Articles tagged as "Epidemiology"

Getting to 90-90-90 in China: where are the gaps?

Disparities in HIV care along the path from infection to viral suppression: a cross-sectional study of HIV/AIDS patient records in 2013, Shandong province, China.

Zhang N, Bussell S, Wang G, Zhu X, Yang X, Huang T, Qian Y, Tao X, Kang D, Wang N. Clin Infect Dis. 2016 Jul 1;63(1):115-21. doi: 10.1093/cid/ciw190. Epub 2016 Mar 29.

Background: The 90-90-90 targets recommended by the Joint United Nations Programme on HIV/AIDS require strengthening human immunodeficiency virus (HIV) care, which includes diagnosis, linkage to and retention in care, assessment for treatment suitability, and optimization of HIV treatment. We sought to quantify patient engagement along the continuum, 10 years after introduction of Chinese HIV care policies.

Methods: We included patients from Shandong, China, who were diagnosed with HIV from 1992 to 2013. Records were obtained from the HIV/AIDS Comprehensive Response Information Management System to populate a 7-step HIV care continuum. Pearson chi2 test and multivariate logistic regression were used for analysis.

Results: Of 6500 estimated HIV-infected persons, 60.1% were diagnosed, of whom 41.9% received highly active antiretroviral therapy (HAART). Only 59.6% of patients on HAART and 15% of all infected persons achieved viral suppression. Children infected by mother-to-child transmission (MTCT) and persons infected by intravenous drug use were less likely to be linked to and retained in care (odds ratio [OR], 0.33 [95% confidence interval {CI}, .14-.80] and OR, 0.58 [95% CI, .40-.90], respectively). Persons tested in custodial institutions were substantially less likely to be on HAART (OR, 0.22 [95% CI, .09-.59]) compared with those tested in medical facilities. Patients on HAART infected by homosexual or heterosexual transmission and those infected by MTCT were less likely to achieve viral suppression (OR, 0.18 [95% CI, .09-.34]; OR, 0.12 [95% CI, .06-.22]; OR, 0.07 [95% CI, .02-.20], respectively).

Conclusions: Our report suggests, at the current rate, Shandong Province has to accelerate HIV care efforts to close disparities in HIV care and achieve the 90-90-90 goals equitably.

Abstract 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 those people on treatment to suppress the virus. This would result in about 73% of all people living with HIV being virally suppressed.

This study estimated coverage of HIV diagnosis, antiretroviral treatment and viral suppression in Shandong Province in 2013, 10 years after the introduction of a Chinese HIV care policy.

The authors found that overall, only about 60% of people on ART and 15% of all people living with HIV achieved viral suppression (defined in this analysis as having a viral load of less than HIV RNA 50 copies per mL). This is in sharp contrast with recently published figures from Botswana where 97% of people on ART, and about 70% of persons living with HIV were virally suppressed (there defined as having a viral load of less than 400 copies per mL).

With only 15% of persons with HIV being virally suppressed in Shandong Province, a big gap remains for reaching the UNAIDS target of 73%. The authors demonstrate that despite a free, inclusive, nationwide HIV care policy, significant inequalities in HIV testing and treatment exist in Shandong Province. For example people who inject drugs and people in custodial institutions were much less likely to be initiated on ART.

The authors conclude that to achieve the 90-90-90 UNAIDS treatment target, Shandong Province needs to close these disparities in HIV care. 

Asia
China
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Accurate country-level data necessary to inform HIV incidence estimates

Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980-2015: the Global Burden of Disease Study 2015.

Wang H, Wolock TM, Carter A, Nguyen G, Kyu HH, Gakidou E, Hay SI, Mills EJ, Trickey A, Msemburi W, Coates MM, Mooney MD, Fraser MS, Sligar A, Salomon J, Larson HJ, Friedman J, Abajobir AA, Abate KH, Abbas KM, Razek MM, Abd-Allah F, Abdulle AM, Abera SF, Abubakar I, Abu-Raddad LJ, Abu-Rmeileh NM, Abyu GY, Adebiyi AO, Adedeji IA, Adelekan AL, Adofo K, Adou AK, Ajala ON, Akinyemiju TF, Akseer N, Lami FH, Al-Aly Z, Alam K, Alam NK, Alasfoor D, Aldhahri SF, Aldridge RW, Alegretti MA, Aleman AV, Alemu ZA, Alfonso-Cristancho R, Ali R, Alkerwi A, Alla F, Mohammad R, Al-Raddadi S, Alsharif U, Alvarez E, Alvis-Guzman N, Amare AT, Amberbir A, Amegah AK, Ammar W, Amrock SM, Antonio CA, Anwari P, Arnlov J, Artaman A, Asayesh H, Asghar RJ, Assadi R, Atique S, Atkins LS, Avokpaho EF, Awasthi A, Quintanilla BP, Bacha U, Badawi A, Barac A, Barnighausen T, Basu A, Bayou TA, Bayou YT, Bazargan-Hejazi S, Beardsley J, Bedi N, Bennett DA, Bensenor IM, Betsu BD, Beyene AS, Bhatia E, Bhutta ZA, Biadgilign S, Bikbov B, Birlik SM, Bisanzio D, Brainin M, Brazinova A, Breitborde NJ, Brown A, Burch M, Butt ZA, Campuzano JC, Cardenas R, Carrero JJ, Castaneda-Orjuela CA, Rivas JC, Catala-Lopez F, Chang HY, Chang JC, Chavan L, Chen W, Chiang PP, Chibalabala M, Chisumpa VH, Choi JY, Christopher DJ, Ciobanu LG, Cooper C, Dahiru T, Damtew SA, Dandona L, Dandona R, das Neves J, de Jager P, De Leo D, Degenhardt L, Dellavalle RP, Deribe K, Deribew A, Des Jarlais DC, Dharmaratne SD, Ding EL, Doshi PP, Driscoll TR, Dubey M, Elshrek YM, Elyazar I, Endries AY, Ermakov SP, Eshrati B, Esteghamati A, Faghmous ID, Farinha CS, Faro A, Farvid MS, Farzadfar F, Fereshtehnejad SM, Fernandes JC, Fischer F, Fitchett JR, Foigt N, Fullman N, Furst T, Gankpe FG, Gebre T, Gebremedhin AT, Gebru AA, Geleijnse JM, Gessner BD, Gething PW, Ghiwot TT, Giroud M, Gishu MD, Glaser E, Goenka S, Goodridge A, Gopalani SV, Goto A, Gugnani HC, Guimaraes MD, Gupta R, Gupta R, Gupta V, Haagsma J, Hafezi-Nejad N, Hagan H, Hailu GB, Hamadeh RR, Hamidi S, Hammami M, Hankey GJ, Hao Y, Harb HL, Harikrishnan S, Haro JM, Harun KM, Havmoeller R, Hedayati MT, Heredia-Pi IB, Hoek HW, Horino M, Horita N, Hosgood HD, Hoy DG, Hsairi M, Hu G, Huang H, Huang JJ, Iburg KM, Idrisov BT, Innos K, Iyer VJ, Jacobsen KH, Jahanmehr N, Jakovljevic MB, Javanbakht M, Jayatilleke AU, Jeemon P, Jha V, Jiang G, Jiang Y, Jibat T, Jonas JB, Kabir Z, Kamal R, Kan H, Karch A, Karema CK, Karletsos D, Kasaeian A, Kaul A, Kawakami N, Kayibanda JF, Keiyoro PN, Kemp AH, Kengne AP, Kesavachandran CN, Khader YS, Khalil I, Khan AR, Khan EA, Khang YH, Khubchandani J, Kim YJ, Kinfu Y, Kivipelto M, Kokubo Y, Kosen S, Koul PA, Koyanagi A, Defo BK, Bicer BK, Kulkarni VS, Kumar GA, Lal DK, Lam H, Lam JO, Langan SM, Lansingh VC, Larsson A, Leigh J, Leung R, Li Y, Lim SS, Lipshultz SE, Liu S, Lloyd BK, Logroscino G, Lotufo PA, Lunevicius R, Razek HM, Mahdavi M, Majdan M, Majeed A, Makhlouf C, Malekzadeh R, Mapoma CC, Marcenes W, Martinez-Raga J, Marzan MB, Masiye F, Mason-Jones AJ, Mayosi BM, McKee M, Meaney PA, Mehndiratta MM, Mekonnen AB, Melaku YA, Memiah P, Memish ZA, Mendoza W, Meretoja A, Meretoja TJ, Mhimbira FA, Miller TR, Mikesell J, Mirarefin M, Mohammad KA, Mohammed S, Mokdad AH, Monasta L, Moradi-Lakeh M, Mori R, Mueller UO, Murimira B, Murthy GV, Naheed A, Naldi L, Nangia V, Nash D, Nawaz H, Nejjari C, Ngalesoni FN, de Dieu Ngirabega J, Nguyen QL, Nisar MI, Norheim OF, Norman RE, Nyakarahuka L, Ogbo FA, Oh IH, Ojelabi FA, Olusanya BO, Olusanya JO, Opio JN, Oren E, Ota E, Padukudru MA, Park HY, Park JH, Patil ST, Patten SB, Paul VK, Pearson K, Peprah EK, Pereira CC, Perico N, Pesudovs K, Petzold M, Phillips MR, Pillay JD, Plass D, Polinder S, Pourmalek F, Prokop DM, Qorbani M, Rafay A, Rahimi K, Rahimi-Movaghar V, Rahman M, Rahman MH, Rahman SU, Rai RK, Rajsic S, Ram U, Rana SM, Rao PV, Remuzzi G, Rojas-Rueda D, Ronfani L, Roshandel G, Roy A, Ruhago GM, Saeedi MY, Sagar R, Saleh MM, Sanabria JR, Santos IS, Sarmiento-Suarez R, Sartorius B, Sawhney M, Schutte AE, Schwebel DC, Seedat S, Sepanlou SG, Servan-Mori EE, Shaikh. Lancet HIV. 2016 Aug;3(8):e361-87. doi: 10.1016/S2352-3018(16)30087-X. Epub 2016 Jul 19.

Background: Timely assessment of the burden of HIV/AIDS is essential for policy setting and programme evaluation. In this report from the Global Burden of Disease Study 2015 (GBD 2015), we provide national estimates of levels and trends of HIV/AIDS incidence, prevalence, coverage of antiretroviral therapy (ART), and mortality for 195 countries and territories from 1980 to 2015.

Methods: For countries without high-quality vital registration data, we estimated prevalence and incidence with data from antenatal care clinics and population-based seroprevalence surveys, and with assumptions by age and sex on initial CD4 distribution at infection, CD4 progression rates (probability of progression from higher to lower CD4 cell-count category), on and off antiretroviral therapy (ART) mortality, and mortality from all other causes. Our estimation strategy links the GBD 2015 assessment of all-cause mortality and estimation of incidence and prevalence so that for each draw from the uncertainty distribution all assumptions used in each step are internally consistent. We estimated incidence, prevalence, and death with GBD versions of the Estimation and Projection Package (EPP) and Spectrum software originally developed by the Joint United Nations Programme on HIV/AIDS (UNAIDS). We used an open-source version of EPP and recoded Spectrum for speed, and used updated assumptions from systematic reviews of the literature and GBD demographic data. For countries with high-quality vital registration data, we developed the cohort incidence bias adjustment model to estimate HIV incidence and prevalence largely from the number of deaths caused by HIV recorded in cause-of-death statistics. We corrected these statistics for garbage coding and HIV misclassification.

Findings: Global HIV incidence reached its peak in 1997, at 3.3 million new infections (95% uncertainty interval [UI] 3.1-3.4 million). Annual incidence has stayed relatively constant at about 2.6 million per year (range 2.5-2.8 million) since 2005, after a period of fast decline between 1997 and 2005. The number of people living with HIV/AIDS has been steadily increasing and reached 38.8 million (95% UI 37.6-40.4 million) in 2015. At the same time, HIV/AIDS mortality has been declining at a steady pace, from a peak of 1.8 million deaths (95% UI 1.7-1.9 million) in 2005, to 1.2 million deaths (1.1-1.3 million) in 2015. We recorded substantial heterogeneity in the levels and trends of HIV/AIDS across countries. Although many countries have experienced decreases in HIV/AIDS mortality and in annual new infections, other countries have had slowdowns or increases in rates of change in annual new infections.

Interpretation: Scale-up of ART and prevention of mother-to-child transmission has been one of the great successes of global health in the past two decades. However, in the past decade, progress in reducing new infections has been slow, development assistance for health devoted to HIV has stagnated, and resources for health in low-income countries have grown slowly. Achievement of the new ambitious goals for HIV enshrined in Sustainable Development Goal 3 and the 90-90-90 UNAIDS targets will be challenging, and will need continued efforts from governments and international agencies in the next 15 years to end AIDS by 2030.

Abstract  Full-text [free] access

Editor’s notes: The global estimates for HIV incidence, prevalence, and deaths produced by the Global Burden of Disease (GBD) mathematical modelling approach for 2015 are somewhat higher than those published by UNAIDS in June 2016 prior to the International Conference on AIDS held in Durban in July. Both GBD and UNAIDS agree that as the scale-up of antiretroviral treatment (ART) continues, HIV-associated mortality is declining with the result that HIV prevalence is rising as the number of people living with HIV continues to grow. The metric of critical interest to policy makers and programme planners is HIV incidence, the number of new infections. Each new infection means ART for life, starting from HIV diagnosis now rather than later in disease progression. Both GBD and UNAIDS estimates suggest that globally annual HIV incidence stopped declining after 2005 and has remained persistently high at 2.5 million (2.2-2.7 million) according to GDB and 2.1 million (1.8-2.4 million) according to UNAIDS. Where the estimates differ is at country level, precisely where they can make the most difference to decision making. GBD estimates for HIV incidence for countries in the regions of northern America, Europe, Australasia, and central Asia are significantly lower than the reported numbers of newly diagnosed cases (see the comparison table in the Lancet commentary by Supervie and Costagliola. For example, 85 252 people were newly diagnosed with HIV in the Russian federation in 2014 whereas the GBD estimate for people newly acquiring HIV in 2015 was only 57 340, albeit with a wide range of uncertainly. For the United States of America, the uncertainly bounds around the GBD estimate of 23 040 do not include 44,073, the number of newly diagnosed cases. Furthermore, new diagnoses likely underestimate actual HIV incidence as they include people who acquired HIV in previous years. Estimates for some high prevalence countries are significantly higher than those produced by those countries with UNAIDS support. For example, http://aidsinfo.unaids.org/ illustrates South Africa as having 380 000 (330 000-430 000) new infections while GBD estimates 529 670 (440 940 to 630 390). Modelling estimates are simply estimates but they cannot be confirmatory or even complementary when they are so different. UNAIDS and IHME (GBD) are already working to understand the differences in the two mathematical modelling approaches - their methodologies, parameters, and assumptions - in order to explain important discrepancies at country level. More importantly, improved data collection by countries of the numbers of HIV diagnoses, people accessing and staying on ART, and the proportion of people living with HIV who achieve viral suppression is necessary to monitor progress towards the UNAIDS 90-90-90 treatment target. Enhanced clinical and epidemiological surveillance systems are also key to the creation of more accurate estimates of country HIV incidence, the metric that reflects HIV prevention programme progress and informs budget allocations and programme planning for HIV treatment. 

195 countries
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Less than half of HIV-positive people identified through HBTC link to care in large community study in KwaZulu-Natal

 Access to HIV care in the context of universal test and treat: challenges within the ANRS 12249 TasP cluster-randomized trial in rural South Africa.

Plazy M, Farouki KE, Iwuji C, Okesola N, Orne-Gliemann J, Larmarange J, Lert F, Newell ML, Dabis F, Dray-Spira R. J Int AIDS Soc. 2016 Jun 1;19(1):20913. doi: 10.7448/IAS.19.1.20913. eCollection 2016.

Introduction: We aimed to quantify and identify associated factors of linkage to HIV care following home-based HIV counselling and testing (HBHCT) in the ongoing ANRS 12249 treatment-as-prevention (TasP) cluster-randomized trial in rural KwaZulu-Natal, South Africa.

Methods: Individuals ≥16 years were offered HBHCT; those who were identified HIV positive were referred to cluster-based TasP clinics and offered antiretroviral treatment (ART) immediately (five clusters) or according to national guidelines (five clusters). HIV care was also available in the local Department of Health (DoH) clinics. Linkage to HIV care was defined as TasP or DoH clinic attendance within three months of referral among adults not in HIV care at referral. Associated factors were identified using multivariable logistic regression adjusted for trial arm.

Results: Overall, 1323 HIV-positive adults (72.9% women) not in HIV care at referral were included, of whom 36.9% (n=488) linked to care <3 months of referral (similar by sex). In adjusted analyses (n=1222), individuals who had never been in HIV care before referral were significantly less likely to link to care than those who had previously been in care (<33% vs. >42%, p<0.001). Linkage to care was lower in students (adjusted odds-ratio [aOR]=0.47; 95% confidence interval [CI] 0.24-0.92) than in employed adults, in adults who completed secondary school (aOR=0.68; CI 0.49-0.96) or at least some secondary school (aOR=0.59; CI 0.41-0.84) versus ≤ primary school, in those who lived at 1 to 2 km (aOR=0.58; CI 0.44-0.78) or 2-5 km from the nearest TasP clinic (aOR=0.57; CI 0.41-0.77) versus <1 km, and in those who were referred to clinic after ≥2 contacts (aOR=0.75; CI 0.58-0.97) versus those referred at the first contact. Linkage to care was higher in adults who reported knowing an HIV-positive family member (aOR=1.45; CI 1.12-1.86) versus not, and in those who said that they would take ART as soon as possible if they were diagnosed HIV positive (aOR=2.16; CI 1.13-4.10) versus not.

Conclusions: Fewer than 40% of HIV-positive adults not in care at referral were linked to HIV care within three months of HBHCT in the TasP trial. Achieving universal test and treat coverage will require innovative interventions to support linkage to HIV care.

Abstract  Full-text [free] access 

Editor’s notes: The UNAIDS treatment target set for 2020 aims 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 manuscript describes the linkage to care after being diagnosed HIV- positive during home based testing and counselling (HBTC) in a Treatment as Prevention trial in Kwazulu-Natal, South Africa. About 30% of consenting participants were HIV-positive. Some 43% of these participants were new diagnoses, 26% had previously been diagnosed but never accessed care, and about 31% had already accessed HIV care but dropped out of care. The authors found disappointingly low linkage proportions: fewer than 40% of participants diagnosed through HBTC accessed an HIV clinic within three months of referral. 

Although stigma is a commonly cited barrier to adherence, the authors did not find an association between perceived stigma and linkage to care. They did find that people with HIV-positive family members were more likely to access HIV care than people who did not, and suggest that this might be because they are more confident in disclosing their status and more likely to receive family support.

These findings are particularly relevant in the context of the results of the parent Treatment as Prevention trial, which were reported at the AIDS2016 conference in Durban. The trial found no effect on HIV incidence of offering immediate ART, mainly due to the low rates of linkage to care following HIV diagnosis. This underscores that while HBTC is useful to ensure that HIV-positive people know their status, further programmes are necessary to maximise the number of people linked to care and initiating ART.

Africa
South Africa
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Unique needs of gay men in sub-Saharan Africa identified with respondent-driven sampling

Respondent-driven sampling as a recruitment method for men who have sex with men in southern sub-Saharan Africa: a cross-sectional analysis by wave.

Stahlman S, Johnston LG, Yah C, Ketende S, Maziya S, Trapence G, Jumbe V, Sithole B, Mothopeng T, Mnisi Z, Baral S. Sex Transm Infect. 2016 Jun;92(4):292-8. doi: 10.1136/sextrans-2015-052184. Epub 2015 Sep 30.

Objectives: Respondent-driven sampling (RDS) is a popular method for recruiting men who have sex with men (MSM). Our objective is to describe the ability of RDS to reach MSM for HIV testing in three southern African nations.

Methods: Data collected via RDS among MSM in Lesotho (N=318), Swaziland (N=310) and Malawi (N=334) were analysed by wave in order to characterise differences in sample characteristics. Seeds were recruited from MSM-affiliated community-based organisations. Men were interviewed during a single study visit and tested for HIV. X2 tests for trend were used to examine differences in the proportions across wave category.

Results: A maximum of 13-19 recruitment waves were achieved in each study site. The percentage of those who identified as gay/homosexual decreased as waves increased in Lesotho (49% to 27%, p<0.01). In Swaziland and Lesotho, knowledge that anal sex was the riskiest type of sex for HIV transmission decreased across waves (39% to 23%, p<0.05, and 37% to 19%, p<0.05). The percentage of participants who had ever received more than one HIV test decreased across waves in Malawi (31% to 12%, p<0.01). In Lesotho and Malawi, the prevalence of testing positive for HIV decreased across waves (48% to 15%, p<0.01 and 23% to 11%, p<0.05). Among those living with HIV, the proportion of those unaware of their status increased across waves in all study sites although this finding was not statistically significant.

Conclusions: RDS that extends deeper into recruitment waves may be a promising method of reaching MSM with varying levels of HIV prevention needs.

Abstract access  

Editor’s notes: The HIV risk profile of gay men and other men who have sex with men have not been well-characterised within sub-Saharan African countries. These key populations are traditionally difficult to reach for purposes of estimating the prevalence of HIV and of behavioural risk factors, and for prevention outreach. This study enrolled recruiters from community based organizations which served gay men and other men who have sex with men in Malawi, Lesotho and Swaziland. Each of these ‘seeds’ could recruit up to three participants. Each subsequent participant could recruit another three participants into a new ‘wave’. The profiles of participants changed in each setting with each additional recruitment wave. Men in Swaziland were less likely to know that anal sex was the riskiest type of sex, men in Malawi were less likely to have ever tested for HIV, and men in Lesotho were less likely to have disclosed their sexual orientation to family members. This type of respondent-driven sampling can be replicated to identify men who are removed from community-based organisations, and to identify their unique service needs. Future research can consider whether the hardest-to-reach men are also people at highest risk of HIV infection.

Africa
Lesotho, Malawi, Swaziland
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Does place of sex change risk behaviours among men who have sex with men?

Is location of sex associated with sexual risk behaviour in men who have sex with men? Systematic review of within-subjects studies.

Melendez-Torres GJ, Nye E, Bonell C. AIDS Behav. 2016 Jun;20(6):1219-27. doi: 10.1007/s10461-015-1093-z.

To understand associations between location of sex and sexual risk, it is most helpful to compare sexual encounters within persons. We systematically reviewed within-subjects comparisons of sexual encounters reported by men who have sex with men (MSM) with respect to location of sex. Within-subjects comparisons of sexual risk and location of sex were eligible if they collected data post-1996 from samples of MSM. We independently screened results and full-text records in duplicate. Of 6336 de-duplicated records, we assessed 138 full-text studies and included six, most of which compared unprotected anal intercourse against other anal intercourse. This small, but high quality, body of evidence suggests that associations between attendance at sex-on-premises venues and person-level sexual risk may be due to overall propensity towards unprotected sex. However, there may be some location factors that promote or are associated with serononconcordant unprotected anal intercourse. Health promoters may wish to focus on person-level characteristics.

Abstract access

Editor’s notes: Venues where gay men and other men who have sex with men, have sex, fit broadly into three categories. These are: i) sex-on premises venues (indoor locations outside the home e.g. bathhouses, saunas, sex clubs, porn cinemas, public sex parties), ii) public sex environments (cruising locations / beats e.g. outdoor parks) and iii) homes of sexual partners. Men will usually have anonymous sexual encounters or sex with casual partners in the first two location categories. Use of specific locations for sex may be associated with specific sexual risk-taking at the person level. However, it is unclear if sexual risk is greater in certain venues compared to others. Is there a ‘location effect’ on sexual risk? Or put in a different way, does the same person behave differently (in terms of sexual risk), depending on the venue where they are having sex? To examine this, it is necessary to compare several sexual encounters within respondents at different sex locations. The authors of this paper systematically reviewed studies which reported within-subjects comparisons analysing the encounter-level association between location of sex and sexual risk behaviours among gay men and other men who have sex with men.

Six studies were included in the final review – four from the United States and two from Australia. It was not possible to conduct a meta-analysis due to differences in defining venue and sexual risk behaviours. Overall, the authors found little evidence of differences between condomless versus protected anal intercourse between public and private locations for sex. Additional studies are necessary, including how smartphone-mediated sex seeking is changing the locations and risk environment where gay men and other men will have sex with men. Research from other countries and contexts is also warranted.    

Northern America, Oceania
Australia, United States of America
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Ending deaths in people with TB and HIV – still some way to go

High mortality in tuberculosis patients despite HIV interventions in Swaziland.

Mchunu G, van Griensven J, Hinderaker SG, Kizito W, Sikhondze W, Manzi M, Dlamini T, Harries AD. Public Health Action. 2016 Jun 21;6(2):105-10. doi: 10.5588/pha.15.0081.

Setting: All health facilities providing tuberculosis (TB) care in Swaziland.

Objective: To describe the impact of human immunodeficiency virus (HIV) interventions on the trend of TB treatment outcomes during 2010-2013 in Swaziland; and to describe the evolution in TB case notification, the uptake of HIV testing, antiretroviral therapy (ART) and cotrimoxazole preventive therapy (CPT), and the proportion of TB-HIV co-infected patients with adverse treatment outcomes, including mortality, loss to follow-up and treatment failure.

Design: A retrospective descriptive study using aggregated national TB programme data.

Results: Between 2010 and 2013, TB case notifications in Swaziland decreased by 40%, HIV testing increased from 86% to 96%, CPT uptake increased from 93% to 99% and ART uptake among TB patients increased from 35% to 75%. The TB-HIV co-infection rate remained around 70% and the proportion of TB-HIV cases with adverse outcomes decreased from 36% to 30%. Mortality remained high, at 14-16%, over the study period, and anti-tuberculosis treatment failure rates were stable over time (<5%).

Conclusion: Despite high CPT and ART uptake in TB-HIV patients, mortality remained high. Further studies are required to better define high-risk patient groups, understand the reasons for death and design appropriate interventions.

Abstract  Full-text [free] access 

Editor’s notes: This article adds to the body of evidence describing a reduction in TB case notifications at national level at a time of increasing coverage of antiretroviral therapy. Despite the apparent strengthening of the HIV treatment cascade in people with TB, mortality remained high. Around one in seven people with TB and HIV died during TB treatment, and additional deaths may have occurred in people lost to follow-up or with no outcome evaluation.

This analysis using aggregated data does not allow for detailed understanding of why people with TB and HIV died. The authors raise a number of important questions arising from these results. To achieve World Health Organization End TB target of reducing TB deaths by 90% by 2030, we need to understand where to focus resources for maximum impact.

Although not the focus of this paper, it is notable that there appeared to be a relatively stable TB case notification rate in HIV negative people across the four-year study period. This is a reminder that although TB/HIV programmes may be the key to reducing TB mortality, broader population-level programmes to interrupt TB transmission will be required to drive down TB incidence rates.           

Africa
Swaziland
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Substantial morbidity despite preserved CD4 count in children with slow-progressing HIV

Chronic morbidity among older children and adolescents at diagnosis of HIV infection.

McHugh G, Rylance J, Mujuru H, Nathoo K, Chonzi P, Dauya E, Bandason T, Simms V, Kranzer K, Ferrand RA. J Acquir Immune Defic Syndr. 2016 May 11. [Epub ahead of print]. doi: 10.1097/QAI.0000000000001073

Background: Substantial numbers of children with HIV present to health care services in older childhood and adolescence, previously undiagnosed. These "slow-progressors" may experience considerable chronic ill-health, which is not well-characterised. We investigated the prevalence of chronic morbidity among children aged 6-15 years at diagnosis of HIV infection.

Methods: A cross sectional study was performed at seven primary care clinics in Harare, Zimbabwe. Children aged 6-15 years who tested HIV positive following provider-initiated HIV testing and counselling were recruited. A detailed clinical history and standardised clinical examination was undertaken. The association between chronic disease and CD4 count was investigated using multivariate logistic regression.

Results: Of the 385 participants recruited (52% female, median age 11 years (IQR 8-13)), 95% were perinatally HIV-infected. The median CD4 count was 375 (IQR 215-599) cells/mm3. Although 78% had previous contact with health care services, HIV testing had not been performed. There was a high burden of chronic morbidity: 23% were stunted, 21% had pubertal delay, 25% had chronic skin disease, 54% had a chronic cough of more than 1 month's duration, 28% had abnormal lung function and 12% reported hearing impairment. There was no association between CD4 count of <500cells/mm3 or <350 cells/mm3 with WHO stage or these chronic conditions.

Conclusion: In children with slow-progressing HIV, there is a substantial burden of chronic morbidity even when CD4 count is relatively preserved. Timely HIV testing and prompt ART initiation are urgently needed to prevent development of chronic complications.

Abstract  Full-text [free] access

Editor’s notes: Substantial numbers of infants who have perinatally acquired HIV are presenting with HIV infection in later childhood or adolescence. It is estimated that a third of infants living with HIV are ‘slow-progressors’ with a median survival of 16 years. This study found a large burden of chronic morbidity among older children and adolescent at the time of HIV diagnosis.   Interestingly, no association between CD4 count and WHO HIV disease stage was seen. Children with slow-progressing disease still appear go on to develop poor growth and chronic lung and skin disease despite preserved CD4 counts. Up until recently many of these children would not have been eligible to start ART based on the WHO 2013 HIV treatment guidelines. Recent changes to WHO guidelines recommending immediate ART for all, including older children, will hopefully reduce the risk of development of chronic complications in this population. Improved outcomes will only occur with timely diagnosis which requires increasing awareness of the burden of undiagnosed HIV disease, strengthening provider-initiated HIV testing and counselling and improving retention in ART care in this vulnerable age group.

Africa
Zimbabwe
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ART reduces, but does not eliminate, HIV transmission in serodiscordant couples in a real-world setting

Antiretroviral therapy to prevent HIV acquisition in serodiscordant couples in a hyperendemic community in rural South Africa.  

Oldenburg CE, Barnighausen T, Tanser F, Iwuji CC, De Gruttola V, Seage GR, 3rd, Mimiaga MJ, Mayer KH, Pillay D, Harling G. Clin Infect Dis. 2016 May 20. pii: ciw335. [Epub ahead of print]

Background: Antiretroviral therapy (ART) was highly efficacious in preventing HIV transmission in stable serodiscordant couples in the HPTN-052 study, a resource-rich randomized controlled trial. However, minimal evidence exists of the effectiveness of ART in preventing HIV acquisition in stable serodiscordant couples in real-life population-based settings in hyperendemic communities of sub-Saharan Africa, where health systems are typically resource-poor and overburdened, adherence to ART is suboptimal, and HIV status disclosure to sexual partners is inconsistent.

Methods: Data arose from a population-based open cohort in KwaZulu-Natal, South Africa. HIV-uninfected individuals present between January 2005 and December 2013 (n=17 016) were included. Interval-censored time-updated proportional hazards regression was used to assess how the ART status affected HIV transmission risk in stable serodiscordant relationships.

Results: Of 17 016 individuals, 1846 had an HIV-uninfected and 196 had an HIV-infected stable partner over the follow-up period. HIV incidence was 3.8 per 100 person-years (100PY) among individuals with an HIV-infected partner (95% confidence interval [CI] 2.3-5.6), corresponding to 1.4 per 100PY (95% CI 0.4-3.5) among those with HIV-infected partners on ART and 5.6 per 100PY (95% CI 3.5-8.4) among those with partners not on ART. Use of ART was associated with a 77% decrease in HIV acquisition risk amongst serodiscordant couples (aHR=0.23, 95% CI 0.07-0.80).

Conclusions: ART initiation was associated with a very large reduction in HIV acquisition in serodiscordant couples in rural KwaZulu-Natal. However, real-life effectiveness was substantially lower than in the HPTN-052 trial. To eliminate HIV transmission in serodiscordant couples, additional prevention interventions are likely needed.

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Editor’s notes: The landmark HPTN-052 multi-country trial among stable serodiscordant couples demonstrated that antiretroviral therapy (ART) substantially lowers the probability of transmission from HIV-positive people to their HIV-negative partners. However, the magnitude of effect of ART on transmission may not be generalisable to population level because in real-life settings, partnerships may not be stable, and there are operational challenges to programmatic delivery of ART at scale.

This study estimated the transmission risk in stable, serodiscordant couples, in a real-life setting in rural KwaZulu-Natal. The study included all stable serodiscordant couples in the community, whereas HPTN-052 enrolled individuals who presented to health services, and restricted recruitment to HIV-positive participants who disclosed their positive status to their partner.

The authors found that ART was associated with a decrease of 77% in transmission risk in this real-world setting, compared to a decrease of about 89% among people who immediately initiated ART in the HPTN-052 study.

The authors attributed this reduced effect size to a higher number of missed visits and lower adherence to ART in a real-life setting compared to the controlled trial. They also found fewer HIV-positive people with virologic suppression (77%, versus about 90% in the HPTN-052 trial) and lower disclosure rates (disclosure of HIV status to their partner was a requirement for inclusion in the trial).

The authors conclude that ART is highly effective in preventing HIV transmission in stable serodiscordant couples, but that to eliminate HIV transmission, additional preventive measures are necessary. 

Epidemiology, treatment
Africa
South Africa
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Routine programmatic data used to estimate HIV incidence and service uptake among female sex workers in Zimbabwe

Implementation and operational research: cohort analysis of program data to estimate HIV incidence and uptake of HIV-related services among female sex workers in Zimbabwe, 2009-2014.

Hargreaves JR, Mtetwa S, Davey C, Dirawo J, Chidiya S, Benedikt C, Naperiela Mavedzenge S, Wong-Gruenwald R, Hanisch D, Magure T, Mugurungi O, Cowan FM. J Acquir Immune Defic Syndr. 2016 May 1;72(1):e1-8. doi: 10.1097/QAI.0000000000000920.

Background: HIV epidemiology and intervention uptake among female sex workers (FSW) in sub-Saharan Africa remain poorly understood. Data from outreach programs are a neglected resource.

Methods: Analysis of data from FSW consultations with Zimbabwe's National Sex Work program, 2009-2014. At each visit, data were collected on sociodemographic characteristics, HIV testing history, HIV tests conducted by the program and antiretroviral (ARV) history. Characteristics at first visit and longitudinal data on program engagement, repeat HIV testing, and HIV seroconversion were analyzed using a cohort approach.

Results: Data were available for 13 360 women, 31 389 visits, 14 579 reported HIV tests, 2750 tests undertaken by the program, and 2387 reported ARV treatment initiations. At first visit, 72% of FSW had tested for HIV; 50% of these reported being HIV positive. Among HIV-positive women, 41% reported being on ARV. 56% of FSW attended the program only once. FSW who had not previously had an HIV-positive test had been tested within the last 6 months 27% of the time during follow-up. After testing HIV positive, women started on ARV at a rate of 23/100 person years of follow-up. Among those with 2 or more HIV tests, the HIV seroconversion rate was 9.8/100 person years of follow-up (95% confidence interval: 7.1 to 15.9).

Conclusions: Individual-level outreach program data can be used to estimate HIV incidence and intervention uptake among FSW in Zimbabwe. Current data suggest very high HIV prevalence and incidence among this group and help identify areas for program improvement. Further methodological validation is required.

Abstract access

Editor’s notes: Female sex workers in resource poor regions have been shown to have higher levels of HIV incidence and prevalence than people in the general population. Due to the highly stigmatised and often illegal nature of their work, these individuals are often marginalised in society. This can lead to poor engagement with the HIV testing and treatment programmes provided for the general population. Targeted outreach programmes for female sex workers such as the “Sisters for Change” programme in Zimbabwe described in this paper, aim to improve the engagement with testing and care for this group.

Collecting reliable data from female sex workers using a convenience sampling approach in order to estimate the prevalence of HIV is challenging due to the difficulty in ensuring the survey sample is representative of the wider female sex worker population. An alternative approach is respondent driven sampling (RDS) in which respondents recruit their peers to produce a generally representative sample of hard-to-reach populations. The results from RDS are however complex to analyse and interpret.

This paper presents an alternative approach using routinely collected data. Using the dates of programme visits, HIV tests (conducted both within and outside of the programme) and dates of antiretroviral initiation, the researchers generated estimates of HIV prevalence (number of positive tests/total number of tests) and HIV incidence (time at risk calculated from the first visit to an imputed date of seroconversion). They also identified risk factors associated with socio-demographic parameters or HIV testing history that were associated with a failure to continue engagement with the programme after a first visit. The prevalence and incidence results are consistent with results from a series of RDS surveys previously conducted in Zimbabwe by this research team.

A difficulty highlighted by the authors is that while this method improves on convenience sampling, it is still difficult to know how HIV incidence and prevalence among programme participants compares to that in the wider female sex worker population. 

In summary this paper presents an approach by which similar programmes elsewhere could make better use of routinely collected data in order to generate estimates of impact and also identify sub-groups of female sex workers with poorer engagement with care. This in turn could lead to a more effective targeting of limited resources.

Africa
Zimbabwe
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How research can both provide evidence of burden of disease and facilitate access to services

Integrated respondent-driven sampling and peer support for persons who inject drugs in Haiphong, Vietnam: a case study with implications for interventions.

Des Jarlais D, Duong HT, Pham Minh K, Khuat OH, Nham TT, Arasteh K, Feelemyer J, Heckathorn DD, Peries M, Moles JP, Laureillard D, Nagot N. AIDS Care. 2016 May 13:1-4. [Epub ahead of print]

Combined prevention for HIV among persons who inject drugs (PWID) has led to greatly reduced HIV transmission among PWID in many high-income settings, but these successes have not yet been replicated in resource-limited settings. Haiphong, Vietnam experienced a large HIV epidemic among PWID, with 68% prevalence in 2006. Haiphong has implemented needle/syringe programs, methadone maintenance treatment (MMT), and anti-retroviral treatment (ART), but there is an urgent need to identify high-risk PWID and link them to services. We examined integration of respondent-driven sampling (RDS) and strong peer support groups as a mechanism for identifying high-risk PWID and linking them to services. The peer support staff performed the key tasks that required building and maintaining trust with the participants, including recruiting the RDS seeds, greeting and registering participants at the research site, taking electronic copies of participant fingerprints (to prevent multiple participation in the study), and conducting urinalyses. A 6-month cohort study with 250 participants followed the RDS cross-sectional study. The peer support staff maintained contact with these participants, tracking them if they missed appointments, and providing assistance in accessing methadone and ART. The RDS recruitment was quite rapid, with 603 participants recruited in three weeks. HIV prevalence was 25%, Hepatitis C (HCV) prevalence 67%, and participants reported an average of 2.7 heroin injections per day. Retention in the cohort study was high, with 86% of participants re-interviewed at 6-month follow-up. Assistance in accessing services led to half of the participants in need of methadone enrolled in methadone clinics, and half of HIV-positive participants in need of ART enrolled in HIV clinics by the 6-month follow-up. This study suggests that integrating large-scale RDS and strong peer support may provide a method for rapidly linking high-risk PWID to combined prevention and care, and greatly reducing HIV transmission among PWID in resource-limited settings.

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Editor’s notes: This paper highlights that evidence on the effectiveness of harm reduction programmes including opioid substitution therapy, needle-syringe programmes and antiretroviral therapy, alone, and in combination have been shown to be effective in reducing incidence of HIV and hepatitis C in Europe, northern America and Australia. But evidence is lacking in countries with the largest or growing populations of people who inject drugs and high prevalence of HIV and hepatitis C. This is particularly true in low-income settings including South-East Asia and East Africa. But this is also true in high income countries such as the Russian Federation which has the fastest growing epidemic of HIV in the world, primarily among people who inject drugs. But opioid substitution therapy is prohibited. The paper is methodologically interesting. It demonstrates the feasibility of following-up a cohort of people who inject drugs over six months. More importantly, it illustrates how research can be used to link the most vulnerable members of the population, including people who inject frequently and people living with HIV who are not on treatment, into opioid substitution therapy and HIV treatment services. As well as demonstrating the practical use of research in increasing access to services, the research is also important for advocacy purposes. The authors illustrate the burden of HIV and hepatitis C among the population, further highlighting the need for harm reduction services and HIV/hepatitis C treatment. 

Asia
Viet Nam
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