Articles tagged as "Epidemiology"

How can we improve the UNAIDS modes of transmission model?

The HIV modes of transmission model: a systematic review of its findings and adherence to guidelines.

Shubber Z, Mishra S, Vesga JF, Boily MC. J Int AIDS Soc. 2014 Jun 23;17:18928. doi: 10.7448/IAS.17.1.18928. eCollection 2014.

Introduction: The HIV Modes of Transmission (MOT) model estimates the annual fraction of new HIV infections (FNI) acquired by different risk groups. It was designed to guide country-specific HIV prevention policies. To determine if the MOT produced context-specific recommendations, we analyzed MOT Results by region and epidemic type, and explored the factors (e.g. data used to estimate parameter inputs, adherence to guidelines) influencing the differences.

Methods: We systematically searched MEDLINE, EMBASE and UNAIDS reports, and contacted UNAIDS country directors for published MOT Results from MOT inception (2003) to 25 September 2012.

Results: We retrieved four journal articles and 20 UNAIDS reports covering 29 countries. In 13 countries, the largest FNI (range 26 to 63%) was acquired by the low-risk group and increased with low-risk population size. The FNI among female sex workers (FSWs) remained low (median 1.3%, range 0.04 to 14.4%), with little variability by region and epidemic type despite variability in sexual behaviour. In India and Thailand, where FSWs play an important role in transmission, the FNI among FSWs was 2 and 4%, respectively. In contrast, the FNI among men who have sex with men (MSM) varied across regions (range 0.1 to 89%) and increased with MSM population size. The FNI among people who inject drugs (PWID, range 0 to 82%) was largest in early-phase epidemics with low overall HIV prevalence. Most MOT studies were conducted and reported as per guidelines but data quality remains an issue.

Conclusions: Although countries are generally performing the MOT as per guidelines, there is little variation in the FNI (except among MSM and PWID) by region and epidemic type. Homogeneity in MOT FNI for FSWs, clients and low-risk groups may limit the utility of MOT for guiding country-specific interventions in heterosexual HIV epidemics.

 Abstract  Full-text [free] access

Editor’s notes: In 2002, the HIV Modes of Transmission model (MoT) was developed by UNAIDS to inform and focus, country-specific HIV prevention policies. The idea behind the model was to use simple mathematical modelling approaches, in combination with country specific data, to predict what the distribution of new HIV infection may look like. In this way, countries would be able to better focus their HIV response. Since its development and through 2012, the MoT has been applied in 29 countries, with the findings being used in many settings to shape priorities. In this study, the authors assess the degree to which the MoT produces different outputs in different epidemic contexts. They explore whether there are key parameters in the model that seem to drive similarities and/or differences in projections between countries. Surprisingly, across a broad range of epidemic settings, they found limited variability in the predicted annual fraction of new HIV infections (FNI) acquired by female sex workers (FSW) (0.04-14.4%). There were higher levels of variability between countries in the projected fraction of new HIV infections among men who have sex with men (0.01-89%) and people who inject drugs (0-82%).

The differences in the MoT projections were largely dependent on whether the country in question was categorised as having a concentrated / low-level epidemic, versus generalised epidemic, as defined by UNAIDS. Differences also arose depending upon whether ‘low risk groups’ were also included in the model. Indeed, for 22 of the 25 studies that included a low-risk group, this group was predicted to have a large annual fraction of new HIV infections (11.8-62.9%). This phenomenon arose, not because of high transmission rates in this group (in comparison to others such as MSM or PWIDs) but because these ‘low risk groups’ are large. They are one third of the total population. These findings may be misleading, as the projected high fraction of transmission is dependent on the assumption that everyone in this ‘low risk group’ does have some risk.

It appears that although the MoT was designed to address an important need, it is likely to have limited utility to guide programming in heterosexually driven epidemics.  To address this limitation, UNAIDS is supporting the HIV Modelling Consortium in their development of a revised MoT model that takes into better consideration risk categorization, data constraints and programmatic needs. The revised model is currently undergoing field testing and will be available for country use in 2015.

Africa, Asia, Europe, Latin America
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Falling death rates among people in HIV care: AIDS remains common, non-AIDS cancers need attention

Trends in underlying causes of death in people with HIV from 1999 to 2011 (D:A:D): a multicohort collaboration.

Smith CJ, Ryom L, Weber R, Morlat P, Pradier C, Reiss P, Kowalska JD, de Wit S, Law M, el Sadr W, Kirk O, Friis-Moller N, Monforte A, Phillips AN, Sabin CA, Lundgren JD, D:A:D Study Group. Lancet. 2014 Jul 19;384(9939):241-8. doi: 10.1016/S0140-6736(14)60604-8.

Background: With the advent of effective antiretroviral treatment, the life expectancy for people with HIV is now approaching that seen in the general population. Consequently, the relative importance of other traditionally non-AIDS-related morbidities has increased. We investigated trends over time in all-cause mortality and for specific causes of death in people with HIV from 1999 to 2011.

Methods: Individuals from the Data collection on Adverse events of anti-HIV Drugs (D:A:D) study were followed up from March, 1999, until death, loss to follow-up, or Feb 1, 2011, whichever occurred first. The D:A:D study is a collaboration of 11 cohort studies following HIV-1-positive individuals receiving care at 212 clinics in Europe, USA, and Australia. All fatal events were centrally validated at the D:A:D coordinating centre using coding causes of death in HIV (CoDe) methodology. We calculated relative rates using Poisson regression.

Findings: 3 909 of the 49 731 D:A:D study participants died during the 308 719 person-years of follow-up (crude incidence mortality rate, 12.7 per 1 000 person-years [95% CI 12.3-13.1]). Leading underlying causes were: AIDS-related (1 123 [29%] deaths), non-AIDS-defining cancers (590 [15%] deaths), liver disease (515 [13%] deaths), and cardiovascular disease (436 [11%] deaths). Rates of all-cause death per 1 000 person-years decreased from 17.5 in 1999-2000 to 9.1 in 2009-11; we saw similar decreases in death rates per 1 000 person-years over the same period for AIDS-related deaths (5.9 to 2.0), deaths from liver disease (2.7 to 0.9), and cardiovascular disease deaths (1.8 to 0.9). However, non-AIDS cancers increased slightly from 1.6 per 1 000 person-years in 1999-2000 to 2.1 in 2009-11 (p=0.58). After adjustment for factors that changed over time, including CD4 cell count, we detected no decreases in AIDS-related death rates (relative rate for 2009-11 vs 1999-2000: 0.92 [0.70-1.22]). However, all-cause (0.72 [0.61-0.83]), liver disease (0.48 [0.32-0.74]), and cardiovascular disease (0.33 [0.20-0.53) death rates still decreased over time. The percentage of all deaths that were AIDS-related (87/256 [34%] in 1999-2000 and 141/627 [22%] in 2009-11) and liver-related (40/256 [16%] in 1999-2000 and 64/627 [10%] in 2009-11) decreased over time, whereas non-AIDS cancers increased (24/256 [9%] in 1999-2000 to 142/627 [23%] in 2009-11).

Interpretation: Recent reductions in rates of AIDS-related deaths are linked with continued improvement in CD4 cell count. We hypothesise that the substantially reduced rates of liver disease and cardiovascular disease deaths over time could be explained by improved use of non-HIV-specific preventive interventions. Non-AIDS cancer is now the leading non-AIDS cause and without any evidence of improvement.

Abstract access

Editor’s notes: Causes of death among people with HIV help to identify priorities for HIV care services. This very large cohort study, including nearly 50 000 HIV-positive people in industrialised country clinics, reports on changes in causes of death since 1999. Effective antiretroviral treatment was widely available for this cohort. All-cause mortality decreased over time, partly explained by effective antiretroviral therapy and increased CD4 cell counts. Death rates due to AIDS declined over time. However, even in 2009-11, AIDS remained a leading cause of death, suggesting that further efforts to diagnose and treat people with HIV earlier are required.

Deaths due to cardiovascular and liver-related causes decreased over time, even after adjustment for other potentially contributing factors. This suggests that people in this cohort were benefitting not only from good management of their HIV disease, but also from other preventive programmes for cardiovascular and other risk factors. By contrast, death rates due to non-AIDS-related cancers have not fallen, suggesting that more attention to prevention and early detection of common malignancies is needed.

Comorbidity, Epidemiology
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Mental health concerns similar for HIV-affected and HIV-positive children in Rwanda

HIV and child mental health: a case-control study in Rwanda

Betancourt T, Scorza P, Kanyanganzi F, Fawzi MC, Sezibera V, Cyamatare F, Beardslee W, Stulac S, Bizimana JI, Stevenson A, Kayiteshonga Y. Paediatrics. 2014 Jul 5. [Epub ahead of print]

The global HIV/AIDS response has advanced in addressing the health and well-being of HIV-positive children. Although attention has been paid to children orphaned by parental AIDS, children who live with HIV-positive caregivers have received less attention. This study compares mental health problems and risk and protective factors in HIV-positive, HIV-affected (due to caregiver HIV), and HIV-unaffected children in Rwanda. A case-control design assessed mental health, risk, and protective factors among 683 children aged 10 to 17 years at different levels of HIV exposure. A stratified random sampling strategy based on electronic medical records identified all known HIV-positive children in this age range in 2 districts in Rwanda. Lists of all same-age children in villages with an HIV-positive child were then collected and split by HIV status (HIV-positive, HIV-affected, and HIV-unaffected). One child was randomly sampled from the latter 2 groups to compare with each HIV-positive child per village. HIV-affected and HIV-positive children demonstrated higher levels of depression, anxiety, conduct problems, and functional impairment compared with HIV-unaffected children. HIV-affected children had significantly higher odds of depression (1.68: 95% confidence interval [CI] 1.15-2.44), anxiety (1.77: 95% CI 1.14-2.75), and conduct problems (1.59: 95% CI 1.04-2.45) compared with HIV-unaffected children, and rates of these mental health conditions were similar to HIV-positive children. These results remained significant after controlling for contextual variables. The mental health of HIV-affected children requires policy and programmatic responses comparable to HIV-positive children.

Abstract access

Editor’s notes: The successes of prevention of mother-to-child transmission programmes have led to a substantial increase in the number of HIV-affected children in sub-Saharan Africa. While the physical health trajectory of these children has been the subject of much research, far less is known about their mental health status. In Rwanda investigators found that, relative to HIV-unaffected children, HIV-positive and HIV-affected children both had similarly compromised mental health and functioning. Many of these differences could be explained by the fact that these latter groups were more likely to have experienced the death of a caregiver and not to have their mother as their primary caregiver. These results make us consider not only the need for psychosocial services for the children of HIV-positive adults, but also to consider parity of services regardless of the child’s own HIV status.

Africa
Rwanda
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HIV-related tweeting: social media for HIV prevention?

Methods of using real-time social media technologies for detection and remote monitoring of HIV outcomes.

Young SD, Rivers C, Lewis B. Prev Med. 2014 Jun;63:112-5. doi: 10.1016/j.ypmed.2014.01.024. Epub 2014 Feb 8.

Objective: Recent availability of "big data" might be used to study whether and how sexual risk behaviors are communicated on real-time social networking sites and how data might inform HIV prevention and detection. This study seeks to establish methods of using real-time social networking data for HIV prevention by assessing 1) whether geolocated conversations about HIV risk behaviors can be extracted from social networking data, 2) the prevalence and content of these conversations, and 3) the feasibility of using HIV risk-related real-time social media conversations as a method to detect HIV outcomes.

Methods: In 2012, tweets (N=553 186 061) were collected online and filtered to include those with HIV risk-related keywords (e.g., sexual behaviors and drug use). Data were merged with AIDSVU data on HIV cases. Negative binomial regressions assessed the relationship between HIV risk tweeting and prevalence by county, controlling for socioeconomic status measures.

Results: Over 9 800 geolocated tweets were extracted and used to create a map displaying the geographical location of HIV-related tweets. There was a significant positive relationship (p<.01) between HIV-related tweets and HIV cases.

Conclusion: Results suggest the feasibility of using social networking data as a method for evaluating and detecting Human immunodeficiency virus (HIV) risk behaviors and outcomes.

 Abstract access 

Editor’s notes: The concept of Big Data refers to data sets so large that they are almost or actually impossible to analyse or manage. Methods for harnessing big data sets, such as from social network sites online, are being developed for a variety of uses. These include understanding consumers for the purposes of building creative product marketing campaigns to predicting outbreaks of influenza. This paper examined the potential for using big data from Twitter to compare with areas of high HIV prevalence in the United States, to predict areas of increasing new HIV infections. There are several limitations for the method used in this paper. However, the idea presents an interesting concept. This study was conducted in a developed country, and while computers may not be readily available in resource limited settings, mobile phones are in use in most populations around the world. With mobile technology becoming increasingly sophisticated, and online social networking becoming more common, even in resource limited settings, this may be a strategy worth considering. It could be used in high HIV incidence networks within countries with high rates of HIV, especially in generalised epidemics. Clearly, this method will require additional research, validation and time to develop, but it could present a novel approach for estimating incidence without expensive testing. 

Epidemiology
Northern America
United States of America
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High human papillomavirus prevalence among men in sub-Saharan Africa, especially among individuals living with HIV

Human papillomavirus prevalence among men in sub-Saharan Africa: a systematic review and meta-analysis.

Olesen TB, Munk C, Christensen J, Andersen KK, Kjaer SK. Sex Transm Infect. 2014 May 7. doi: 10.1136/sextrans-2013-051456. [Epub ahead of print]

Background: We performed a systematic review and meta-analysis to summarise the available data on the prevalence of human papillomavirus (HPV) among men in sub-Saharan Africa.

Methods: PubMed and Embase were searched up to 10 March 2014. Random effects meta-analyses were used to calculate a pooled prevalence of any HPV and high-risk (HR) HPV.

Results: A total of 11 studies comprising 9 342 men were identified. We found that HPV is very common among men in sub-Saharan Africa, the prevalence of any HPV ranging between 19.1% and 100%. Using random effects meta-analysis, the pooled prevalence of any HPV was 78.2% (95% CI 54.2 to 91.6) among HIV-positive and 49.4% (95% CI 30.4 to 68.6) among HIV-negative men (p=0.0632). When restricting the analyses to PCR-based studies, the pooled prevalence of any HPV was 84.5% (95% CI 74.2 to 91.2) among HIV-positive and 56.4% (95% CI 49.7 to 62.9) among HIV-negative men (p<0.0001). Of the HPV types included in the nine-valent HPV vaccine, the most common HR HPV types were HPV16 and HPV52, and HPV6 was the most common low-risk HPV type. When examining the prevalence of HPV in relation to age no clear trend was observed.

Conclusions: The prevalence of HPV is high among men in sub-Saharan Africa, which could contribute to the high rates of penile and cervical cancer in this part of the world. Implementation of the prophylactic HPV vaccines could potentially help prevent this large burden of HPV and HPV-associated disease in sub-Saharan Africa.

Abstract access 

Editor’s notes: The majority of cases of penile cancer and ano-genital warts are caused by genotypes of human papillomavirus (HPV) that are included in currently available vaccines. Sub-Saharan Africa has among the highest prevalence of HPV-related infections in the world. This review summarizes HPV prevalence in this region, showing strong evidence of a higher prevalence of HPV in HIV-positive men compared to HIV-negative men. The pooled prevalence of HPV by PCR shows a significant difference in prevalence by HIV status – as is seen for women. The high HPV prevalence may partly explain the higher rate of ano-genital cancer/warts among HIV-positive men. This is important for the consideration of vaccinating men as well as women against HPV in sub-Saharan Africa (although herd immunity through vaccination of women may offer men some protection in the long term). High HPV prevalence among HIV-negative men is also important given that there is some evidence for the association between prevalent penile-HPV and HIV acquisition. The high HPV prevalence may also add to the arguments for rapid scale-up of voluntary medical male circumcision (VMMC) in sub-Saharan Africa, since VMMC has been shown to reduce HPV prevalence and incidence, in addition to HIV incidence.

Africa
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Refusal bias in HIV prevalence estimates from nationally-representative surveys: small overall effects may conceal substantial bias for certain subgroups

Refusal bias in the estimation of HIV prevalence.

Janssens W, van der Gaag J, Rinke de Wit TF, Tanovic Z. Janssens W, van der Gaag J, Rinke de Wit TF, Tanović Z. Demography. 2014 May 2. [Epub ahead of print]

In 2007, UNAIDS corrected estimates of global HIV prevalence downward from 40 million to 33 million based on a methodological shift from sentinel surveillance to population-based surveys. Since then, population-based surveys are considered the gold standard for estimating HIV prevalence. However, prevalence rates based on representative surveys may be biased because of nonresponse. This article investigates one potential source of nonresponse bias: refusal to participate in the HIV test. We use the identity of randomly assigned interviewers to identify the participation effect and estimate HIV prevalence rates corrected for unobservable characteristics with a Heckman selection model. The analysis is based on a survey of 1 992 individuals in urban Namibia, which included an HIV test. We find that the bias resulting from refusal is not significant for the overall sample. However, a detailed analysis using kernel density estimates shows that the bias is substantial for the younger and the poorer population. Nonparticipants in these subsamples are estimated to be three times more likely to be HIV-positive than participants. The difference is particularly pronounced for women. Prevalence rates that ignore this selection effect may be seriously biased for specific target groups, leading to misallocation of resources for prevention and treatment.

Abstract access 

Editor’s notes: Refusal bias in HIV prevalence estimates from nationally representative surveys has been a contested issue ever since UNAIDS made a downward revision of its estimates to accommodate the evidence from such surveys. Most authors nowadays agree that an adjustment of estimates based on unobserved characteristics – for example, prior knowledge of one’s HIV status – is necessary. The Heckman sample selection model with the interviewer identities as the instrumental variable is often used for that. Results from Heckman models have not always been conclusive however, and this study is no exception. The authors take the lack of significant bias as a starting point for exploring the characteristics of nonparticipants and their relative contribution to HIV prevalence estimates in greater detail. They conclude that even though the impact of refusal on national-level HIV prevalence estimates may be small, it could lead to substantial downward bias of HIV prevalence estimates for certain subgroups, in this case women, younger individuals and the poor.

Africa
Namibia
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Systematic review highlights gaps in depression research in sub-Saharan Africa

Reliability and validity of depression assessment among persons with HIV in sub-Saharan Africa: systematic review and meta-analysis.

Tsai AC. J Acquir Immune Defic Syndr. 2014 May 21. [Epub ahead of print]

Objectives: To systematically review the reliability and validity of instruments used to screen for major depressive disorder or assess depression symptom severity among persons with HIV in sub-Saharan Africa.

Design: Systematic review and meta-analysis.

Methods: A systematic evidence search protocol was applied to seven bibliographic databases. Studies examining the reliability and/or validity of depression assessment tools were selected for inclusion if they were based on data collected from HIV-positive adults in any African member state of the United Nations. Random-effects meta-analysis was employed to calculate pooled estimates of depression prevalence. In a subgroup of studies of criterion-related validity, the bivariate random-effects model was used to calculate pooled estimates of sensitivity and specificity.

Results: Of 1 117 records initially identified, I included 13 studies of 5 373 persons with HIV in 7 sub-Saharan African countries. Reported estimates of Cronbach's alpha ranged from 0.63-0.95, and analyses of internal structure generally confirmed the existence of a depression-like construct accounting for a substantial portion of variance. The pooled prevalence of probable depression was 29.5% (95% CI, 20.5-39.4), while the pooled prevalence of major depressive disorder was 13.9% (95% CI, 9.7-18.6). The Center for Epidemiologic Studies-Depression scale was the most frequently studied instrument, with a pooled sensitivity of 0.82 (95% CI, 0.73-0.87) for detecting major depressive disorder.

Conclusions: Depression screening instruments yielded relatively high false positive rates. Overall, few studies described the reliability and/or validity of depression instruments in sub-Saharan Africa.

Abstract access 

Editor’s notes: This is the first systematic review of depression screening and diagnostic instruments among HIV-positive people in sub-Saharan Africa. The depression treatment gap for people living with HIV in high-income countries is considerable, and is likely to be even greater in sub-Saharan Africa. The eligible studies in this review were geographically concentrated in southern and eastern Africa. Prevalence of depression overall was high, but was substantially lower among people who had initiated HIV treatment than among people who had not. Additionally, depression prevalence estimates were twice as high when using screening tools rather than diagnostic criteria, indicating a high false positivity rate. This systematic review highlights critical areas for future research, particularly in validating depression screening tools and in expanding investigation of HIV and depression co-morbidity beyond South Africa and Uganda.

Africa
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Meta-analysis finds partial support for elevated HIV prevalence among the military

Systematic review and meta-analysis of HIV prevalence among men in militaries in low income and middle income countries. 

Lloyd J, Papworth E, Grant L, Beyrer C, Baral S. Sex Transm Infect. 2014 Apr 7. doi: 10.1136/sextrans-2013-051463. [Epub ahead of print]

Objectives: To determine whether the current HIV prevalence in militaries of low-income and middle-income countries is higher, the same, or lower than the HIV prevalence in the adult male population of those countries.

Methods: HIV prevalence data from low-income and middle-income countries' military men were systematically reviewed during 2000-2012 from peer reviewed journals, clearing-house databases and the internet. Standardised data abstraction forms were used to collect information on HIV prevalence, military branch and sample size. Random effects meta-analyses were completed with the Mantel-Haenszel method comparing HIV prevalence among military populations with other men in each country.

Results: 2 214 studies were retrieved, of which 18 studies representing nearly 150 000 military men across 11 countries and 4 regions were included. Military male HIV prevalence across the studies ranged from 0.06% (n=22 666) in India to 13.8% (n=2 733) in Tanzania with a pooled prevalence of 1.1% (n=147 591). HIV prevalence in male military populations in sub-Saharan Africa was significantly higher when compared with reproductive age (15-49 years) adult men (OR: 2.8, 95% CI 1.01 to 7.81). HIV prevalence in longer-serving male military populations compared with reproductive age adult men was significantly higher (OR: 2.68, 95% CI 1.65 to 4.35).

Conclusions: Our data reveals that across the different settings, the burden of HIV among militaries may be higher or lower than the civilian male populations. In this study, male military populations in sub-Saharan Africa, low-income countries and longer-serving men have significantly higher HIV prevalence. Given the national security implications of the increased burden of HIV, interventions targeting military personnel in these populations should be scaled up where appropriate.

Abstract access 

Editor’s notes: Men in military service are considered a key population because they spend protracted periods away from home and may engage in casual or other high-risk sex. This is not just a health concern for the armed forces themselves, but countries have in the past refused the assistance of peacekeeping forces because they were deemed a source of new infections. This systematic review concludes that HIV infection rates in the military are not universally higher than among men of reproductive age in the general population. However, significantly elevated prevalence was detected in studies from sub-Saharan Africa and among military who have been in service for over one year. The latter suggests that the relatively high prevalence results from increased exposure during service rather than the disproportional recruitment of men with HIV into service. On the contrary, the prevalence among new recruits is lower than in the general population. Prevention efforts, including HIV testing and counselling, and condom distribution, need to be increased during deployment in settings where exposure to HIV is high.

Epidemiology
Africa, Asia, Latin America
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Antiretroviral therapy decreases risk of clinically significant depression by about half

Risk of clinically significant depression in HIV-infected patients: effect of antiretroviral drugs.

Gutiérrez F, García L, Padilla S, Alvarez D, Moreno S, Navarro G, Gómez-Sirvent J, Vidal F, Asensi V, Masiá M; CoRIS. HIV Med. 2014 Apr;15(4):213-23. doi: 10.1111/hiv.12104. Epub 2013 Nov 11.

Objectives: We aimed to characterize depression in newly diagnosed HIV-infected patients, to determine the effect of antiretroviral therapy (ART) on its incidence, and to investigate whether efavirenz use was associated with a higher risk, compared with non-efavirenz-containing regimens, in the Spanish CoRIS cohort.

Methods: CoRIS is a contemporary, multicentre cohort of HIV-infected patients, antiretroviral-naive at entry, launched in 2004. Poisson regression models were used to investigate demographic, clinical and treatment-related factors associated with a higher incidence of clinically significant depression to October 2010.

Results: In total, 5 185 patients (13 089 person-years) participated in the study, of whom 3 379 (65.2%) started ART during follow-up. The incidence rates of depression before and after starting ART were 11.68 [95% confidence interval (CI) 9.01-15.15] and 7.06 (95% CI 5.45-9.13) cases per 1 000 person-years, respectively. After adjustment, there was an inverse association between the occurrence of depression and the initiation of ART [incidence rate ratio (IRR) 0.53; 95% CI 0.28-0.99], while the likelihood of depression increased in patients of age > 50 years (IRR 1.94; 95% CI 1.21-3.12). Longer exposure to ART was associated with a decreased IRR of depression in unadjusted and adjusted analyses. The IRR for patients receiving < 2, 2-4 and > 4 years of ART was 0.72 (95% CI 0.36-1.44), 0.10 (95% CI 0.04-0.25) and 0.05 (95% CI 0.01-0.17), respectively, compared with ART-naive patients. This protective effect was also observed when durations of exposure to nonnucleoside reverse transcriptase inhibitor-based regimens and efavirenz-containing regimens were analysed separately.

Conclusions: The incidence of clinically significant depression was lower among HIV-infected patients on ART. The protective effect of ART was also observed with efavirenz-containing regimens.

Abstract access 

Editor’s notes: There is a need to consider the mental health implications of initiating antiretroviral therapy (ART) particularly as people living with HIV are initiating treatment sooner and living longer. This is the first large-scale cohort study to examine the effect of ART on incidence of depression. The results are striking, with a 50% lower incidence of “clinically significant depression” among participants who had initiated ART, after adjusting for potential confounders. Clinically significant depression is defined as depression requiring drug therapy or suicide attempts. Older age and female sex were also associated with a higher risk of depression. This is consistent with existing literature. The association with ART was stronger among participants who were on treatment for longer periods of time, for both non-nucleoside reverse-transcriptase inhibitors (NNRTI) and efavirenz-containing regimens. There are several potential mechanisms by which ART may reduce incidence of depression, although the specific mechanism remains unclear.  Regardless, this data shows a clear additional benefit of early ART initiation.

Europe
Spain
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Hunting for HIV and TB in households

Incidence of TB and HIV in prospectively followed household contacts of TB index patients in South Africa.

van Schalkwyk C, Variava E, Shapiro AE, Rakgokong M, Masonoke K, Lebina L, Welte A, Martinson N. PLoS One. 2014 Apr 23;9(4):e95372. doi: 10.1371/journal.pone.0095372. eCollection 2014.

Objective: To report the incidence rates of TB and HIV in household contacts of index patients diagnosed with TB.

Design: A prospective cohort study in the Matlosana sub-district of North West Province, South Africa.

Methods: Contacts of index TB patients received TB and HIV testing after counseling at their first household visit and were then followed up a year later, in 2010. TB or HIV diagnoses that occurred during the period were determined.

Results: For 2 377 household contacts, the overall observed TB incidence rate was 1.3 per 100 person years (95% CI 0.9-1.9/100py) and TB incidence for individuals who were HIV-infected and HIV seronegative at baseline was 5.4/100py (95% CI 2.9-9.0/100py) and 0.7/100py (95% CI 0.3-1.4/100py), respectively. The overall HIV incidence rate was 2.2/100py (95% CI 1.3-8.4/100py).

Conclusions: In the year following a household case finding visit when household contacts were tested for TB and HIV, the incidence rate of both active TB and HIV infection was found to be extremely high. Clearly, implementing proven strategies to prevent HIV acquisition and preventing TB transmission and progression to disease remains a priority in settings such as South Africa.

 Abstract  Full-text [free] access

Editor’s notes: This study was conducted at the epicentre of the African HIV and TB epidemics in southern Africa. It provides important confirmatory data of the high incidence of new HIV infections and of TB in household contacts of index TB cases. These data provide an evidence base for planning household-based programmes with active TB case finding and HIV screening in this population. Unsurprisingly, TB incidence was 7.7-fold higher in HIV-positive household contacts, re-emphasizing the importance of simultaneous active screening for these diseases. 

Avoid TB deaths
Comorbidity, Epidemiology
Africa
South Africa
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