Articles tagged as "Epidemiology"

Does having an older male partner actually protect women over 30 in KwaZulu-Natal?

Partner age-disparity and HIV incidence risk for older women in rural South Africa.

Harling G, Newell ML, Tanser F, Barnighausen T. AIDS Behav. 2015 Feb 11. [Epub ahead of print]

While sexual partner age disparity is frequently considered as a potential risk factor for HIV among young women in Africa, no research has addressed this question among older women. Our aim was thus to determine whether sex partner age disparity was associated with subsequent HIV acquisition in women over 30 years of age. To achieve this aim we conducted a quantitative analysis of a population-based, open cohort of women in rural KwaZulu-Natal, South Africa (n = 1737) using Cox proportional hazards models. As partner age rose, HIV acquisition risk fell significantly: compared to a same-aged partner, a 5-year older partner was associated with a one-third reduction [hazard ratio (HR) 0.63, 95 % CI 0.52-0.76] and a 10-year older partner with a one-half reduction (HR 0.48, 95 % CI 0.35-0.67) in acquisition risk. This result was neither confounded nor effect-modified by women's age or socio-demographic factors. These findings suggest that existing HIV risk-reduction campaigns warning young women about partnering with older men may be inappropriate for older women. HIV prevention strategies interventions specifically tailored to older women are needed.

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Editor’s notes: The effect of partner age disparity is important for the dynamics of HIV transmission. This is because of the potential of transmission across generations, and also that it may reflect power imbalances with associated vulnerabilities and risks. This study is the first to assess HIV risk and partner age disparity in women between the ages of 30 and 50 years. As might be expected, the associations are different to those generally found in young women where having an older partner typically increases HIV risk. In this study, having a partner five years older reduces HIV risk by one third, and having a partner 10 years older reduces HIV risk by half. This is not surprising for several reasons, including that HIV prevalence decreases with older age. But it highlights the need for HIV prevention campaigns that advocate for women to avoid older men, to be nuanced by the age of the woman.  However, it is also notable that in this population, a previous paper showed no evidence of an association of partner age disparity and HIV risk for women aged 15-29. The results illustrate the need to continue to broaden and improve HIV prevention programming and to tailor prevention messages for different age groups, as the traditional ‘risky behaviours’ for young women may not be appropriate for older ages.

Africa
South Africa
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Stigma, alcohol dependence and consulting traditional doctors associated with non-adherence to ART

Incomplete adherence among treatment-experienced adults on antiretroviral therapy in Tanzania, Uganda and Zambia.

Denison JA, Koole O, Tsui S, Menten J, Torpey K, van Praag E, Mukadi YD, Colebunders R, Auld AF, Agolory S, Kaplan JE, Mulenga M, Kwesigabo GP, Wabwire-Mangen F, Bangsberg DR. AIDS. 2015 Jan 28;29(3):361-71. doi: 10.1097/QAD.0000000000000543.

Objectives: To characterize antiretroviral therapy (ART) adherence across different programmes and examine the relationship between individual and programme characteristics and incomplete adherence among ART clients in sub-Saharan Africa.

Design: A cross-sectional study.

Methods: Systematically selected ART clients (≥18 years; on ART ≥6 months) attending 18 facilities in three countries (250 clients/facility) were interviewed. Client self-reports (3-day, 30-day, Case Index ≥48 consecutive hours of missed ART), healthcare provider estimates and the pharmacy medication possession ratio (MPR) were used to estimate ART adherence. Participants from two facilities per country underwent HIV RNA testing. Optimal adherence measures were selected on the basis of degree of association with concurrent HIV RNA dichotomized at less than or greater/equal to 1000 copies/ml. Multivariate regression analysis, adjusted for site-level clustering, assessed associations between incomplete adherence and individual and programme factors.

Results: A total of 4489 participants were included, of whom 1498 underwent HIV RNA testing. Nonadherence ranged from 3.2% missing at least 48 consecutive hours to 40.1% having an MPR of less than 90%. The percentage with HIV RNA at least 1000 copies/ml ranged from 7.2 to 17.2% across study sites (mean = 9.9%). Having at least 48 consecutive hours of missed ART was the adherence measure most strongly related to virologic failure. Factors significantly related to incomplete adherence included visiting a traditional healer, screening positive for alcohol abuse, experiencing more HIV symptoms, having an ART regimen without nevirapine and greater levels of internalized stigma.

Conclusion: Results support more in-depth investigations of the role of traditional healers, and the development of interventions to address alcohol abuse and internalized stigma among treatment-experienced adult ART patients.

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Editor’s notes: Antiretroviral therapy (ART) non-adherence is a strong predictor of incomplete viral suppression, disease progression and mortality in people living with HIV. Declining adherence rates over long-term follow-up of people on ART have been illustrated in a number of observational studies in both low- and high-income settings. This multi-country study gives valuable insight into the challenges that treatment-experienced people living with HIV in low-income countries face on a daily basis. Incomplete adherence was found to be associated with a number of social and behavioural factors. These include internalised stigma, alcohol dependence, low levels of social support and consulting a traditional healer/herbalist. The factor most strongly associated with incomplete adherence was visiting a traditional healer because of HIV. The data contribute to the growing evidence on the role that traditional healers may have in care-seeking behaviours and influencing sustained ART adherence. Findings from this study corroborate research from other studies that alcohol abuse and HIV stigma are broad and consistent correlates of ART adherence. The study also highlights the variability of existing adherence measures and the need for accurate programme-level methods for assessing pill-taking behaviour in order to inform programme strategies and assess impact.

Improving adherence and thereby longer-term healthy outcomes for people living with HIV requires programmatic activities to address alcohol dependence and internalised stigma among treatment-experienced adults. Greater understanding of the role that traditional healers/herbalists play in how people living with HIV manage their infection is also needed to support life-long ART adherence in sub-Saharan Africa.

Africa
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Injecting drug use increases risk of TB disease in Indonesians living with HIV

Active and latent tuberculosis among HIV-positive injecting drug users in Indonesia.

Meijerink H, Wisaksana R, Lestari M, Meilana I, Chaidir L, van der Ven AJ, Alisjahbana B, van Crevel R. J Int AIDS Soc. 2015 Feb 16;18(1):19317. doi: 10.7448/IAS.18.1.19317. eCollection 2015.

Introduction: Injecting drug use (IDU) is associated with tuberculosis but few data are available from low-income settings. We examined IDU in relation to active and latent tuberculosis (LTBI) among HIV-positive individuals in Indonesia, which has a high burden of tuberculosis and a rapidly growing HIV epidemic strongly driven by IDU.

Methods: Active tuberculosis was measured prospectively among 1900 consecutive antiretroviral treatment (ART)-naive adult patients entering care in a clinic in West Java. Prevalence of LTBI was determined cross-sectionally in a subset of 518 ART-experienced patients using an interferon-gamma release assay.

Results: Patients with a history of IDU (53.1%) more often reported a history of tuberculosis treatment (34.8% vs. 21.9%, p < 0.001), more often received tuberculosis treatment during follow-up (adjusted HR = 1.71; 95% CI: 1.25-2.35) and more often had bacteriologically confirmed tuberculosis (OR = 1.67; 95% CI: 0.94-2.96). LTBI was equally prevalent among people with and without a history of IDU (29.1 vs. 30.4%, NS). The risk estimates did not change after adjustment for CD4 cell count or ART.

Conclusions: HIV-positive individuals with a history of IDU in Indonesia have more active tuberculosis, with similar rates of LTBI. Within the HIV clinic, LTBI screening and isoniazid preventive therapy may be prioritized to patients with a history of IDU.

Abstract  Full-text [free] access

Editor’s notes: In Europe and northern America, HIV-positive people who inject drugs are at greater risk of TB infection and disease compared with other HIV-positive individuals. In many Asian countries, there is a growing problem of injecting drug use which has contributed to the HIV epidemic. This study explored the association between injecting drug use and TB among people living with HIV in Indonesia. The main analysis included 1900 HIV-positive, ART-naive individuals without TB disease and followed them from enrolment in HIV care to starting TB treatment. Just over half of the study population gave a history of injecting drug use. There was no differentiation between current and historical drug use.

A history of injecting drug use was associated with a 71% increased risk of TB disease during the first year after enrolment in HIV care. This association was maintained after adjusting for age, CD4 cell count and the use of antiretroviral therapy. The association was similar when the analysis was restricted to microbiologically-proven TB disease. The divergence in risk seemed to be early after enrolment, the first six months after entering HIV care. And the majority of TB diagnoses occurred before initiation of ART. This suggests the need for intensified TB diagnostic strategies on enrolment in HIV care. Despite enrolment over almost six years and follow-up for up to six years, the median follow-up was less than a year in the group without a history of injecting drug use. This compares to just under two years for people who inject drugs. This suggests substantial loss to follow-up and may have contributed to the higher observed risk of TB among people who inject drugs. 

This article also reports the prevalence of a positive QuantiFERON Gold In-Tube assay in a separate group of HIV-positive individuals with a median time on ART of over two years. There was no difference in the proportion with a positive QuantiFERON test among individuals with and without a history of injecting drug use. This was a very different study population, however, with a median CD4 cell count >350 cells/µl. Almost half reported previous TB treatment, which makes the QuantiFERON results more difficult to interpret.

These data underline the importance of screening for active TB among people entering HIV care, and of isoniazid preventive therapy for individuals with latent infection.

Avoid TB deaths
Asia
Indonesia
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Incentives for orphans to stay in school: a structural programme for HIV prevention in Zimbabwe

The impact of school subsidies on HIV-related outcomes among adolescent female orphans.

Hallfors DD, Cho H, Rusakaniko S, Mapfumo J, Iritani B, Zhang L, Luseno W, Miller T. J Adolesc Health. 2015 Jan;56(1):79-84. doi: 10.1016/j.jadohealth.2014.09.004.

Purpose: We examine effects of school support as a structural HIV prevention intervention for adolescent female orphans in Zimbabwe after 5 years.

Methods: Three hundred twenty-eight orphan adolescent girls were followed in a clustered randomized controlled trial from 2007 to 2010. The experimental group received school fees, uniforms, and school supplies and were assigned a school-based "helper." In 2011-2012, the control group received delayed partial treatment of school fees only. At the final data point in 2012, survey, HIV, and Herpes Simplex Virus Type 2 (HSV-2) biomarker data were collected from approximately 88% of the sample. Bivariate and multivariate analyses were conducted on end point outcomes, controlling for age, religious affiliation, and baseline socioeconomic status.

Results: The two groups did not differ on HIV or HSV-2 biomarkers. The comprehensive 5-year intervention continued to reduce the likelihood of marriage, improve school retention, improve socioeconomic status (food security), and marginally maintain gains in quality of life, even after providing school fees to the control group.

Conclusions: Paying school fees and expenses resulted in significant improvements in life outcomes for orphan adolescent girls. Biological evidence of HIV infection prevention, however, was not observed. Our study adds to the growing body of research on school support as HIV prevention for girls in sub-Saharan Africa, but as yet, no clear picture of effectiveness has emerged.

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Editor’s notes: Structural programmes for HIV prevention potentially offer a means to mitigate the risk factors which are thought to drive the substantially higher rates of HIV observed among adolescent women in low-income settings. In Zimbabwe, female orphans in the programme arm of this randomized control trial were offered a package of school support. This included payment of their school fees. There was low power to assess differences in HIV or HSV-2 prevalence by arm, but there were promising impacts on several important mediating factors for HIV infection. These included sexual debut, marriage, school drop-out, and socioeconomic status. The long follow-up period of five years and the high rate of retention in the study, 88%, are major strengths of this study. The study joins a limited evidence base on structural programmes for adolescent women in sub-Saharan Africa. Future research must re-consider the pathways by which structural determinants of HIV infection operate.

Africa
Zimbabwe
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Context-specific combination HIV prevention for female sex workers

Combination HIV prevention for female sex workers: what is the evidence?

Bekker LG, Johnson L, Cowan F, Overs C, Besada D, Hillier S, Cates W, Jr. Lancet. 2015 Jan 3;385(9962):72-87. doi: 10.1016/S0140-6736(14)60974-0. Epub 2014 Jul 22.

Sex work occurs in many forms and sex workers of all genders have been affected by HIV epidemics worldwide. The determinants of HIV risk associated with sex work occur at several levels, including individual biological and behavioural, dyadic and network, and community and social environmental levels. Evidence indicates that effective HIV prevention packages for sex workers should include combinations of biomedical, behavioural, and structural interventions tailored to local contexts, and be led and implemented by sex worker communities. A model simulation based on the South African heterosexual epidemic suggests that condom promotion and distribution programmes in South Africa have already reduced HIV incidence in sex workers and their clients by more than 70%. Under optimistic model assumptions, oral pre-exposure prophylaxis together with test and treat programmes could further reduce HIV incidence in South African sex workers and their clients by up to 40% over a 10-year period. Combining these biomedical approaches with a prevention package, including behavioural and structural components as part of a community-driven approach, will help to reduce HIV infection in sex workers in different settings worldwide.

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Editor’s notes: Sex workers live within complex contexts of risk when it comes to HIV, other STIs and diseases, and life more broadly. But relatively few large-scale HIV prevention programmes exist for female sex workers. This paper presents a framework for combination HIV prevention among female sex workers. The paper evaluates the effect of activities at the individual, sexual/social network, community, and public policy levels. It models the impact of combining more established individual and structural approaches with biomedical approaches. These include earlier treatment and vaginal or oral PrEP, in South Africa. The model simulations suggest that individual and structural programmes, including condom promotion and distribution programmes, and community-led initiatives, are key in reducing HIV incidence among female sex workers and their clients in South Africa. Expansion of voluntary, effective earlier treatment, together with PrEP could further reduce HIV incidence in this setting.  

Africa
South Africa
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Lower, long-term risk of TB disease with early versus deferred antiretroviral therapy

CD4 deficit and tuberculosis risk persist with delayed antiretroviral therapy: 5-year data from CIPRA HT-001.

Collins SE, Jean Juste MA, Koenig SP, Secours R, Ocheretina O, Bernard D, Riviere C, Calnan M, Dunning A, Hurtado Rua SM, Johnson WD, Pape JW, Fitzgerald DW, Severe P. Int J Tuberc Lung Dis. 2015 Jan;19(1):50-7. doi: 10.5588/ijtld.14.0217.

Setting: Port-au-Prince, Haiti.

Objective: To determine long-term effects of early vs. delayed initiation of antiretroviral therapy (ART) on immune recovery and tuberculosis (TB) risk in human immunodeficiency virus (HIV) infected individuals.

Design: Open-label randomized controlled trial of immediate ART in HIV-infected adults with CD4 counts between 200 and 350 cells/mm3 vs. deferring ART until the CD4 count was <200 cells/mm3. The primary comparisons were CD4 counts over time and risk for incident TB, with 5 years of follow-up.

Results: A total of 816 participants were enrolled, with 408 in each treatment arm. The early treatment group started ART within 2 weeks, while the deferred treatment group started ART a median of 1.3 years after enrollment. After 5 years, the mean CD4 count in the early treatment group was significantly higher than in the deferred treatment group (496 cells/mm3, 95% confidence interval [CI] 477-515 vs. 373 cells/mm3, 95%CI 357-389; P < 0.0001). TB risk was higher in the deferred treatment group (unadjusted HR 2.41, 95%CI 1.56-3.74; P < 0.0001) and strongly correlated with lower CD4 counts in time-dependent multivariate analysis.

Conclusion: Delays in ART initiation for HIV-infected adults with CD4 counts of 200-350 cells/mm3 can result in long-term immune dysfunction and persistent increased risk for TB.

Abstract access 

Editor’s notes: There is a solid evidence base to support the initiation of antiretroviral therapy (ART) for adults living with HIV with CD4+ cell count ≤350 cells/µL. One randomised controlled trial in Haiti (CIPRA HT-001) demonstrated a 75% reduction in mortality with initiation of ART at CD4+ cell count 200-350 cells/µL compared to deferring until CD4+ cell count was <200 cells/µL. That same trial demonstrated a 50% reduction in incident TB disease with early ART, over three years of follow-up.

This paper presents a subsequent analysis from this trial with extended follow-up to five years. This analysis reports on whether or not the effect of early ART was maintained, and the long-term effect on CD4+ recovery. The beneficial impact of early ART on incident TB disease was indeed maintained over the five years of follow-up. Half of the TB cases in the deferred ART group occurred before the initiation of ART but the differential risk persisted beyond the initiation of ART. 

There was also a clear benefit of early ART on immune recovery. More than 75% of participants in the early ART group achieved a CD4+ cell count >500 cells/µL by five years, compared to fewer than 25% of people in the deferred ART group. The effect of early ART on incident TB was only partially modified after adjustment for time-updated CD4+ cell count, suggesting that early ART has benefit over and above its effect on CD4+ cell count recovery.

Although this is clear evidence to start ART promptly in people with severe immunosupression, these data do not address the question of whether ART at CD4+ cell counts above 350 cells/µL influences the risk of TB disease, and this information is eagerly awaited from ongoing clinical trials. 

Avoid TB deaths
Latin America
Haiti
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Refocussing on sex workers in Swaziland - even in generalized epidemics

Reconceptualizing the HIV epidemiology and prevention needs of female sex workers (FSW) in Swaziland.

Baral S, Ketende S, Green JL, Chen PA, Grosso A, Sithole B, Ntshangase C, Yam E, Kerrigan D, Kennedy CE, Adams D. PLoS One. 2014 Dec 22;9(12):e115465. doi: 10.1371/journal.pone.0115465. eCollection 2014

Background: HIV is hyperendemic in Swaziland with a prevalence of over 25% among those between the ages of 15 and 49 years old. The HIV response in Swaziland has traditionally focused on decreasing HIV acquisition and transmission risks in the general population through interventions such as male circumcision, increasing treatment uptake and adherence, and risk-reduction counseling. There is emerging data from Southern Africa that key populations such as female sex workers (FSW) carry a disproportionate burden of HIV even in generalized epidemics such as Swaziland. The burden of HIV and prevention needs among FSW remains unstudied in Swaziland.

Methods: A respondent-driven-sampling survey was completed between August-October, 2011 of 328 FSW in Swaziland. Each participant completed a structured survey instrument and biological HIV and syphilis testing according to Swazi Guidelines.

Results: Unadjusted HIV prevalence was 70.3% (n = 223/317) among a sample of women predominantly from Swaziland (95.2%, n = 300/316) with a mean age of 21 (median 25) which was significantly higher than the general population of women. Approximately one-half of the FSW (53.4%, n = 167/313) had received HIV prevention information related to sex work in the previous year, and about one-in-ten had been part of a previous research project (n = 38/313). Rape was common with nearly 40% (n = 123/314) reporting at least one rape; 17.4% (n = 23/314) reported being raped 6 or more times. Reporting blackmail (34.8%, n = 113/314) and torture (53.2%, n = 173/314) was prevalent.

Conclusions: While Swaziland has a highly generalized HIV epidemic, reconceptualizing the needs of key populations such as FSW suggests that these women represent a distinct population with specific vulnerabilities and a high burden of HIV compared to other women. These women are understudied and underserved resulting in a limited characterization of their HIV prevention, treatment, and care needs and only sparse specific and competent programming. FSW are an important population for further investigation and rapid scale-up of combination HIV prevention including biomedical, behavioral, and structural interventions.

Abstract  Full-text [free] access

Editor’s notes: In countries with high prevalence generalised epidemics, research and resources often focus on the general population, and the role of key populations is often ignored. This study, from Swaziland, illustrates how the sex worker population in Swaziland suffer from a concentrated epidemic within a generalized one. The study highlights the need for focused services to address the very high HIV prevalence, some 70%, in this population. The study further highlights the lack of services, education and support reaching sex workers in this setting. Given large sexual networks, high prevalence of HIV and limited condom use, this vulnerable population is likely to be contributing substantially to the widespread epidemic in Swaziland. In this and similar settings, HIV treatment and prevention services specifically for sex workers are necessary and should be a central plank of service delivery programming, and policy making. 

Africa
Swaziland
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Associations between HIV and intimate partner violence in ten African countries

Intimate partner violence and HIV in ten sub-Saharan African countries: what do the Demographic and Health Surveys tell us?

Durevall D, Lindskog A. Lancet Glob Health. 2015 Jan;3(1):e34-43. doi: 10.1016/S2214-109X(14)70343-2. Epub 2014 Nov 21.

Background: Many studies have identified a significant positive relation between intimate partner violence and HIV in women, but adjusted analyses have produced inconsistent results. We systematically assessed the association, and under what condition it holds, using nationally representative data from ten sub-Saharan African countries, focusing on physical, sexual, and emotional violence, and on the role of male controlling behaviour.

Methods: We assessed cross-sectional data from 12 Demographic and Health Surveys from ten countries in sub-Saharan Africa. The data are nationally representative for women aged 15-49 years. We estimated odds ratios using logistic regression with and without controls for demographic and socioeconomic factors and survey-region fixed effects. Exposure was measured using physical, sexual, emotional violence, and male controlling behaviour, and combinations of these. The samples used were ever-married women, married women, and women in their first union. Depending on specification, the sample size varied between 11 231 and 45 550 women.

Findings: There were consistent and strong associations between HIV infection in women and physical violence, emotional violence, and male controlling behaviour (adjusted odds ratios ranged from 1.2 to 1.7; p values ranged from <0.0001 to 0.0058). The evidence for an association between sexual violence and HIV was weaker and only significant in the sample with women in their first union. The associations were dependent on the presence of controlling behaviour and a high regional HIV prevalence rate; when women were exposed to only physical, sexual, or emotional violence, and no controlling behaviour, or when HIV prevalence rates are lower than 5%, the adjusted odds ratios were, in general, close to 1 and insignificant.

Interpretation: The findings indicate that male controlling behaviour in its own right, or as an indicator of ongoing or severe violence, puts women at risk of HIV infection. HIV prevention interventions should focus on high-prevalence areas and men with controlling behaviour, in addition to violence.

Abstract  Full-text [free] access

Editor’s notes: Despite two cohort studies illustrating that exposures to intimate partner violence are associated with incident HIV infection, evidence from cross-sectional analysis of population data is more mixed. Using Demographic and Health Surveys data for women aged 15-49 years from 10 sub-Saharan countries, this paper illustrates that HIV infection is strongly associated with physical violence and/or emotional violence and controlling behaviour, with a weaker association with sexual violence. For all forms of violence, the association was strongest among women who also reported that their partner was controlling, and in settings where HIV prevalence exceeds five percent. This study adds to the growing literature on HIV and intimate partner violence that suggests that risk is not only linked to forced sex, but rather to being in a violent and controlling relationship. The paper highlights the importance of male control as a risk factor for HIV, and supports the need for HIV prevention programmes that focus on reducing intimate partner violence in higher-prevalence settings.

Africa
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TB pre- and post- antiretroviral therapy initiation in India

Incidence and mortality of tuberculosis before and after initiation of antiretroviral therapy: an HIV cohort study in India.

Alvarez-Uria G, Pakam R, Midde M, Naik PK. J Int AIDS Soc. 2014 Dec 9;17:19251. doi: 10.7448/IAS.17.1.19251. eCollection 2014.

Introduction: India has the highest burden of tuberculosis (TB) in the world, but the epidemiology of HIV-associated TB is not well known.

Methods: We describe the incidence and the mortality of TB from HIV diagnosis to antiretroviral therapy (ART) initiation (pre-ART group) and after ART initiation (on-ART group) in an HIV cohort study in Anantapur, India. Multivariable analysis of factors associated with TB was performed using competing risk regression and restricted cubic spline methods.

Results: A total of 4590 patients and 3133 person-years (py) of follow-up were included in the pre-ART group, and 3784 patients and 4756 py were included in the on-ART group. In the pre-ART group, the incidence of TB was high during the first month after HIV diagnosis and dropped nearly four times soon after. In the on-ART group, the incidence of TB increased after ART initiation reaching a peak in the third month. The probability of having TB within 30 months was 22.3% (95% confidence interval [CI], 21.1-23.6) in the pre-ART group and 17.8% (95% CI, 16.3-19.3) in the on-ART group. In a multivariable analysis, women had a lower risk of TB in both groups. Poor socio-economic conditions were associated with an increased risk of TB in the pre-ART group, but not in the group on-ART. While the association between low CD4 counts and TB was strong in the pre-ART group, this association was weaker in the on-ART group, and the highest risk of TB was seen in those patients with CD4 counts around 110 cells/mm3. The cumulative incidence of mortality at 12 months in patients with TB was 29.6% (95% CI, 26.9-32.6) in pre-ART TB and 34.9% (95% CI, 31-39.1) in on-ART TB. Half deaths before ART initiation and two thirds of deaths after ART initiation occurred in patients with TB.

Conclusions: The high incidence and mortality of TB seen in this study underscore the urgent need to improve the prevention and diagnosis of HIV-associated TB in India. We found substantial differences between TB before and after ART initiation.

Abstract  Full-text [free] access

Editor’s notes: Although India has a huge burden of TB, there are relatively few published data regarding the epidemiology of HIV-associated TB, which this retrospective analysis begins to address. This study describes the incidence of TB and mortality among people with TB. The study looked at a cohort of people living with HIV, attending a rural hospital funded by a non-governmental organisation where medical care, including antiretroviral therapy and TB treatment, were provided free of charge. The authors report extremely high incidence of TB shortly after both HIV diagnosis and antiretroviral therapy initiation. They also report high mortality among individuals with TB, all of which are far greater than described in antiretroviral therapy programmes in South Africa. As the authors note, this likely reflects multiple issues. These include the fact that people often first present for HIV care due to symptoms of TB, unsatisfactory screening for TB, and inadequate investigation of individuals with TB symptoms, which relies on sputum microscopy and radiology. Furthermore, isoniazid preventive therapy is not yet implemented in India and the authors report that buildings designated as antiretroviral therapy centres are often inadequate in terms of infection control. This study highlights the urgency of comprehensive implementation of WHO’s three I’s (intensified case finding, isoniazid preventive therapy, infection control) for tuberculosis strategy in this setting and access to better, affordable and rapid diagnostic tests for TB.

Avoid TB deaths
Asia
India
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Longitudinal study illustrates link between alcohol use, traumatic stress and risk of HIV

Traumatic stress and the mediating role of alcohol use on HIV-related sexual risk behavior: Results from a longitudinal cohort of South African women who attend alcohol-serving venues.

Abler L, Sikkema KJ, Watt MH, Pitpitan EV, Kalichman SC, Skinner D, Pieterse D. J Acquir Immune Defic Syndr. 2014 Nov 12. [Epub ahead of print]

Background: In South Africa, alcohol contributes to the HIV epidemic, in part, by influencing sexual behaviors. For some, high levels of alcohol consumption may be driven by previous traumatic experiences that result in traumatic stress. The purpose of this study was to quantify the longitudinal association between traumatic stress and unprotected sex among women who attend drinking venues and to assess whether this association was explained by mediation through alcohol use.

Methods: Data were collected in four waves over a year from a prospective cohort of 560 women who regularly attended alcohol-serving venues in a Cape Town township. Longitudinal mixed models examined: 1) the relationship between traumatic stress and counts of unprotected sex, and 2) whether alcohol use mediated the association between traumatic stress and unprotected sex.

Results: Most women reported elevated traumatic stress (80%) and hazardous alcohol use (88%) at least once during the study period. In models adjusted for covariates, traumatic stress was associated with unprotected sex (b=0.28, SE=0.06, t=4.82, p<.001). In addition, traumatic stress was associated with alcohol use (b=0.27, SE=0.02, t=14.25, p<.001), and was also associated with unprotected sex (b=0.20, SE=0.06, t=3.27, p<.01) while controlling for alcohol use (b=0.28, SE=0.07, t=4.25, p<.001). The test for the mediated effect established that alcohol use was a significant mediator, accounting for 27% of the total effect of traumatic stress on unprotected sex.

Conclusions: These results highlight the need to address traumatic stress among female venue patrons as an important precursor of HIV risk due to alcohol use.

Abstract access

Editor’s notes: There is an established link between alcohol use and high-risk sexual behaviour, but the role of mental health in this relationship is often overlooked. Traumatic stress can lead to problematic drinking patterns and increased high-risk sexual behaviour. These negative coping mechanisms may in turn increase traumatic stress, further elevating the risk of HIV infection. A longitudinal cohort study of 560 South African women was conducted to quantify this association. The study benefits from a large sample size and good participant retention throughout the study period.

Traumatic stress was measured using a 17-item Post Traumatic Stress Disorder checklist (PCL) and alcohol use was measured using the 10-item Alcohol Use Disorders Identification Test (AUDIT). The primary outcome was the number of unprotected sexual events that participants reported having in the previous four months. Participants who scored higher for traumatic stress and alcohol use reported having more unprotected sex. Traumatic stress was also found to be independently associated with alcohol use. These findings provide support for programmes that focus on both alcohol use and traumatic stress, owing to their tendency to co-occur and heighten the risk of HIV infection. The authors recommend adapting such programmes to the South African setting and call for further research into how best to identify women at risk of traumatic stress in South African drinking venues.

Africa
South Africa
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