Articles tagged as "Epidemiology"

Street children are vulnerable to HIV in Tehran, Iran

Prevalence of HIV, HBV and HCV among street and labour children in Tehran, Iran.

Foroughi M, Moayedi-Nia S, Shoghli A, Bayanolhagh S, Sedaghat A, Mohajeri M, Mousavinasab SN, Mohraz M. Sex Transm Infect. 2016 Sep 6. pii: sextrans-2016-052557. doi: 10.1136/sextrans-2016-052557. [Epub ahead of print]

Objectives: The existence of street and working children in Iran is undeniable. The precarious conditions of these children (including disrupted family, poverty, high prevalence of crime among relatives, family members and peers) cause social harm and high-risk behaviours, including drug addiction, selling sex or having sex with adolescents or peers. Here we explore the HIV, hepatitis B and hepatitis C status of street and working children in Tehran.

Methods: One thousand street and labour children, aged 10-18 years, were recruited by using the time-location sampling method, and semistructured questionnaires were used to find demographic information and information on HIV/AIDS-related high-risk sexual behaviours. Blood samples were collected from children, with use of the dried blood sampling method.

Results: 4.5% of children were HIV infected, 1.7% were infected with hepatitis B virus and 2.6% were infected with hepatitis C virus (HCV). Having parents who used drug, infected with HCV and having experience in trading sex significantly increased the likelihood of getting HIV among the street children of Tehran.

Conclusion: HIV prevalence among street children is much higher than general population (<0.1%), and in fact, the rate of positivity comes close to that among female sex workers in Iran. These findings must be an alarm for HIV policymakers to consider immediate and special interventions for this at-risk group.

Abstract access 

Editor’s notes: Relatively few studies have been published on the prevalence of HIV and other communicable diseases in vulnerable populations in Iran. This paper presents results from a prevalence study among street children in Tehran, Iran. Researchers were able to survey 1000 street children, and children exploited by labour between the ages of 10-18, finding an HIV prevalence of 4.5%. The survey data revealed high rates of physical abuse, drug use, and school dropout, but it is not clear whether any of the children were already aware of their HIV status, or how many had acquired HIV perinatally. These important findings point to the imperative for programmes to address the needs of street children in Tehran, and additional research in other areas within the country where similar issues may be prevalent. 

Iran (Islamic Republic of)
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Changes in sexual risk behaviour and sustained HIV incidence among MSM in the UK

Sexual behaviours, HIV testing, and the proportion of men at risk of transmitting and acquiring HIV in London, UK, 2000-13: a serial cross-sectional study.

Aghaizu A, Wayal S, Nardone A, Parsons V, Copas A, Mercey D, Hart G, Gilson R, Johnson AM. Lancet HIV. 2016 Sep;3(9):e431-40. doi: 10.1016/S2352-3018(16)30037-6. Epub 2016 Jul 14.

Background: HIV incidence in men who have sex with men (MSM) in the UK has remained unchanged over the past decade despite increases in HIV testing and antiretroviral therapy (ART) coverage. In this study, we examine trends in sexual behaviours and HIV testing in MSM and explore the risk of transmitting and acquiring HIV.

Methods: In this serial cross-sectional study, we obtained data from ten cross-sectional surveys done between 2000 and 2013, consisting of anonymous self-administered questionnaires and oral HIV antibody testing in MSM recruited in gay social venues in London, UK. Data were collected between October and January for all survey years up to 2008 and between February and August thereafter. All men older than 16 years were eligible to take part and fieldworkers attempted to approach all MSM in each venue and recorded refusal rates. Data were collected on demographic and sexual behavioural characteristics. We analysed trends over time using linear, logistic, and quantile regression.

Findings: Of 13 861 questionnaires collected between 2000 and 2013, we excluded 1985 (124 had completed the survey previously or were heterosexual reporting no anal intercourse in the past year, and 1861 did not provide samples for antibody testing). Of the 11 876 eligible MSM recruited, 1512 (13%) were HIV positive, with no significant trend in HIV positivity over time. 35% (531 of 1505) of HIV-positive MSM had undiagnosed infection, which decreased non-linearly over time from 34% (45 of 131) to 24% (25 of 106; p=0.01), while recent HIV testing (ie, in the past year) increased from 26% (263 of 997) to 60% (467 of 777; p<0.0001). The increase in recent testing in undiagnosed men (from 29% to 67%, p<0.0001) and HIV-negative men (from 26% to 62%, p<0.0001) suggests that undiagnosed infection might increasingly be recently acquired infection. The proportion of MSM reporting unprotected anal intercourse (UAI) in the past year increased from 43% (513 of 1187) to 53% (394 of 749; p<0.0001) and serosorting (exclusively) increased from 18% (207 of 1132) to 28% (177 of 6369; p<0.0001). 268 (2%) of 11 570 participants had undiagnosed HIV and reported UAI in the past year were at risk of transmitting HIV. Additionally 259 (2%) had diagnosed infection and reported UAI and non-exclusive serosorting in the past year. Although we did not collect data on antiretroviral therapy or viral load, surveillance data suggests that a small proportion of men with diagnosed infection will have detectable viral load and hence might also be at risk of transmitting HIV. 2633 (25%) of 10 364 participants were at high risk of acquiring HIV (defined as HIV-negative MSM either reporting one or more casual UAI partners in the past year or not exclusively serosorting). The proportions of MSM at risk of transmission or acquisition changed little over time (p=0.96 for MSM potentially at risk of transmission and p=0.275 for MSM at high risk of acquiring HIV). Undiagnosed men reporting UAI and diagnosed men not exclusively serosorting had consistently higher partner numbers than did other MSM over the period (median ranged from one to three across surveys in undiagnosed men reporting UAI, two to ten in diagnosed men not exclusively serosorting, and none to two in other men).

Interpretation: An increasing proportion of undiagnosed HIV infections in MSM in London might have been recently acquired, which is when people are likely to be most infectious. High UAI partner numbers of MSM at risk of transmitting HIV and the absence of a significant decrease in the proportion of men at high risk of acquiring the infection might explain the sustained HIV incidence. Implementation of combination prevention interventions comprising both behavioural and biological interventions to reduce community-wide risk is crucial to move towards eradication of HIV.

Abstract access  

Editor’s notes: Despite wide-scale ART coverage, HIV incidence among gay men and other men who have sex with men remains high in many high-income countries, and is increasing in some locations. Although expanded testing and treatment are expected to lower HIV incidence, there are concerns that changes in risk behaviour may offset the impact of ART on HIV transmission. In this paper, the authors illustrate that among gay men and other men who have sex with men in London, the proportion who had tested for HIV in the past year increased considerably over the period 2000 and 2013, with a corresponding decrease in the numbers with undiagnosed HIV.  However, there were increasing rates of condomless anal intercourse in both HIV-negative and HIV-positive men.  Furthermore, men living with HIV who were undiagnosed, and men who were not exclusively serosorting (having sex with partners of the presumed same HIV status), reported increased numbers of sexual partners over the period of the surveys. Despite the increases in recent HIV testing, three percent of men in 2013 incorrectly perceived themselves to be HIV negative. This suggests that many men who are undiagnosed may be recent infections, so could be at high risk of transmission. Previous modelling studies have illustrated that increased sexual risk behaviour, particular among people who are unaware that they are HIV positive, could account for the observed increase in incidence in gay men and other men who have sex with men. The findings of this study demonstrate the importance of core groups to the continued transmission of HIV. Test and treat programmes alone may not be sufficient to reduce HIV incidence in gay men and other men who have sex with men populations. There is the need for appropriately tailored combination prevention programmes in order to make real gains against HIV among gay men and other men who have sex with men.

United Kingdom
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Violence and HIV among poor urban women in the USA

Physical and sexual violence predictors: 20 years of the women's interagency HIV study cohort.

Decker MR, Benning L, Weber KM, Sherman SG, Adedimeji A, Wilson TE, Cohen J, Plankey MW, Cohen MH, Golub ET. Am J Prev Med. 2016 Nov;51(5):731-742. pii: S0749-3797(16)30253-7. doi: 10.1016/j.amepre.2016.07.005. [Epub 2016 Aug 29]. 

Introduction: Gender-based violence (GBV) threatens women's health and safety. Few prospective studies examine physical and sexual violence predictors. Baseline/index GBV history and polyvictimization (intimate partner violence, non-partner sexual assault, and childhood sexual abuse) were characterized. Predictors of physical and sexual violence were evaluated over follow-up.

Methods: HIV-infected and uninfected participants (n=2838) in the Women's Interagency HIV Study provided GBV history; 2669 participants contributed 26 363 person years of follow-up from 1994 to 2014. In 2015-2016, multivariate log-binomial/Poisson regression models examined violence predictors, including GBV history, substance use, HIV status, and transactional sex.

Results: Overall, 61% reported index GBV history; over follow-up, 10% reported sexual and 21% reported physical violence. Having experienced all three forms of past GBV posed the greatest risk (adjusted incidence rate ratio [AIRR]physical=2.23, 95% CI=1.57, 3.19; AIRRsexual=3.17, 95% CI=1.89, 5.31). Time-varying risk factors included recent transactional sex (AIRRphysical=1.29, 95% CI=1.03, 1.61; AIRRsexual=2.98, 95% CI=2.12, 4.19), low income (AIRRphysical=1.22, 95% CI=1.01, 1.45; AIRRsexual=1.38, 95% CI=1.03, 1.85), and marijuana use (AIRRphysical=1.43, 95% CI=1.22, 1.68; AIRRsexual=1.57, 95% CI=1.19, 2.08). For physical violence, time-varying risk factors additionally included housing instability (AIRR=1.37, 95% CI=1.15, 1.62); unemployment (AIRR=1.38, 95% CI=1.14, 1.67); exceeding seven drinks/week (AIRR=1.44, 95% CI=1.21, 1.71); and use of crack, cocaine, or heroin (AIRR=1.76, 95% CI=1.46, 2.11).

Conclusions: Urban women living with HIV and their uninfected counterparts face sustained GBV risk. Past experiences of violence create sustained risk. Trauma-informed care, and addressing polyvictimization, structural inequality, transactional sex, and substance use treatment, can improve women's safety.

Abstract access  

Editor’s notes: Gender-based violence results in physical, sexual and mental health morbidities, including HIV risk behaviours and HIV infection. There is limited prospective research on risk factors for physical and sexual violence. This study characterised leading violence forms – that is, intimate partner violence, non-partner sexual assault and childhood sexual assault – among a cohort of low-income women living in six American cities, some of whom are living with HIV. It also examined predictors of violence experience during follow-up. This study found extensive gender-based violence of all types, listed above, among this cohort of 2838 HIV positive and HIV negative women. Lifetime gender-based violence history was highly prevalent among white women (72%), non-heterosexual women (74%), homeless / unstably housed women (80%) and among women with a sex work history (81%). Experience of different types of gender-based violence by baseline conferred significant risk for subsequent physical and sexual violence. HIV status did not confer risk for violence victimisation indicating that low-income women in this setting are at considerable risk for violence, regardless of their HIV status.

This study presents data from the largest ongoing prospective cohort study among American women living with HIV and includes a demographically matched HIV negative comparison group. The key limitation of this study was the non-probability sample, which limits generalisability of these results. The results are best generalised to urban American women in high-HIV prevalence settings. Additional cohort studies are necessary in other settings and contexts. However, the findings demonstrate the need to understand and address different forms of violence experienced by the same woman for violence prevention and health promotion. They support the USA 2015 National HIV/AIDS strategy recommendations to address violence and trauma for women both at risk for and living with HIV. 

Northern America
United States of America
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Ending HIV deaths in South Africa: progress made but still a long way to go

Mortality trends and differentials in South Africa from 1997 to 2012: second National Burden of Disease Study.

Pillay-van Wyk V, Msemburi W, Laubscher R, Dorrington RE, Groenewald P, Glass T, Nojilana B, Joubert JD, Matzopoulos R, Prinsloo M, Nannan N, Gwebushe N, Vos T, Somdyala N, Sithole N, Neethling I, Nicol E, Rossouw A, Bradshaw D. Lancet Glob Health. 2016 Sep;4(9):e642-53. doi: 10.1016/S2214-109X(16)30113-9.

Background: The poor health of South Africans is known to be associated with a quadruple disease burden. In the second National Burden of Disease (NBD) study, we aimed to analyse cause of death data for 1997-2012 and develop national, population group, and provincial estimates of the levels and causes of mortality.

Method: We used underlying cause of death data from death notifications for 1997-2012 obtained from Statistics South Africa. These data were adjusted for completeness using indirect demographic techniques for adults and comparison with survey and census estimates for child mortality. A regression approach was used to estimate misclassified HIV/AIDS deaths and so-called garbage codes were proportionally redistributed by age, sex, and population group population group (black African, Indian or Asian descent, white [European descent], and coloured [of mixed ancestry according to the preceding categories]). Injury deaths were estimated from additional data sources. Age-standardised death rates were calculated with mid-year population estimates and the WHO age standard. Institute of Health Metrics and Evaluation Global Burden of Disease (IHME GBD) estimates for South Africa were obtained from the IHME GHDx website for comparison.

Findings: All-cause age-standardised death rates increased rapidly since 1997, peaked in 2006 and then declined, driven by changes in HIV/AIDS. Mortality from tuberculosis, non-communicable diseases, and injuries decreased slightly. In 2012, HIV/AIDS caused the most deaths (29.1%) followed by cerebrovascular disease (7.5%) and lower respiratory infections (4.9%). All-cause age-standardised death rates were 1.7 times higher in the province with the highest death rate compared to the province with the lowest death rate, 2.2 times higher in black Africans compared to whites, and 1.4 times higher in males compared with females. Comparison with the IHME GBD estimates for South Africa revealed substantial differences for estimated deaths from all causes, particularly HIV/AIDS and interpersonal violence.

Interpretation: This study related the reversal of HIV/AIDS, non-communicable disease, and injury mortality trends in South Africa during the study period. Mortality differentials show the importance of social determinants, raise concerns about the quality of health services, and provide relevant information to policy makers for addressing inequalities. Differences between GBD estimates for South Africa and this study emphasise the need for more careful calibration of global models with local data.

Abstract   Full-text [free] access 

Editor’s notes: In South Africa in 2012, almost 500 people died every day from HIV or TB. One in every three deaths was associated with HIV or TB. Although these figures represent a substantial decline from the peak of the epidemic impact in 2006, they highlight the enormous challenge still facing this country.

South Africa is one of the few countries in Africa to have a robust civil registration system for deaths. However, there continue to be problems with misclassification of HIV-associated deaths. This analysis relied on somewhat complicated analytical methods to adjust mortality estimates. Only around half of those deaths ultimately defined as HIV associated had been originally coded as such in the registration system. The methods for adjustment differed from those used in the Global Burden of Disease (GBD) study. This explains the quite marked discrepancy in number of deaths attributed to HIV - this study estimated 40% fewer HIV-associated deaths than the GBD study.

This highlights that there is still quite a lot of uncertainty around cause-specific mortality estimates. So, although these data are useful to guide national and provincial priority setting, more fine-grain analysis is required to properly inform public health policies. There is a particular need to unpick the contribution of TB. In this respect, the recent announcement by the South African Department of Science of Technology to establish a network of health and demographic surveillance sites as a key component of the national research infrastructure is very welcome. With established verbal autopsy methods and innovations such as routine linkage to health service records, this will provide a framework to allow a deeper understanding of mortality.

South Africa
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Poor linkage to care may undermine benefits of universal test and treat

Uptake of home-based HIV testing, linkage to care, and community attitudes about ART in rural KwaZulu-Natal, South Africa: descriptive results from the first phase of the ANRS 12249 TasP cluster-randomised trial.

Iwuji CC, Orne-Gliemann J, Larmarange J, Okesola N, Tanser F, Thiebaut R, Rekacewicz C, Newell ML, Dabis F. PLoS Med. 2016 Aug 9;13(8):e1002107. doi: 10.1371/journal.pmed.1002107. eCollection 2016.

Background: The 2015 WHO recommendation of antiretroviral therapy (ART) for all immediately following HIV diagnosis is partially based on the anticipated impact on HIV incidence in the surrounding population. We investigated this approach in a cluster-randomised trial in a high HIV prevalence setting in rural KwaZulu-Natal. We present findings from the first phase of the trial and report on uptake of home-based HIV testing, linkage to care, uptake of ART, and community attitudes about ART.

Methods and findings: Between 9 March 2012 and 22 May 2014, five clusters in the intervention arm (immediate ART offered to all HIV-positive adults) and five clusters in the control arm (ART offered according to national guidelines, i.e., CD4 count ≤ 350 cells/µl) contributed to the first phase of the trial. Households were visited every 6 mo. Following informed consent and administration of a study questionnaire, each resident adult (≥16 y) was asked for a finger-prick blood sample, which was used to estimate HIV prevalence, and offered a rapid HIV test using a serial HIV testing algorithm. All HIV-positive adults were referred to the trial clinic in their cluster. Those not linked to care 3 mo after identification were contacted by a linkage-to-care team. Study procedures were not blinded. In all, 12 894 adults were registered as eligible for participation (5790 in intervention arm; 7104 in control arm), of whom 9927 (77.0%) were contacted at least once during household visits. HIV status was ever ascertained for a total of 8233/9927 (82.9%), including 2569 ascertained as HIV-positive (942 tested HIV-positive and 1627 reported a known HIV-positive status). Of the 1177 HIV-positive individuals not previously in care and followed for at least 6 mo in the trial, 559 (47.5%) visited their cluster trial clinic within 6 mo. In the intervention arm, 89% (194/218) initiated ART within 3 mo of their first clinic visit. In the control arm, 42.3% (83/196) had a CD4 count ≤350 cells/µl at first visit, of whom 92.8% initiated ART within 3 mo. Regarding attitudes about ART, 93% (8802/9460) of participants agreed with the statement that they would want to start ART as soon as possible if HIV-positive. Estimated baseline HIV prevalence was 30.5% (2028/6656) (95% CI 25.0%, 37.0%). HIV prevalence, uptake of home-based HIV testing, linkage to care within 6 mo, and initiation of ART within 3 mo in those with CD4 count ≤350 cells/µl did not differ significantly between the intervention and control clusters. Selection bias related to noncontact could not be entirely excluded.

Conclusions: Home-based HIV testing was well received in this rural population, although men were less easily contactable at home; immediate ART was acceptable, with good viral suppression and retention. However, only about half of HIV-positive people accessed care within 6 mo of being identified, with nearly two-thirds accessing care by 12 mo. The observed delay in linkage to care would limit the individual and public health ART benefits of universal testing and treatment in this population.

Trial registration: NCT01509508.

Abstract  Full-text [free] access 

Editor’s notes: The UNAIDS treatment target set for 2020 aim for at least 90 percent of all people living with HIV to be diagnosed, at least 90 percent of people diagnosed to receive antiretroviral therapy, and for treatment to be effective and consistent enough in at least 90 percent of people on treatment to suppress the virus. This would result in about 73% of all HIV-positive people being virally suppressed. 

This paper describes the key process indicators (such as uptake of initial and repeat home-based HIV testing, linkage to care, uptake of ART, and viral suppression) along the treatment cascade during the two-year initial phase of a trial evaluating a treatment as prevention package in a rural South African setting. Although the investigators were unable to contact one-quarter of the potential key population - especially men - they found good acceptance of home-based HIV testing.

However, they found disappointingly low rates of linkage to care. Only about half of HIV-positive participants not yet in care attended a clinic within six months of diagnosis. This increased to two-thirds after 12 months, partly due the efforts of a linkage-to-care team. They contacted those not linked to care three months after an HIV-positive test. Among people who did present to the clinics, the rates of ART uptake, retention in care and viral suppression were high.

The main study (reported at the AIDS 2016 conference in Durban) did not demonstrate an effect of offering immediate ART on HIV incidence at population level, mainly due the low rates of linkage to care following HIV diagnosis. 

These results suggest that systems to improve linkage to care will be necessary if the individual and public health benefits of universal testing and treatment are to be maximised.

South Africa
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Access improved to HIV testing through peer administered oral fluid HIV tests in key populations in Brazil

Point-of-care HIV tests done by peers, Brazil.

Pascom AR, Dutra de Barros CH, Lobo TD, Pasini EN, Comparini RA, Caldas de Mesquita F. Bull World Health Organ. 2016 Aug 1; 94(8): 626–630.

Problem: Early diagnosis of infections with human immunodeficiency virus (HIV) is needed - especially among key populations such as sex workers, transgender people, men who have sex with men and people who use drugs.

Approach: The Brazilian Ministry of Health developed a strategy called Viva Melhor Sabendo ("live better knowing") to increase HIV testing among key populations. In partnership with nongovernmental organizations (NGOs), a peer point-of-care testing intervention, using an oral fluid rapid test, was introduced at social venues for key populations at different times of the day.

Local setting: Key populations in Brazil can have 40 times higher HIV prevalence than the general population (14.8% versus 0.4%).

Relevant changes: Legislation was reinterpreted, so that oral fluid rapid tests could be administered by any person trained in rapid testing by the health ministry. Between January 2014 and March 2015, 29 723 oral fluid tests were administered; 791 (2.7%) were positive. Among the key populations, transgender people had the greatest proportion of positive results (10.7%; 172/1612), followed by men who declared themselves as commercial sex workers (8.7%; 165/1889) and men who have sex with men (4.8%; 292/6055).

Lessons learnt: The strategy improved access to HIV testing. Testing done by peers at times and locations suitable for key populations increased acceptance of testing. Working with relevant NGOs is a useful approach when reaching out to these key populations.

Abstract  Full-text [free] access 

Editor’s notes: Brazil was a pioneer in provision of universal access to ART, adopting universal treatment for all people living with HIV in 2013. The HIV epidemic in Brazil is largely concentrated in key populations, where early treatment is less likely to be initiated than in the general population. In this report, the authors describe the results of a new strategy to allow trained peers from 53 non-governmental organisations (NGOs) to conduct rapid HIV screening tests using oral fluid tests, and refer clients with positive results for treatment. Key features were the full ownership of the testing implementation by the NGOs, extension of testing to social venues, and the matching of testers and clients by demographic characteristics. About half of the clients (53%) were first-time testers, providing clear evidence of the success of this new strategy. Future work should describe how individual NGOs revised their strategy over time, which NGOs were more successful in reaching key populations, and which NGOs were more successful in referring clients with positive results for test confirmation and treatment.

Latin America
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Migration and HIV – a double synergy

Migration and HIV infection in Malawi.

Anglewicz P, VanLandingham M, Manda-Taylor L, Kohler HP. AIDS. 2016 Aug 24;30(13):2099-105. doi: 10.1097/QAD.0000000000001150.

Objective: To evaluate the assumption that moving heightens HIV infection by examining the time-order between migration and HIV infection and investigate differences in HIV infection by migration destination and permanence.

Methods: We employ four waves of longitudinal data (2004-2010) for 4265 men and women from a household-based study in rural Malawi and a follow-up of migrants (2013). Using these data, we examine HIV status prior to migration. Migrants are disaggregated by destination (rural, town, and urban) and duration (return and permanent); all compared with individuals who consistently resided in the rural origin ('nonmigrants').

Results: HIV-positive individuals have significantly greater odds of migration than those who are HIV negative [odds ratio 2.75; 95% confidence interval (CI) 1.89-4.01]. Being HIV positive significantly increases the relative risk (RR) that respondent will be a rural-urban migrant [RR ratio (RRR) 6.28; 95% CI 1.77-22.26), rural-town migrant (RRR 3.62; 95% CI 1.24-10.54), and a rural-rural migrant (RRR 4.09; 95% CI 1.68-9.97), instead of a nonmigrant. Being HIV positive significantly increases the RR that a respondent will move and return to the village of origin (RRR 2.58; 95% CI 1.82-3.66) and become a permanent migrant (RRR 3.21; 95% CI 1.77-5.82) instead of not migrating.

Conclusion: HIV-positive status has a profound impact on mobility: HIV infection leads to significantly higher mobility through all forms of migration captured in our study. These findings emphasize that migration is more than just an independent risk factor for HIV infection: greater prevalence of HIV among migrants is partly due to selection of HIV-positive individuals into migration.

Abstract access  

Editor’s notes: Previous studies in sub-Saharan Africa have identified that migrants are at greater risk of living with HIV than their non-migrant counterparts. There is however a lack of knowledge of the direction of causality between migration status and HIV status. This longitudinal study enabled analysis of the direction of causality between HIV acquisition and migration.  Individuals living with HIV were significantly more likely to migrate in the future than people who were not living with HIV.  The effect was seen for all types of migration (rural to rural, rural to town (district capital) and rural to urban (regional capital).

The true association between HIV status and migration status may exceed that illustrated as some individuals who were HIV negative at baseline may have become HIV positive prior to migration. The patterns identified could be driven by better healthcare being available in an urban setting. Alternatively individuals may move to avoid HIV-associated stigma in the relative anonymity of an urban environment. Previous research in Malawi has also illustrated that marriage and migration are closely linked. Thus marital dissolution following HIV infection may in part explain the patterns seen.  Further qualitative studies are necessary to investigate such factors.

This study illustrates that an increasing emphasis needs to be placed on HIV prevention in the rural communities from which migrants originate, in addition to focusing on the risk in the urban areas. 

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High spatial variation of HIV – implications for focused responses

Heterogeneity of the HIV epidemic in agrarian, trading, and fishing communities in Rakai, Uganda: an observational epidemiological study.

Chang LW, Grabowski MK, Ssekubugu R, Nalugoda F, Kigozi G, Nantume B, Lessler J, Moore SM, Quinn TC, Reynolds SJ, Gray RH, Serwadda D, Wawer MJ. Lancet HIV. 2016 Aug;3(8):e388-96. doi: 10.1016/S2352-3018(16)30034-0. Epub 2016 Jul 9.

Background: Understanding the extent to which HIV burden differs across communities and the drivers of local disparities is crucial for an effective and targeted HIV response. We assessed community-level variations in HIV prevalence, risk factors, and treatment and prevention service uptake in Rakai, Uganda.

Methods: The Rakai Community Cohort Study (RCCS) is an open, population-based cohort of people aged 15-49 years in 40 communities. Participants are HIV tested and interviewed to obtain sociodemographic, behavioural, and health information. RCCS data from Aug 10, 2011, to May 30, 2013, were used to classify communities as agrarian (n=27), trading (n=9), or lakeside fishing sites (n=4). We mapped HIV prevalence with Bayesian methods, and characterised variability across and within community classifications. We also assessed differences in HIV risk factors and uptake of antiretroviral therapy and male circumcision between community types.

Findings: 17 119 individuals were included, 9215 (54%) of whom were female. 9931 participants resided in agrarian, 3318 in trading, and 3870 in fishing communities. Median HIV prevalence was higher in fishing communities (42%, range 38-43) than in trading (17%, 11-21) and agrarian communities (14%, 9-26). Antiretroviral therapy use was significantly lower in both men and women in fishing communities than in trading (age-adjusted prevalence risk ratio in men 0.64, 95% CI 0.44-0.97; women 0.53, 0.42-0.66) and agrarian communities (men 0.55, 0.42-0.72; women 0.65, 0.54-0.79), as was circumcision coverage among men (vs trading 0.48, 0.42-0.55; vs agrarian 0.64, 0.56-0.72). Self-reported risk behaviours were significantly higher in men than in women and in fishing communities than in other community types.

Interpretation: Substantial heterogeneity in HIV prevalence, risk factors, and service uptake in Rakai, Uganda, emphasises the need for local surveillance and the design of targeted HIV responses. High HIV burden, risk behaviours, and low use of combination HIV prevention in fishing communities make these populations a priority for intervention.

Abstract access  


Editor’s notes: National estimates of HIV prevalence often conceal concentrated ‘sub-epidemics’ in particular geographical areas or populations. In this paper, the authors illustrate that within the Rakai region of Uganda, there is extensive community-level variation in HIV prevalence, behavioural risk factors, and HIV service coverage. Such clustering of HIV infections can reduce the impact of population-based prevention. UNAIDS, along with other organisations, have called for a more focused response to HIV treatment and prevention, concentrating efforts on key populations to increase the effectiveness of programmes. While regional and national data are important to provide an overview of the epidemic, they do not provide the in-depth picture that is necessary. Understanding the extent to which HIV prevalence differs across communities and the drivers of these differences is crucial to provide an effective, community-specific HIV response. In Rakai, HIV prevalence was 2-3 times higher, and ART use was nearly 50% lower, in fishing communities than in trading and agrarian communities.  However, the areas with the highest number of people living with HIV were in the larger, lower risk populations. One of the challenges of focused treatment and prevention programmes is the identification of geographical areas or sub-populations at highest risk. A better understanding of the community-level heterogeneity and transmission links between high and low risk areas is necessary. In this study, detailed household surveillance and epidemiological data were available; however, such fine-scale data are often not available. This finding of extensive heterogeneity across relatively close and seemingly similar communities has implications for focused approaches to HIV programmes, and demonstrates the importance of strong local HIV surveillance data.

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Real-world barriers to active TB case detection in HIV clinics

Implementation and operational research: use of symptom screening and sputum microscopy testing for active tuberculosis case detection among HIV-infected patients in real-world clinical practice in Uganda.

Roy M, Muyindike W, Vijayan T, Kanyesigye M, Bwana M, Wenger M, Martin J, Geng E. J Acquir Immune Defic Syndr. 2016 Aug 15;72(5):e86-91. doi: 10.1097/QAI.0000000000001067.

Background: The uptake of intensified active TB case-finding among HIV-infected patients using symptom screening is not well understood. We evaluated the rate and completeness of each interim step in the TB pulmonary "diagnostic cascade" to understand real-world barriers to active TB case detection.

Methods: We conducted a cohort analysis of new, antiretroviral therapy-naive, HIV-infected patients who attended a large HIV clinic in Mbarara, Uganda (March 1, 2012-September 30, 2013). We used medical records to extract date of completion of each step in the diagnostic cascade: symptom screen, order, collection, processing, and result. Factors associated with lack of sputum order were evaluated using multivariate Poisson regression and chart review of 50 screen-positive patients.

Results: Of 2613 patients, 2439 (93%) were screened for TB and 682 (28%) screened positive. Only 90 (13.2%) had a sputum order. Of this group, 83% completed the diagnostic cascade, 13% were diagnosed with TB, and 50% had a sputum result within 1 day of their visit. Sputum ordering was associated with WHO stage 3 or 4 HIV disease and greater number of symptoms. The main identifiable reasons for lack of sputum order in chart review were treatment of presumed malaria (51%) or bacterial infection (43%).

Conclusions: The majority of newly enrolled HIV-infected patients who screened positive for suspected TB did not have a sputum order, and those who did were more likely to have more symptoms and advanced HIV disease. Further evaluation of provider behavior in the management of screen-positive patients could improve active TB case detection rates.

Abstract access  

Editor’s notes: This cohort analysis of people enrolling for HIV care at a President’s Emergency Plan for AIDS Relief (PEPFAR) clinic in Uganda used medical record review to identify barriers to active TB case finding in a programmatic setting. This study is unique in evaluating each step along the entire TB diagnostic cascade, from the WHO screening tool, which asks about four symptoms, through to sputum result, in a setting where TB diagnosis was based on sputum microscopy, prior to availability of Xpert ® MTB/RIF.

The authors found high uptake of TB symptom screening at enrolment to HIV care, with cough being the most commonly reported symptom. However, most people with symptoms suggestive of TB were not documented to have had sputum investigation ordered, this being the major point of loss from the TB diagnostic pathway. Given that the prevalence of active TB among people newly testing HIV positive is consistently high in African countries, this represents a substantial missed opportunity for prompt identification and treatment of TB. The study design did not allow in-depth evaluation of the reasons for lack of sputum order since this may not be clearly documented in medical records. Factors such as a person’s inability to produce sputum should also be considered. Ultimately, a high sensitivity, affordable, non-sputum based, point-of-care diagnostic test for TB is necessary to overcome the barriers inherent in the current complex TB diagnostic pathway.

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HIV-exposed uninfected children – why the increased mortality risk?

HIV-exposed children account for more than half of 24-month mortality in Botswana.

Zash R, Souda S, Leidner J, Ribaudo H, Binda K, Moyo S, Powis KM, Petlo C, Mmalane M, Makhema J, Essex M, Lockman S, Shapiro R. BMC Pediatr. 2016 Jul 21;16:103. doi: 10.1186/s12887-016-0635-5.

Background: The contribution of HIV-exposure to childhood mortality in a setting with widespread antiretroviral treatment (ART) availability has not been determined.

Methods: From January 2012 to March 2013, mothers were enrolled within 48 h of delivery at 5 government postpartum wards in Botswana. Participants were followed by phone 1-3 monthly for 24 months. Risk factors for 24-month survival were assessed by Cox proportional hazards modeling.

Results: Three thousand mothers (1499 HIV-infected) and their 3033 children (1515 HIV-exposed) were enrolled. During pregnancy 58% received three-drug ART, 23% received zidovudine alone, 11% received no antiretrovirals (8% unknown); 2.1% of children were HIV-infected by 24 months. Vital status at 24 months was known for 3018 (99.5%) children; 106 (3.5%) died including 12 (38%) HIV-infected, 70 (4.7%) HIV-exposed uninfected, and 24 (1.6%) HIV-unexposed. Risk factors for mortality were child HIV-infection (aHR 22.6, 95% CI 10.7, 47.5), child HIV-exposure (aHR 2.7, 95% CI 1.7, 4.5) and maternal death (aHR 8.9, 95% CI 2.1, 37.1). Replacement feeding predicted mortality when modeled separately from HIV-exposure (aHR 2.3, 95% CI 1.5, 3.6), but colinearity with HIV-exposure status precluded investigation of its independent effect. Applied at the population level (26% maternal HIV prevalence), an estimated 52% of child mortality occurs among HIV-exposed or HIV-infected children.

Conclusions: In a programmatic setting with high maternal HIV prevalence and widespread maternal and child ART availability, HIV-exposed and HIV-infected children still account for most deaths at 24 months. Lack of breastfeeding was a likely contributor to excess mortality among HIV-exposed children.

Abstract  Full-text [free] access 

Editor’s notes: It has been known for some time that HIV-exposed but uninfected children have a higher risk of death than HIV-unexposed children. There is now a need for prospective studies to explore the mechanisms underlying this observation. In this study from Botswana, one of every 20 HIV-exposed but uninfected children had died by 24 months. Four in every five deaths in the HIV-exposed but uninfected children were attributed to infectious diseases, most commonly diarrhoeal illness and respiratory infections.

The analysis was unfortunately not able to unpick the effect of infant feeding on mortality in the HIV-exposed uninfected children. Only 16% of HIV-exposed children were breastfed. This is consistent with national guidelines at the time, where formula feeding was recommended for mothers living with HIV. It is reassuring that in recently updated national guidelines, exclusive breastfeeding for six months is now recommended for mothers living with HIV on ART with virologic suppression.

Mother-to-child HIV transmission at 24 months was still around 2%, and further infections may have been undiagnosed in children who died before being tested. More than one in three children living with HIV died within 24 months. This reminds us that while there is increasing interest in HIV-exposed uninfected children, our priority for now should still be achieving elimination of mother-to-child HIV transmission.

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