). Assay-derived incidence estimates were corrected for misclassification using recommended adjustment factors and, where possible, were compared to mathematically modeled incidence in the same populations. Trends in HIV prevalence were compared to trends in assay-derived incidence to assess plausibility in the assay-derived trends. Unadjusted incidence was 3.8% [95% confidence interval (CI) 3.3-4.5] in Côte d'Ivoire, 3.5% (2.7-4.3) in Kenya, and 4.4% (CI 2.3-6.5]) in South Africa. Adjusted incidence was 2.9% (CI 2.1-3.7) in Côte d'Ivoire, 2.6% (CI 2.0-3.2) in Kenya, and 2.4% (CI 1.7-3.1) in South Africa. After adjustment, peak incidence shifted from older to younger age groups in Côte d'Ivoire and South Africa. Modeled HIV incidence was 1.0% (CI 1.02-1.08) in Kenya and 2.0% (CI 1.7-2.4) in South Africa. After applying the recommended adjustments factors, adjusted assay-derived estimates remained implausibly high in two of three populations evaluated. For more accurate measures of assay-derived population incidence, adjustment factors must be locally derived and validated. Until improved assays are available, caution should be applied in the use and interpretation of data from incidence assays.

Age at sexual debut: a determinant of multiple partnership among South African youth

Age at sexual debut is an important determinant of HIV infection. The paper investigates the effects of age at sexual debut on sexual behaviour among South African youth. Among 2 875 respondents who ever had sexual intercourse, 39% had early sexual debut (sexual debut at age 16 years and below). Males (44.6%) were significantly more likely than females (35.1%) to report early sexual debut (odds ratio (OR) = 1.45, p-value < 0.001). Multiple sexual partners are significantly more common among those that had early sexual debut (10.4% vs. 4.8%) than those who had late sexual debut, (OR = 2.29, p-value < 0.001). Those aged 15 to 19 years were 1.4 times more likely to report multiple partners compared to those aged 20 to 24 years. Delaying sexual debut is a strategy many national programmes are promoting. The results of this study provide additional arguments to support such initiatives and show the need to strengthen intervention targeting youth.

Estimating HIV Incidence in Populations Using Tests for Recent Infection: Issues, Challenges and the Way Forward

INTRODUCTION: HIV incidence is the rate of new infections in a population over time. HIV incidence is a critical indicator needed to assess the status and trends of the HIV epidemic in populations and guide and assess the impact of prevention interventions. METHODS: Several methods exist for estimating population-level HIV incidence: direct observation of HIV incidence through longitudinal follow-up of persons at risk for new HIV infection, indirect measurement of HIV incidence using data on HIV prevalence and mortality in a population, and direct measurement of HIV incidence through use of tests for recent infection (TRIs) that can differentiate "recent" from "non-recent" infections based on biomarkers in cross-sectional specimens. Given the limitations in measuring directly observed incidence and the assumptions needed for indirect measurements of incidence, there is an increasing demand for TRIs for HIV incidence surveillance and program monitoring and evaluation purposes. RESULTS: Over ten years since the introduction of the first TRI, a number of low-, middle-, and high-income countries have integrated this method into their HIV surveillance systems to monitor HIV incidence in the population. However, the accuracy of these assays for measuring HIV incidence has been unsatisfactory to date, mainly due to misclassification of chronic infections as recent infection on the assay. To improve the accuracy of TRIs for measuring incidence, countries are recommended to apply case-based adjustments, formula-based adjustments using local correction factors, or laboratory-based adjustment to minimize error related to assay misclassification. Multiple tests may be used in a recent infection testing algorithm (RITA) to obtain more accurate HIV incidence estimates. CONCLUSION: There continues to be a high demand for improved TRIs and RITAs to monitor HIV incidence, determine prevention priorities, and assess impact of interventions. Current TRIs have noted limitations, but with appropriate adjustments, interpreted in parallel with other epidemiologic data, may still provide useful information on new infections in a population. New TRIs and RITAs with improved accuracy and performance are needed and development of these tools should be supported.

Accuracy of serological assays for detection of recent infection with HIV and estimation of population incidence: a systematic review

We systematically reviewed the accuracy of serological tests for recent infections with HIV that have become widely used for measuring population patterns incidence of HIV. Across 13 different assays, sensitivity to detect recent infections ranged from 42-100% (median 89%). Specificity for detecting established infections was between 49.5% and 100% (median 86.8%) and was higher for infections of durations longer than 1 year (median 98%, range 31.5-100.0). For four different assays, comparisons were made between assay-derived population incidence estimates and a reference incidence estimate. The median percentage difference between the assay-derived incidence and reference incidence was 26.0%. Serological assays have reasonable sensitivity for the detection of recent infection with HIV, but are vulnerable to misclassifying established infections as recent-potentially leading to biases in incidence estimates. This conclusion is highly qualified by the apparent absence of a standardised approach to assay evaluation. There is an urgent need for an internationally agreed framework for evaluating and comparing these tests.

National HIV incidence measures--new insights into the South African epidemic

BACKGROUND AND OBJECTIVES

Currently South Africa does not have national HIV incidence data based on laboratory testing of blood specimens. The 2005 South African national HIV household survey was analysed to generate national incidence estimates stratified by age, sex, race, province and locality type, to compare the HIV incidence and HIV prevalence profiles by sex, and to examine the relationship between HIV prevalence, HIV incidence and associated risk factors.

METHOD

The detection of recent infections was performed on confirmed HIV-positive samples, using the BED capture enzyme immunoassay optimised for dried blood spot (DBS) specimens. BED HIV incidence calculations applied adjustment procedures that were recently revised and approved by the Centers for Disease Control and Prevention for subtype C blood specimens.

RESULTS

HIV incidence in the study population aged 2 years and older was 1.4% per year, with 571,000 new HIV infections estimated for 2005. An HIV incidence rate of 2.4% was recorded for the age group 15-49 years. The incidence of HIV among females peaked in the 20-29-year age group at 5.6%, more than six times the incidence found in 20-29-year-old males (0.9%). Among youth aged 15-24 years, females account for 90% of the recent HIV infections. Non-condom use among youth, current pregnancy and widowhood were the socio-behavioural factors associated with the highest HIV incidence rates.

CONCLUSIONS

The HIV incidence estimates reflect the underlying transmission dynamics that are currently at work in South Africa. The findings suggest that the current prevention campaigns are not having the desired impact, particularly among young women.

Public perceptions on national health insurance: moving towards universal health coverage in South Africa

BACKGROUND

Since 1994, considerable progress has been made in transforming the South African health care system, implementing programmes that improve the health of the population, and improving access to health care services. However, amid escalating health care costs disparities continue to exist between the public and private health sectors. The implementation of a national or social health insurance remains elusive despite three government-appointed committees on the matter.

METHOD AND OBJECTIVE

This paper reports on the findings of a national probability household sample of the South African population, drawn as part of the 2005 HIV/AIDS national survey, to gauge public opinion on universal health care coverage. The perceptions of South Africans were assessed on selected health care affordability and financing issues.

RESULTS

The majority support efforts to contain medicine costs and one-third are of the opinion that the country can provide everyone with all the needed health care and medical services. A large percentage of participants thought it more important to provide improved health care coverage even if it meant raising taxes, while a small percentage said it is better to hold down taxes despite lack of access to health care for some South Africans. Almost a quarter of participants were unable to comment on questions posed to them, indicating the need for improved public education and communication.

CONCLUSION

The study provides important insights into public opinion on key policy issues. However, greater public awareness is needed to ensure an informed debate, while the design of a universal national health insurance scheme must take into account both the current context and public opinion.

Behavioural data as an adjunct to HIV surveillance data

BACKGROUND

Second generation surveillance for HIV aims to improve the validity and utility of routine serial HIV prevalence data. It includes the collection of data on sexual behaviour and sexually transmitted disease prevalence.

METHODS

This paper reviews the function of sexual behaviour data in HIV surveillance and the methods used to determine which behaviours are monitored and how changes in behaviour can be assessed.

RESULTS

Sexual behaviour data provide a poor predictor of the future spread of HIV, but these data can provide corroboration of changes in HIV incidence and assist in attributing changes to particular aspects of risk. Significance tests should be used to assess changes in behaviour, but this requires transparent reporting of methods and sample sizes.

CONCLUSIONS

Collection of behavioural data will provide important retrospective information about the HIV epidemic progress and should not be neglected because of the focus on improving HIV sero-surveillance.

Declines in HIV prevalence can be associated with changing sexual behaviour in Uganda, urban Kenya, Zimbabwe, and urban Haiti

OBJECTIVE

To determine whether observed changes in HIV prevalence in countries with generalised HIV epidemics are associated with changes in sexual risk behaviour.

METHODS

A mathematical model was developed to explore the relation between prevalence recorded at antenatal clinics (ANCs) and the pattern of incidence of infection throughout the population. To create a null model a range of assumptions about sexual behaviour, natural history of infection, and sampling biases in ANC populations were explored to determine which factors maximised declines in prevalence in the absence of behaviour change. Modelled prevalence, where possible based on locally collected behavioural data, was compared with the observed prevalence data in urban Haiti, urban Kenya, urban Cote d'Ivoire, Malawi, Zimbabwe, Rwanda, Uganda, and urban Ethiopia.

RESULTS

Recent downturns in prevalence observed in urban Kenya, Zimbabwe, and urban Haiti, like Uganda before them, could only be replicated in the model through reductions in risk associated with changes in behaviour. In contrast, prevalence trends in urban Cote d'Ivoire, Malawi, urban Ethiopia, and Rwanda show no signs of changed sexual behaviour.

CONCLUSIONS

Changes in patterns of HIV prevalence in urban Kenya, Zimbabwe, and urban Haiti are quite recent and caution is required because of doubts over the accuracy and representativeness of these estimates. Nonetheless, the observed changes are consistent with behaviour change and not the natural course of the HIV epidemic.

Second-generation HIV surveillance: better data for decision-making

This paper seeks to outline the key elements of the expanded surveillance efforts recommended by the second-generation HIV surveillance approach. Second-generation systems focus on improving and expanding existing surveillance methods and combine them in ways that have the greatest explanatory power. The main elements of this approach include: considering biological surveillance - HIV, AIDS, sexually transmitted infections (STIs) - and behavioural surveillance as integral components, targeting surveillance efforts at segments of the population where most new infections are concentrated - which might differ depending on the stage and type of the epidemic - and providing the rationale for the optimal use of data generated for monitoring the HIV epidemic and evaluating national AIDS control programmes. The paper emphasizes improvements in existing surveillance methodologies and discusses in detail crucial issues such as the validity of HIV prevalence data measured in pregnant women and linking HIV surveillance and behavioural data collection. In addition, a strategic partnership between second-generation surveillance and AIDS programme evaluation is proposed that stresses the complementary roles of these data collection activities in determining the effectiveness of prevention and care programmes and explaining the epidemiological trend data collected by sentinel serosurveillance systems. In conclusion, second-generation HIV surveillance systems provide a comprehensive, cost-effective and appropriate response to the information needs of AIDS control programmes. The implementation of such systems, including a better use of the data generated by the system, will ensure that national programmes are in the best possible position to respond to the challenges of the epidemic.

HIV risk behavioral surveillance: a methodology for monitoring behavioral trends

OBJECTIVE

This article summarizes issues and recommendations for conducting HIV risk behavioral surveillance surveys (BSS) based on experiences from ten BSS projects in eight countries in Asia and Africa.

BACKGROUND

BSS consists of systematic and repeated cross-sectional surveys of HIV and sexually transmitted disease-related behaviors, with other knowledge and attitudinal variables added where appropriate. Its major purpose and utility is in detecting trends among selected vulnerable and high-risk population groups whose behavioral change can have the most impact on the epidemic. BSS is also useful for tracking trends in behaviors over time in regions exposed to HIV prevention activities, as a contributing component to the comprehensive monitoring and evaluation of interventions.

RECOMMENDATIONS

(i) implement BSS as an essential adjunct to HIV/STD epidemiological surveillance; (ii) use BSS for evaluation purposes in combination with process data and triangulate results with qualitative research; (iii) choose sentinel groups based on epidemiological considerations, evaluation and monitoring needs, representative sampling frames, and political and cultural considerations; (iv) maintain 1-year intervals between survey waves for most groups in order to provide yearly updates on behavioral trends for programmatic adjustments; (v) use internationally standardized indicators and question wording; (vi) maintain strict quality control standards to enhance data validity and reliability; and (vii) develop a clear dissemination strategy during BSS design to increase the likelihood of utilization of BSS results.

CONCLUSION

BSS represents a cost-effective way to determine whether programmatic behavioral targets and goals are being met, to identify persisting risk behaviors over time, and to indicate whether new intervention approaches are necessary.

Determinants of HIV infection among female commercial sex workers in northeastern Thailand: results from a longitudinal study

Our objective was to estimate HIV seroconversion rates among commercial sex workers (CSWs) between 1990 and 1991 and to identify the behavioral, demographic, and reproductive determinants of these rates. This study has a prospective (n = 240 with 15 cases) and a cross-sectional component (n = 271 with 34 cases). In November 1990, HIV-negative female CSWs from 24 brothels in Khon Kaen city were interviewed and were followed prospectively for up to 1 year. In March, June, and September 1991, additional HIV-negative CSWs were enrolled and prospectively followed. HIV seroconversion rates were calculated, and the Cox regression model was used to estimate the relative risks of HIV seroconversion from demographic, sexual practice, and reproductive factors, adjusted for the effects of the others, among 232 of the 240 without missing data. Seroprevalence rates were also calculated for the 271 participants enrolled between March and December 1991, and relative risks of HIV seroprevalence were calculated for demographic, sexual practice, and reproductive risk factors among 184 of the 271 without missing data. The average seroprevalence was 12.5% (95% confidence interval 9.6-15.4%). With 1,947 person-months of observation obtained from 240 participants who were uninfected at baseline and seen at least twice during the course of the study, the cumulative incidence of HIV seroconversion between November 1990 and December 1991 was 9.4% (95% confidence interval 5.4-13.4%), and the average incidence rate of HIV seroconversion was 9.2 per 100 person-years (95% confidence interval 4.6-13.9 per 100 person-years). In the multivariate analysis, later date of enrollment into the study, having < 3 months experience as a CSW, and use of injectable contraceptives were the only risk factors that remained significant, with relative risks of 2.1 (95% confidence interval 1.2-3.7) for enrollment 3 months later, 3.8 (95% confidence interval 1.0-14.4) for < 3 months experience as a CSW versus > 3 months experience, and 3.9 (95% confidence interval 1.3-11.8) [corrected] for use of injectable contraceptives. In multivariate analysis of the cross-sectional data with 184 participants, of whom 21 were HIV seropositive, risk of HIV seropositivity increased significantly with current syphilis infection (odds ratio 5.8, 95% confidence interval 1.1-31.0). The results of this study will contribute to a better understanding of the risk factors of infection with HIV and thus allow for better targeting of group-specific interventions, particularly for CSWs and their clients. Further investigation of a possible association between injectable contraceptive use and HIV infection is needed.

HIV-1 infection among malnourished children in Butare, Rwanda

In order to investigate the relationship between human immunodeficiency virus (HIV-1) infection and protein-energy malnutrition (PEM), all 101 malnourished children who were admitted to the Department of Pediatrics of the National University Hospital between February and July of 1989 (median age = 2.5 years), and who were accompanied by their mother were screened for HIV-1 antibody. Mothers were also screened and interviewed. Mother-child pairs were followed-up 2 years later to determine mortality and clinical status. Fourteen per cent of malnourished children were HIV-1 seropositive. Only one seropositive child had a seronegative mother. This child had a history of multiple blood transfusions and injections. Among children above 15 months of age, HIV-1 seropositivity was more common among marasmic children than among malnourished children presenting with oedema at admission to the hospital. Also, HIV-1 infection was found more frequently among chronically malnourished children (low height for age and weight for age) than among acutely malnourished children (low weight for height). Mortality during the 2-year follow-up was 75 per cent among HIV-1 seropositive children and 23 per cent among HIV-1 seronegatives (mortality density ratio = 6.2; 95 per cent confidence interval = 2.2-17.4). Severe, chronic PEM should always alert health workers to the possible diagnosis of pediatric AIDS, and its implications for treatment and prognosis.

Risk factors of HIV-1 infection among female prostitutes in Khon Kaen, Northeast Thailand

HIV infection has increased to epidemic proportions in Thailand since 1987. There have been separate epidemics among population groups at high risk of infection and significant increases in different localities. The northeast region of Thailand has been affected by the epidemic since early 1989. The purpose of this study was to identify factors associated with HIV transmission among prostitutes during an early phase of the epidemic in the regional center of Khon Kaen. Three hundred and fifty-six prostitutes known to work in the urban area of Khon Kaen (Ampur Muang) in November 1990 were included in the study. Prostitutes were divided into two groups according to the type of place where they worked: direct prostitutes (in brothels, n = 217) and indirect prostitutes (in massage parlors, n = 139). The prevalence of HIV infection was found to be 12% among direct prostitutes and 2% among indirect prostitutes. Four variables were significantly associated with HIV infection after adjusting for confounders by logistic regression analysis: previous work in an area of high HIV prevalence, working in Khon Kaen less than one month, a low price charged for sex and using injectable contraceptives. Follow-up investigations are currently being carried out to explore in detail the association between the use of injectable contraceptives and HIV infection.

Strategies to maintain health in the Third World

International cooperation with Third World countries aims at reducing the high morbidity and mortality of the population to a tolerable level. The main health problems are caused by poverty. Thus, the range of diseases in tropical countries can be explained more readily by the socio-economic situation than solely by the climate. Health services, in Africa in particular, have had to reduce drastically their budgets in the last ten years and now have only approximately 1/1000th of the funds usually available in industrialised countries. High population growth reduces the resources available per head, increases infection potential and worsens living conditions. Control strategies must take account of these circumstances in order to achieve the required sustained effect within the framework of primary health care. The example of the control of several infectious diseases, such as schistosomiasis, pneumonia, malaria and AIDS, is used to show that control programmes can be effective but, in the current conditions, can hardly be maintained without outside support. In the future, diseases caused by environmental problems and new life styles as a result of industrialization, urbanization and slum growth will move dramatically into the foreground.

Risk of transfusion-associated HIV transmission in Kinshasa, Zaire

Between 5 March and 12 April 1990, we assessed transfusion practices and the risk of transfusion-associated HIV transmission in all the hospitals and medical centres in Kinshasa, Zaire. Of the 733 hospitals and medical centres surveyed, 62 (8.5%) transfuse blood. Of 3741 units of blood transfused in February 1990, 1045 (27.9%) were not screened for HIV infection. Eighteen out of 62 centres (29%) received HIV test kits on a regular basis. Twenty of the centres (32.3%) recorded HIV test results. Major blood group cross-matching was done by 9.7% (six out of 62) of the centres. Bacteriological results indicated contamination in 17% (four out of 23) of stocked blood units, 6.4% (four out of 62) of solutions for disinfections, and 22% (13 out of 59) of sterilized instruments (possessed by 59 centres only). Transfusion practices in Kinshasa are associated with considerable health risks. The establishment and appropriate supervision of HIV screening facilities should be integrated into primary health-care programmes in order to increase safe transfusions in Kinshasa.

Voluntary blood donor recruitment: a strategy to reduce transmission of HIV-1, hepatitis-B and syphilis in Kinshasa, Zaïre

We evaluated the use of voluntary blood donor recruitment in Kinshasa, Zaïre, as a means of reducing transmission of HIV-1 and other infectious agents by blood transfusion. Between January 1, 1989, and April 7, 1989, 2,237 blood donors were enrolled in the study at the transfusion centre of the Mama Yemo Hospital. Each donor was tested for antibodies to HIV-1 confirmed by IFA and Western blot, Treponema pallidum, antibodies to hepatitis B virus (HBV) core antigen and screened for the presence of the HBV surface antigen. Test results were related to the data of the blood donors: age, sex, haematocrit, voluntary blood donor, family member donor, paid donor. The serological results of all donors for Anti-HIV-1. Anti-HBc, HBsAg and TPHA were 4.8%, 70.9%, 13.1% and 13.3% respectively. Lower seroprevalence rates were found among voluntary blood donors. However, only TPHA seroprevalence was significantly lower in voluntary blood donors (8.4%, 23/275) compared with paid donors (15.2%, 87/571) (p less than 0.01). A greater proportion of voluntary donors provides a store of blood which allows more extensive screening of blood for HIV-1 and other infectious diseases. Voluntary blood donor recruitment is critical for the provision of safe blood supplies in Kinshasa.

Prevention of transfusion-associated HIV transmission in Kinshasa, Zaire: HIV screening is not enough

The purpose of this study was to develop a strategy to reduce transfusion-related HIV transmission which went beyond the limits of routine HIV screening of blood donors. Current blood transfusion practices were assessed in 1044 patients for whom staff physicians had requested a transfusion between 5 September and 19 October, 1988. Children under 5 years of age with malaria, and pregnant women with acute anaemia requiring blood transfusion were the two highest risk groups. Many of the transfusions were given without an obvious medical indication; 22.7% (214 out of 955) of the recipients were transfused without prior laboratory tests [haemoglobin (Hb) or haematocrit (Hct)], 7.2% with Hb greater than 6g/100ml or Hct greater than 25% and 16.6% without clinical signs of severe anaemia (pulse less than 100/min without shortness of breath). The data of this study were used to organize a workshop for all the physicians responsible for blood transfusions in Kinshasa and two nearby health zones. A consensus statement on the indications for blood transfusion was developed. Subsequently, transfusion centres adopted this consensus statement instead of previous guidelines.

Clinical evolution of cutaneous T cell lymphoma in a patient with antibodies to human T-lymphotropic virus type I

A woman who emigrated to the United States from the Dominican Republic developed the first signs of cutaneous T cell lymphoma during the last trimester of her pregnancy. This patient, found to have a positive reaction against human T-lymphotropic (leukemia-lymphoma) virus type I (HTLV-I), was followed up prospectively from the appearance of the initial skin lesion to the development of high-count helper T cell leukemia. Antibodies reactive with the core protein of HTLV-I were also identified in her husband and mother but not in her 2-year-old daughter. Examination of the patient's course provides clues about the latency period and transmission of HTLV-I and highlights similarities between HTLV-I-positive and HTLV-I-negative cutaneous T cell lymphoma.

Tumor-associated antigen is expressed on lymphocytes from patients with acquired immunodeficiency syndrome

Monoclonal antibody BE2 recognizes an antigen found on malignant T4+ lymphocytes from cutaneous T-cell lymphoma patients (CTCL). Normal peripheral blood lymphocytes do not express detectable levels of BE2 antigen. Forty-eight percent of patients with the acquired immunodeficiency syndrome (AIDS) had lymphocyte populations that were reactive with monoclonal antibody BE2. Peripheral blood lymphocytes from healthy homosexuals, patients with classical Kaposi's sarcoma or viral syndromes, and healthy normal controls were BE2-. Double-labeling studies demonstrated that BE2+ cells were T lymphocytes. This observation demonstrates that some AIDS patients as well as CTCL patients have circulating cells that express a common lymphocyte abnormality.

Level of a membrane-bound high-molecular-weight melanoma-associated antigen and a cytoplasmic melanoma-associated antigen in surgically removed tissues and in sera from patients with melanoma

Utilizing double-determinant immunoassays (DDIAs), the high-molecular-weight melanoma-associated antigen (HMW-MAA) was detected only in fetal skin and in one nipple of 54 normal tissues from adults tested, while the cytoplasmic MAA recognized by the monoclonal antibody 465. 12S was found in most of the normal tissues tested. Among malignant lesions, the HMW-MAA was found in melanomas, astrocytomas, and skin carcinomas; the cytoplasmic MAA was found in all of the malignant lesions tested, even those which originated from normal tissues without detectable cytoplasmic MAA. The levels of the HMW-MAA and of the cytoplasmic MAA showed marked variations in malignant lesions removed from various patients, as well as in autologous metastatic lesions removed from four patients with melanoma. No relationship was found between the degree of expression of the two MAA analyzed and the clinical stage of the disease. Both types of MAA were found in sera from patients with melanoma or other types of cancers, as well as in sera from healthy donors. The level of the HMW-MAA tended to be higher in patients with Stage IV melanoma.