Articles tagged as "Epidemiology"

Tell it like it is: risky sex after 40

Sexual behaviors and HIV status: a population-based study among older adults in rural South Africa.

Rosenberg MS, Gomez-Olive FX, Rohr JK, Houle BC, Kabudula CW, Wagner RG, Salomon JA, Kahn K, Berkman LF, Tollman SM, Barnighausen T. J Acquir Immune Defic Syndr. 2017 Jan 1;74(1):e9-e17.

Objective: To identify the unmet needs for HIV prevention among older adults in rural South Africa.

Methods: We analyzed data from a population-based sample of 5059 men and women aged 40 years and older from the study Health and Aging in Africa: Longitudinal Studies of INDEPTH Communities (HAALSI), which was carried out in the Agincourt health and sociodemographic surveillance system in the Mpumalanga province of South Africa. We estimated the prevalence of HIV (laboratory-confirmed and self-reported) and key sexual behaviors by age and sex. We compared sexual behavior profiles across HIV status categories with and without age-sex standardization.

Results: HIV prevalence was very high among HAALSI participants (23%, 95% confidence interval [CI]: 21 to 24), with no sex differences. Recent sexual activity was common (56%, 95% CI: 55 to 58) across all HIV status categories. Condom use was low among HIV-negative adults (15%, 95% CI: 14 to 17), higher among HIV-positive adults who were unaware of their HIV status (27%, 95% CI: 22 to 33), and dramatically higher among HIV-positive adults who were aware of their status (75%, 95% CI: 70 to 80). Casual sex and multiple partnerships were reported at moderate levels, with slightly higher estimates among HIV-positive compared to HIV-negative adults. Differences by HIV status remained after age-sex standardization.

Conclusions: Older HIV-positive adults in an HIV hyperendemic community of rural South Africa report sexual behaviors consistent with high HIV transmission risk. Older HIV-negative adults report sexual behaviors consistent with high HIV acquisition risk. Prevention initiatives tailored to the particular prevention needs of older adults are urgently needed to reduce HIV risk in this and similar communities in sub-Saharan Africa.

Abstract  Full-text [free] access 

Editor’s notes: This large population-based survey was designed to collect data on well-being, health status, cognitive functioning, and aspects of ageing among men and women 40 years of age or older (40+) in Mpumalanga, South Africa. The survey documented an unexpectedly high HIV prevalence of 23% in this age group. In the 50+ age group, almost one in five people (20%) was HIV-positive. This compares to an overall South African national estimate for adults 50 and over in 2012 of 7.6%, the Africa Centre KwaZulu-Natal estimate of 9.5%, and the previous Agincourt estimate of 16.5% in 2010-11. One explanation is that HIV prevalence among older South Africans is climbing as more people access life-prolonging antiretroviral treatment. In addition to this, each year people with HIV are ageing into the older age group. This study focused on the 40+ age group because life expectancy in the Agincourt study area had been low and collected sexual behaviour information for the previous two-year period, rather than the usual time period of 12 months. Nonetheless, the data obtained through computer-assisted personal interviews reveal ‘recent’ sexual behaviour that both challenges stereotypes that older people are not sexually active and suggests significant risk of HIV transmission and HIV acquisition. Two-thirds reported more than one lifetime sexual partner and although sexual activity did tend to decrease with age, 52% of men and 6% of women age 80 years and older had been sexually active in the previous two years. Only about half of people found to be HIV-positive knew their status (12%). This group of people living with HIV were far more likely to use condoms. This suggests that an offer of HIV testing in ways that can reach older people would assist in avoiding transmission to partners and in accessing antiretroviral therapy. Only one in seven sexually active HIV-negative people 40+ are using condoms in this setting. This highlights the urgent need for awareness raising to foster new sexual norms to avoid HIV acquisition by practising safer sex. It is time to get our heads out of the sand, recognise the sexuality of older people, and work with them to tailor specific HIV strategies to reduce HIV transmission and acquisition – they too are key to ending AIDS. 

Africa
South Africa
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People who inject drugs living with HIV in Russia face more mental health issues and diminished quality of life

Psychiatric symptoms, quality of life, and HIV status among people using opioids in Saint Petersburg, Russia.

Desrosiers A, Blokhina E, Krupitsky E, Zvartau E, Schottenfeld R, Chawarski M. Drug Alcohol Depend. 2017 Mar 1;172:60-65. doi: 10.1016/j.drugalcdep.2016.12.007. Epub 2017 Jan 23.

Background: The Russian Federation is experiencing a very high rate of HIV infection among people who inject drugs (PWID). However, few studies have explored characteristics of people with co-occurring opioid use disorders and HIV, including psychiatric symptom presentations and how these symptoms might relate to quality of life. The current study therefore explored a.) differences in baseline psychiatric symptoms among HIV+ and HIV- individuals with opioid use disorder seeking naltrexone treatment at two treatment centers in Saint Petersburg, Russia and b.) associations between psychiatric symptom constellations and quality of life.

Methods: Participants were 328 adults enrolling in a randomized clinical trial evaluating outpatient treatments combining naltrexone with different drug counseling models. Psychiatric symptoms and quality of life were assessed using the Brief Symptom Inventory and The World Health Organization Quality of Life-BREF, respectively.

Results: Approximately 60% of participants were HIV+. Those who were HIV+ scored significantly higher on BSI anxiety, depression, psychoticism, somatization, paranoid ideation, phobic anxiety, obsessive-compulsive, and GSI indexes (all p<0.05) than those HIV-. A K-means cluster analysis identified three distinct psychiatric symptom profiles; the proportion of HIV+ was significantly greater and quality of life indicators were significantly lower in the cluster with the highest psychiatric symptom levels.

Conclusion: Higher levels of psychiatric symptoms and lower quality of life indicators among HIV+ (compared to HIV-) individuals injecting drugs support the potential importance of combining interventions that target improving psychiatric symptoms with drug treatment, particularly for HIV+ patients.

Abstract access 

Editor’s notes: The higher prevalence of mental health disorders among people living with HIV is well known. This paper focuses on the association of mental health disorders and HIV among people who inject drugs, in St Petersburg, Russian Federation – the city with the highest prevalence of HIV and drug use in the Russian Federation. HIV positive people who inject drugs had significantly higher prevalence of mental health problems than HIV negative people who inject drugs. They had a lower quality of life according to a validated scale, underscoring the need for strong, combination public health programmes to support this vulnerable group. The population studied was selected through existing service provision. Since these individuals were already seeking treatment on their own, there could be many more who are not engaged in care either for HIV treatment or drug use support. This suggests the need to strengthen awareness and services, especially in areas where clean needles and other risk management methods are not yet available.

Europe
Russian Federation
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Person-to-person spread driving XDR-TB epidemic in KwaZulu-Natal

Transmission of extensively drug-resistant tuberculosis in South Africa.

Shah NS, Auld SC, Brust JC, Mathema B, Ismail N, Moodley P, Mlisana K, Allana S, Campbell A, Mthiyane T, Morris N, Mpangase P, van der Meulen H, Omar SV, Brown TS, Narechania A, Shaskina E, Kapwata T, Kreiswirth B, Gandhi NR. N Engl J Med. 2017 Jan 19;376(3):243-253. doi: 10.1056/NEJMoa1604544.

Background: Drug-resistant tuberculosis threatens recent gains in the treatment of tuberculosis and human immunodeficiency virus (HIV) infection worldwide. A widespread epidemic of extensively drug-resistant (XDR) tuberculosis is occurring in South Africa, where cases have increased substantially since 2002. The factors driving this rapid increase have not been fully elucidated, but such knowledge is needed to guide public health interventions.

Methods: We conducted a prospective study involving 404 participants in KwaZulu-Natal Province, South Africa, with a diagnosis of XDR tuberculosis between 2011 and 2014. Interviews and medical-record reviews were used to elicit information on the participants' history of tuberculosis and HIV infection, hospitalizations, and social networks. Mycobacterium tuberculosis isolates underwent insertion sequence (IS)6110 restriction-fragment-length polymorphism analysis, targeted gene sequencing, and whole-genome sequencing. We used clinical and genotypic case definitions to calculate the proportion of cases of XDR tuberculosis that were due to inadequate treatment of multidrug-resistant (MDR) tuberculosis (i.e., acquired resistance) versus those that were due to transmission (i.e., transmitted resistance). We used social-network analysis to identify community and hospital locations of transmission.

Results: Of the 404 participants, 311 (77%) had HIV infection; the median CD4+ count was 340 cells per cubic millimeter (interquartile range, 117 to 431). A total of 280 participants (69%) had never received treatment for MDR tuberculosis. Genotypic analysis in 386 participants revealed that 323 (84%) belonged to 1 of 31 clusters. Clusters ranged from 2 to 14 participants, except for 1 large cluster of 212 participants (55%) with a LAM4/KZN strain. Person-to-person or hospital-based epidemiologic links were identified in 123 of 404 participants (30%).

Conclusions: The majority of cases of XDR tuberculosis in KwaZulu-Natal, South Africa, an area with a high tuberculosis burden, were probably due to transmission rather than to inadequate treatment of MDR tuberculosis. These data suggest that control of the epidemic of drug-resistant tuberculosis requires an increased focus on interrupting transmission.

Abstract   Full-text [free] access

Editor’s notes: This paper provides further evidence to support person-to-person transmission being the main driver of the XDR-TB epidemic in KwaZulu-Natal, the most populous province of South Africa. The study combined classical and molecular epidemiology: detailed characterisation of people’s clinical history and social networks alongside genotypic methods to characterise their TB strains. With the most conservative estimate, almost seven in ten XDR-TB cases resulted from transmission. However, combining the clinical and genotypic information, as many as nine in ten cases may have been attributable to transmission.

So where was transmission happening? This unfortunately was more difficult to answer. Although epidemiological links (mainly at home or at hospitals) could be defined for around one in three cases, many did not share the same TB strain. More detailed understanding of transmission may have been affected by the relatively low coverage of XDR-TB cases by this study. Full information was available for just over one in three laboratory-confirmed XDR-TB cases in the province over the study period. Also, although there was some genetic diversity in the TB strains, there was one dominant strain (LAM4/KZN). This is the strain responsible for the well-characterised clonal outbreak of XDR-TB involving Tugela Ferry.

Most people with XDR-TB in this study were HIV positive. Interestingly, three-quarters of people living with HIV were on ART at the time of their XDR-TB diagnosis, and two-thirds of people had undetectable viral load. This flags up two things. Firstly, it is a reminder that ART alone is unlikely to control the TB (or drug-resistant TB) epidemic in South Africa. Secondly, it raises further questions that could not be definitively answered here as to whether some of these people might have been infected with XDR-TB while accessing HIV treatment and care in the public health system. 

So what do we do with this new information? These findings should encourage us to focus on developing strategies to interrupt drug-resistant TB transmission. We need better evidence of what works in community settings and health care settings. We need better evidence of how to deliver proven programmes. We still do not know whether we might need different activities to interrupt MDR- and XDR-TB transmission, or whether this should just be encompassed within broader strategies to interrupt all TB transmission. South Africa is leading the way in implementing molecular diagnostics to help with earlier detection of drug-resistant TB, and is at the forefront of developing and testing new drug regimens for drug-resistant TB. This provides a solid platform on which to develop public health programmes to stop the spread of drug-resistant TB.

Comorbidity, Epidemiology
Africa
South Africa
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Anal high-risk HPV and high-grade lesions: screening is required for women living with HIV

Prevalence of anal HPV and anal dysplasia in HIV-infected women from Johannesburg, South Africa.

Goeieman BJ, Firnhaber CS, Jong E, Michelow P, Swarts A, Williamson AL, Allan B, Smith JS, Kegorilwe P, Wilkin TJ. J Acquir Immune Defic Syndr. 2017 Jan 30. doi: 10.1097/QAI.0000000000001300. [Epub ahead of print]

Background: Anal cancer is a relatively common cancer among HIV-infected populations. There are limited data on the prevalence of anal high-risk human papillomavirus (HR-HPV) infection and anal dysplasia in HIV-infected women from resource-constrained settings.

Methods: A cross-sectional study of HIV-infected women age 25-65 recruited from an HIV clinic in Johannesburg, South Africa. Cervical and anal swabs were taken for conventional cytology and HR-HPV testing. Women with abnormal anal cytology and 20% of women with negative cytology were seen for high resolution anoscopy (HRA) with biopsy of visible lesions.

Results: Two hundred women were enrolled. Anal HR-HPV was found in 43%. The anal cytology results were negative in 51 (26%); 97 (49%) had low-grade squamous intraepithelial lesions (SIL), 32 (16%) had atypical squamous cells of unknown significance and 19 (9.5%) had high-grade SIL or atypical squamous cells suggestive of high-grade SIL. On HRA, 71 (36%) had atypia or low-grade SIL on anal histology and 17 (8.5%) had high-grade SIL. Overall 31 (17.5%) had high-grade SIL present on anal cytology or histology. Abnormal cervical cytology was found in 70% and cervical HR-HPV in 41%.

Conclusion: We found a significant burden of anal HR-HPV infection, abnormal anal cytology and high-grade SIL in our cohort. This is the first study of the prevalence of anal dysplasia in HIV-infected women from sub-Saharan Africa. Additional studies are needed to define the epidemiology of these conditions, as well as the incidence of anal cancer, in this population.

Abstract access

Editor’s notes: Women living with HIV have a higher incidence of anogenital cancers compared to HIV-negative women, even in the ART era. Previous studies have illustrated that women living with HIV in South Africa have a high risk of cervical high-risk (HR)-HPV, and high rates of high-grade cervical intraepithelial neoplasia. This is the first study to report the prevalence of anal HR-HPV and anal high-grade squamous intraepithelial lesions (HSIL+) among women living with HIV in Africa.

This cross-sectional study among 200 women living with HIV attending a HIV treatment centre in Johannesburg, South Africa, the majority (97%) of whom were on ART, reported a high  prevalence of anal HR-HPV and anal HSIL+ by high-resolution anoscopy (43% and 8.5%, respectively). Women with low current CD4+ cell count and with shorter duration of ART use had marginally higher prevalence of anal HR-HPV and HSIL+.

It remains unclear whether high-grade anal lesions among women living with HIV have the same propensity to progress to anal cancer as is known to occur for high-grade cervical lesions to cervical cancer. Studies among HIV-positive and HIV-negative men report frequent spontaneous regression of anal intraepithelial lesions (AIN) and high rates of recurrence following treatment, but longitudinal data are limited among women living with HIV. Prolonged ART use may have contributed to a reduction in HPV-associated cervical lesions, and the same could be true for anal lesions. Larger prospective studies are necessary to define the rates of high-grade lesion incidence and progression and associated risk factors among women living with HIV in order to guide screening and management decisions.  

Comorbidity, Epidemiology
Africa
South Africa
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At the halfway mark? Community viral suppression in East Africa

Population levels and geographical distribution of HIV RNA in rural Ugandan and Kenyan communities, including serodiscordant couples: a cross-sectional analysis.

Jain V, Petersen ML, Liegler T, Byonanebye DM, Kwarisiima D, Chamie G, Sang N, Black D, Clark TD, Ladai A, Plenty A, Kabami J, Ssemmondo E, Bukusi EA, Cohen CR, Charlebois ED, Kamya MR, Havlir DV. Lancet HIV. 2016 Dec 15. pii: S2352-3018(16)30220-X. doi: 10.1016/S2352-3018(16)30220-X. [Epub ahead of print]

Background: As sub-Saharan Africa transitions to a new era of universal antiretroviral therapy (ART), up-to-date assessments of population-level HIV RNA suppression are needed to inform interventions to optimise ART delivery. We sought to measure population viral load metrics to assess viral suppression and characterise demographic groups and geographical locations with high-level detectable viraemia in east Africa.

Methods: The Sustainable East Africa Research in Community Health (SEARCH) study is a cluster-randomised controlled trial of an HIV test-and-treat strategy in 32 rural communities in Uganda and Kenya, selected on the basis of rural setting, having an approximate population of 10 000 people, and being within the catchment area of a President's Emergency Plan for AIDS Relief-supported HIV clinic. During the baseline population assessment in the SEARCH study, we did baseline HIV testing and HIV RNA measurement. We analysed stable adult (aged 15 years) community residents. We defined viral suppression as a viral load of less than 500 copies per mL. To assess geographical sources of transmission risk, we established the proportion of all adults (both HIV positive and HIV negative) with a detectable viral load (local prevalence of viraemia). We defined transmission risk hotspots as geopolitical subunits within communities with an at least 5% local prevalence of viraemia. We also assessed serodiscordant couples, measuring the proportion of HIV-positive partners with detectable viraemia. The SEARCH study is registered with ClinicalTrials.gov, number NCT01864603.

Findings: Between April 2, 2013, and June 8, 2014, of 303 461 stable residents, we enumerated 274 040 (90.3%), of whom 132 030 (48.2%) were adults. Of these, 117 711 (89.2%) had their HIV status established, of whom 11 964 (10.2%) were HIV positive. Of these, we measured viral load in 8828 (73.8%) people. Viral suppression occurred in 3427 (81.6%) of 4202 HIV-positive adults on ART and 4490 (50.9%) of 8828 HIV-positive adults. Regional viral suppression among HIV-positive adults occurred in 881 (48.2%) of 1827 people in west Uganda, 516 (45.0%) of 1147 in east Uganda, and 3093 (52.8%) of 5854 in Kenya. Transmission risk hotspots occurred in three of 21 parishes in west Uganda and none in east Uganda and in 24 of 26 Kenya geopolitical subunits. In Uganda, 492 (2.9%) of 16 874 couples were serodiscordant: in 287 (58.3%) of these couples, the HIV-positive partner was viraemic (and in 69 [14.0%], viral load was >100 000 copies per mL). In Kenya, 859 (10.0%) of 8616 couples were serodiscordant: in 445 (53.0%) of these couples, the HIV-positive partner was viraemic (and in 129 [15%], viral load was >100 000 copies per mL).

Interpretation: Before the start of the SEARCH trial, 51% of east African HIV-positive adults had viral suppression, reflecting ART scale-up efforts to date. Geographical hotspots of potential HIV transmission risk and detectable viraemia among serodiscordant couples warrant intensified interventions.

Abstract access  

Editor’s notes: Half of all people living with HIV with a valid viral load measurement in these East African communities had viral suppression (<500 copies/mL) at the start of this cluster randomised trial in 2013-14. These results already provided good evidence of the effectiveness and impact of antiretroviral programmes in East Africa. However, at the AIDS conference in July 2016 the study group presented updated results following two years of a universal test and treat (UTT) strategy with expansion of community-based HIV testing services (access abstract here). By this point, the UNAIDS 90-90-90 treatment target had been exceeded in the study communities and, overall, 82% of people living with HIV had viral suppression. 

These results highlight the role of community viral load metrics as indicators of programme impact. What gives rise to more debate is the role of these metrics in estimating the risk of ongoing HIV transmission in the community. Consensus seems to be emerging that the population prevalence of viraemia may be the metric best suited for this purpose. In this study, the estimated population prevalence of viraemia varied quite widely from 0.5 to 14.1% at the level of local communities (of between around 500 and 5000 people). This measure was also used to define several transmission hotspots, based on an arbitrary cut-off of five percent prevalence of viraemia.

Additional research is necessary in different epidemiological contexts to understand the association between these metrics and risk of HIV transmission. There is also some way to go to understand if such metrics can have practical public health implications for HIV prevention. Whether revealing such heterogeneity in transmission risk within generalized epidemics can inform the application of geographically focussed programmes is a question that now should be addressed.

Africa
Kenya, Uganda
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ART has dramatically improved life expectancy for people living with HIV in KwaZulu-Natal, South Africa

Trends in the burden of HIV mortality after roll-out of antiretroviral therapy in KwaZulu-Natal, South Africa: an observational community cohort study.

Reniers G, Blom S, Calvert C, Martin-Onraet A, Herbst AJ, Eaton JW, Bor J, Slaymaker E, Li ZR, Clark SJ, Barnighausen T, Zaba B, Hosegood V Lancet HIV. 2016 Dec 9. pii: S2352-3018(16)30225-9. doi: 10.1016/S2352-3018(16)30225-9

Background: Antiretroviral therapy (ART) substantially decreases morbidity and mortality in people living with HIV. In this study, we describe population-level trends in the adult life expectancy and trends in the residual burden of HIV mortality after the roll-out of a public sector ART programme in KwaZulu-Natal, South Africa, one of the populations with the most severe HIV epidemics in the world.

Methods: Data come from the Africa Centre Demographic Information System (ACDIS), an observational community cohort study in the uMkhanyakude district in northern KwaZulu-Natal, South Africa. We used non-parametric survival analysis methods to estimate gains in the population-wide life expectancy at age 15 years since the introduction of ART, and the shortfall of the population-wide adult life expectancy compared with that of the HIV-negative population (ie, the life expectancy deficit). Life expectancy gains and deficits were further disaggregated by age and cause of death with demographic decomposition methods.

Findings: Covering the calendar years 2001 through to 2014, we obtained information on 93 903 adults who jointly contribute 535 428 person-years of observation to the analyses and 9992 deaths. Since the roll-out of ART in 2004, adult life expectancy increased by 15.2 years for men (95% CI 12.4-17.8) and 17.2 years for women (14.5-20.2). Reductions in pulmonary tuberculosis and HIV-related mortality account for 79.7% of the total life expectancy gains in men (8.4 adult life-years), and 90.7% in women (12.8 adult life-years). For men, 9.5% is the result of a decline in external injuries. By 2014, the life expectancy deficit had decreased to 1.2 years for men (-2.9 to 5.8) and to 5.3 years for women (2.6-7.8). In 2011-14, pulmonary tuberculosis and HIV were responsible for 84.9% of the life expectancy deficit in men and 80.8% in women.

Interpretation: The burden of HIV on adult mortality in this population is rapidly shrinking, but remains large for women, despite their better engagement with HIV-care services. Gains in adult life-years lived as well as the present life expectancy deficit are almost exclusively due to differences in mortality attributed to HIV and pulmonary tuberculosis.

Abstract access

Editor’s notes: Health and demographic surveillance system (HDSS) sites allow for monitoring of population health through the collection of detailed data on tens of thousands of individuals. Such sites in countries with high HIV prevalence have played an important role in measuring the effects of large-scale programmes, such as the global roll-out of antiretroviral therapy (ART). The data presented in this paper, from the Africa Centre Demographic Information System (ACDIS) in KwaZulu-Natal, South Africa, span 13 years (2001–14) and represent over 93 000 individuals living in an area with extremely high HIV prevalence (29% in adults aged 15–49 years in 2011). At least 15 000 of people studied were HIV-positive, of whom at least 2000 died. ART was first made available to people living with HIV (PLHIV) in this area in 2004.

Among adults aged 15–49 years, the authors report an overall reduction in death rate from 2001–14.  This translates into large increases in life expectancy (i.e., the expected number of years lived from age 15) of 15 and 17 years for men and women, respectively, between 2001 and 2014.  The changes in life expectancy are greater in people who were confirmed HIV-positive: 18 and 21 years for men and women, respectively, from 2007–14.  The large difference in life expectancies between the sexes that still exists (31 versus 44 years in HIV-positive men and women, respectively) are consistent with previously published estimates from Rwanda and Uganda. This study, however, illustrates that HIV-positive men are catching up to their HIV-negative counterparts faster than women are. The ‘deficit’ in 2014 - the gap in life expectancies between HIV-positive and HIV-negative individuals, was 1.2 years in men but still 5.3 years in women.

The authors propose that increased access to ART is the primary driver of the gains in life expectancy seen in this cohort. To further support this, they include data from verbal autopsies (VAs), which suggest that reductions in deaths due to HIV and pulmonary tuberculosis were responsible for 80% and 90% of the increases in life expectancy in men and women, respectively. VAs have limitations, however, particularly in areas of high HIV prevalence, but the overall mortality patterns suggested by these findings are likely to be accurate, even if the precise estimates differ.

The dramatic increases in life expectancy, in only seven years, for HIV-positive individuals in this cohort add to the encouraging observations from other low- and middle-income countries that many people receiving ART can expect to live for nearly as long as HIV-negative individuals.  Of course, people with advanced disease starting ART are still at high risk of death and there remain considerable challenges in getting treatment to all people in need of it. 

Africa
South Africa
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High prevalence of gender based violence among adolescent female sex workers - need to improve access to health services

Prevalence and correlates of sexual and gender-based violence against Chinese adolescent women who are involved in commercial sex: a cross-sectional study.

Zhang XD, Myers S, Yang HJ, Li Y, Li JH, Luo W, Luchters S. BMJ Open. 2016 Dec 19;6(12):e013409. doi: 10.1136/bmjopen-2016-013409.

Objectives: Despite the vast quantity of research among Chinese female sex workers (FSWs) to address concerns regarding HIV/sexually transmitted infection (STI) risk, there is a paucity of research on issues of sexual and gender-based violence (SGBV) and the missed opportunity for sexual and reproductive health (SRH) promotion among young FSWs. Our research aimed to assess the prevalence and correlates of SGBV among Chinese adolescent FSWs, and to explore SRH service utilisation.

Design and methods: A cross-sectional study using a one-stage cluster sampling method was employed. A semistructured questionnaire was administered by trained peer educators or health workers. Multivariable logistic regression was conducted to determine individual and structural correlates of SGBV.

Setting and participants: Between July and September 2012, 310 adolescent women aged 15-20 years, and who self-reported having received money or gifts in exchange for sex in the past 6 months were recruited and completed their interview in Kunming, Yunnan Province, China.

Results: Findings confirm the high prevalence of SGBV against adolescent FSWs in China, with 38% (118/310) of participants affected in the past year. Moreover, our study demonstrated the low uptake of public health services and high rates of prior unwanted pregnancy (52%; 61/118), abortion (53%; 63/118) and self-reported STI symptoms (84%; 99/118) in participants who were exposed to SGBV. Forced sexual debut was reported by nearly a quarter of FSWs (23%; 70/310) and was independently associated with having had a drug-using intimate partner and younger age (<17 years old) at first abortion. When controlling for potential confounders, having experienced SGBV was associated with frequent alcohol use, having self-reported symptoms of STI, having an intimate partner and having an intimate partner with illicit drug use.

Conclusions: This study calls for effective and integrated interventions addressing adolescent FSWs' vulnerability to SGBV and broader SRH consequences.

Abstract  Full-text [free] access 

Editor’s notes: The paper reports a study conducted to measure the prevalence and correlates of sexual and gender-based violence among Chinese adolescent female sex workers, given the paucity of data on this. A cross-sectional survey was conducted in the Yunnan Province, which has a relatively high HIV-1 prevalence. Around 300 women aged 15-19 years, who had received money or gifts in exchange for sex in the past six months were recruited for a survey.

The survey revealed that over half the female sex workers were married or cohabiting but lived predominantly with other sex workers or friends, or alone. The majority reported that they had been a sex worker for less than six months. Over the past year, 82% of the female sex workers had an intimate partner, and most of these relationships were for less than one year. Alcohol use was common, with 83% of the female sex workers reporting drinking alcohol at least twice a week. Inconsistent condom use in the past month was reported by 57% of the female sex workers.

Around a quarter of women’s first sexual experience was forced. Thirty-eight per cent of the female sex workers reported having experienced sexual and gender-based violence in the past year, with three quarters of women reporting the perpetrator as their intimate male partner and (62%) a male paying client. The female sex workers experiencing sexual and gender-based violence in the past year were more likely to be frequent drinkers or have a drug-using intimate partner. Women who experienced sexual and gender-based violence were more likely to report unwanted pregnancy, and less likely to use public health facilities or HIV testing services.

The authors suggest that their findings reveal a missed opportunity for the public health sector to address sexual and gender-based violence and associated sexual and reproductive health issues. However, they suggested there is a need to involve women-led community-based organisations to build relationships with female sex workers to enable them to utilise such services. There is also a need for further research on integrated programmes to prevent or reduce sexual and gender-based violence against adolescent female sex workers. 

Epidemiology, Gender
Asia
China
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Comparing different methods to measure HIV incidence in a sub-Saharan African population

Estimating HIV incidence using a cross-sectional survey: comparison of three approaches in a hyperendemic setting, Ndhiwa sub-county, Kenya, 2012.

Blaizot S, Kim AA, Zeh C, Riche B, Maman D, DeCock K, Etard JF, Ecochard R. AIDS Res Hum Retroviruses. 2016 Dec 13. [Epub ahead of print]

Objectives: Estimating HIV incidence is critical for identifying groups at risk for HIV infection, planning and targeting interventions, and evaluating these interventions over time. The use of reliable estimation methods for HIV incidence is thus of high importance. The aim of this study was to compare methods for estimating HIV incidence in a population-based cross-sectional survey.

Design/methods: The incidence estimation methods evaluated included assay-derived methods, a testing history-derived method, and a probability-based method applied to data from the Ndhiwa HIV Impact in Population Survey (NHIPS). Incidence rates by sex and age and cumulative incidence as a function of age were presented.

Results: HIV incidence ranged from 1.38 [95% confidence interval (CI) 0.67-2.09] to 3.30 [95% CI 2.78-3.82] per 100 persons-years overall; 0.59 [95% CI 0.00-1.34] to 2.89 [95% CI 0.11-5.68] in men; and 1.62 [95% CI 0.16-6.04] to 4.03 [95% CI 3.30-4.77] per 100 persons-years in women. Women had higher incidence rates than men for all methods. Incidence rates were highest among women aged 15-24 and 25-34 years and highest among men aged 25-34 years.

Conclusion: Comparison of different methods showed variations in incidence estimates, but they were in agreement to identify most-at-risk groups. The use and comparison of several distinct approaches for estimating incidence are important to provide the best-supported estimate of HIV incidence in the population.

Abstract access

Editor’s notes: The estimation of HIV incidence is important both for planning effective HIV prevention strategies, and also to provide a proximal measure of changes in HIV epidemics both in general populations and in higher risk sub-groups. Further development of methods for accurately measuring HIV incidence that can be applied in routine monitoring settings is necessary.

This study compares three assay-based incidence estimation methods with approaches using self-reported testing history and a probabilistic technique on age and sex stratified sero-prevalence data. Two of the assays, BioRad and Lag, use antibody markers and a recent infection testing algorithm (RITA). The BioRad assay allowed for a longer time window for detection post-infection than the Lag. Recent infections were reclassified using results from HIV viral load tests and self-reported ART use, as appropriate. The other assay detected trace levels of HIV RNA in HIV seronegative individuals. The results for the two RITA assays were very similar at 1.38 [95% CI 0.67 – 2.09] infections per 100 person years (PY) for the BioRad and 1.46 [95% CI 0.71 – 2.22] per 100 PY for Lag. Combining these with HIV-RNA results led to small increases in each incidence estimate. The results for the probability-based incidence assays were very close to those derived from the combination of the RITA and HIV-RNA assays. However, the testing history-derived approach estimated incidence as almost double that from the other methods and this is likely to be in large part due to reporting/recall bias.

Despite the limitations of the methods, it was possible to identify population sub-groups defined by age and sex at higher risk of HIV infection. 

Africa
Kenya
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Poor adherence during the first three months post-delivery among women on Option B+

Adherence to antiretroviral therapy during and after pregnancy: cohort study on women receiving care in Malawi's Option B+ program.

Haas AD, Msukwa MT, Egger M, Tenthani L, Tweya H, Jahn A, Gadabu OJ, Tal K, Salazar-Vizcaya L, Estill J, Spoerri A, Phiri N, Chimbwandira F, van Oosterhout JJ, Keiser O. Clin Infect Dis. 2016 Nov 1;63(9):1227-1235. Epub 2016 Jul 26.

Background: Adherence to antiretroviral therapy (ART) is crucial to preventing mother-to-child transmission of human immunodeficiency virus (HIV) and ensuring the long-term effectiveness of ART, yet data are sparse from African routine care programs on maternal adherence to triple ART.

Methods: We analyzed data from women who started ART at 13 large health facilities in Malawi between September 2011 and October 2013. We defined adherence as the percentage of days "covered" by pharmacy claims. Adherence of ≥90% was deemed adequate. We calculated inverse probability of censoring weights to adjust adherence estimates for informative censoring. We used descriptive statistics, survival analysis, and pooled logistic regression to compare adherence between pregnant and breastfeeding women eligible for ART under Option B+, and nonpregnant and nonbreastfeeding women who started ART with low CD4 cell counts or World Health Organization clinical stage 3/4 disease.

Results: Adherence was adequate for 73% of the women during pregnancy, for 66% in the first 3 months post partum, and for about 75% during months 4-21 post partum. About 70% of women who started ART during pregnancy and breastfeeding adhered adequately during the first 2 years of ART, but only about 30% of them had maintained adequate adherence at every visit. Risk factors for inadequate adherence included starting ART with an Option B+ indication, at a younger age, or at a district hospital or health center.

Conclusions: One-third of women retained in the Option B+ program adhered inadequately during pregnancy and breastfeeding, especially soon after delivery. Effective interventions to improve adherence among women in this program should be implemented.

Abstract  Full-text [free] access

Editor’s notes: To maximize the impact of antiretroviral therapy (ART), people living with HIV should be diagnosed early, enrolled and retained in pre-ART care, initiated on ART and retained in ART care.  Long-term adherence to achieve and maintain viral load suppression is the last step in the continuum of HIV care.

“Option B+” is the programmatic option for preventing mother-to-child HIV transmission, pioneered by Malawi, in which combination ART is started during pregnancy and continued life-long. This manuscript describes adherence to ART among pregnant women in the Option B+ programme in Malawi. The authors had access to prospectively-collected pharmacy data, and created an adherence measure that estimates the percentage of days ARVs were actually available to women during a time period. Therefore, this indicator measures the maximum number of days that ART could have been taken, but does not measure how much of the treatment was actually consumed. In this study, about a quarter of women started on ART with an Option B+ indication were lost to follow-up during the first year of ART. Among women retained, 30% adhered inadequately during pregnancy and breastfeeding, especially during the first three months after delivery. Unreported transfers of care to other clinics after delivery, postnatal depression, or difficulties with travelling to the facilities may be explanations for this temporary decline in adherence.

The authors validated their pharmacy-based adherence measure against viral load data in a subsample of about 500 people. They found that their adherence measure correlated well with the viral load measurement, and suggest that if access to viral load testing is limited, pharmacy-based adherence measures might be useful to identify people with adherence problems for targeted viral load testing.

These data are consistent with other studies reporting suboptimal retention particularly among women starting ART during pregnancy. Suboptimal adherence to ART during breastfeeding increases the risk of post-natal transmission, and the risk of the emergence of resistant virus in both mother and infant, as well as compromising the mother’s treatment outcome. Programmes need to address these issues in order to support adherence and retention in the early post-natal period. 

Africa
Malawi
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Needle-syringe programmes and treatment will dramatically reduce HIV epidemic among people who inject drugs in Russia and Ukraine

Reducing HIV infection in people who inject drugs is impossible without targeting recently-infected subjects.

Vasylyeva TI, Friedman SR, Lourenco J, Gupta S, Hatzakis A, Pybus OG, Katzourakis A, Smyrnov P, Karamitros T, Paraskevis D, Magiorkinis G. AIDS. 2016 Nov 28;30(18):2885-2890.

Objective: Although our understanding of viral transmission among people who inject drugs (PWID) has improved, we still know little about when and how many times each injector transmits HIV throughout the duration of infection. We describe HIV dynamics in PWID to evaluate which preventive strategies can be efficient.

Design: Due to the notably scarce interventions, HIV-1 spread explosively in Russia and Ukraine in 1990s. By studying this epidemic between 1995 and 2005, we characterized naturally occurring transmission dynamics of HIV among PWID.

Method: We combined publicly available HIV pol and env sequences with prevalence estimates from Russia and Ukraine under an evolutionary epidemiology framework to characterize HIV transmissibility between PWID. We then constructed compartmental models to simulate HIV spread among PWID.

Results: In the absence of interventions, each injector transmits on average to 10 others. Half of the transmissions take place within 1 month after primary infection, suggesting that the epidemic will expand even after blocking all the post-first month transmissions. Primary prevention can realistically target the first month of infection, and we show that it is very efficient to control the spread of HIV-1 in PWID. Treating acutely infected on top of primary prevention is notably effective.

Conclusion: As a large proportion of transmissions among PWID occur within 1 month after infection, reducing and delaying transmissions through scale-up of harm reduction programmes should always form the backbone of HIV control strategies in PWID. Growing PWID populations in the developing world, where primary prevention is scarce, constitutes a public health time bomb

Abstract  Full-text [free] access 

Editor’s notes: This paper presents powerful findings from a mathematical model that sought to estimate how much prevalence of HIV will increase among people who inject drugs in 10-20 years’ time in the absence of HIV treatment and needle-syringe programmes. Findings suggest HIV prevalence will reach 86% in 20 years in the absence of programmes. The paper provides important new information to the growing body of evidence that estimates the impact of needle-syringe programmes and opioid substitution therapy in reducing HIV transmission among people who inject drugs, in the region. The authors focus on the impact of needle-syringe programmes and of the prevention benefits of treatment, reducing transmission among individuals recently acquiring HIV where infectivity is higher in the first month of infection. The estimates provide projections of programme impact in the realities of the current policy environment, given the prohibition of opioid substitution therapy in the Russian Federation. The model focusses on injection transmission routes only and does not consider sexual transmission among people who inject drugs. Therefore, projected estimates of HIV are likely to be underestimates. The paper is important in highlighting the urgent need for needle-syringe programmes and treatment among people who inject drugs in the region and highlighting the crisis in relation to HIV among people who inject drugs in Russia and Ukraine. Modelling estimates such as these are powerful tools to persuade policy makers of the urgent need for programmes.  Importantly the authors recognize the need for structural programmes. They highlight the need to create an enabling environment in which needle-syringe programmes can operate. This environment needs to include supportive policing practices and reducing stigma. 

Europe
Russian Federation, Ukraine
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