Articles tagged as "Health care delivery"

Do people take more risks when they know they are “protected”?

Editor’s notes: Risk compensation is a phenomenon well known to behavioural scientists.  When car-drivers wear seat belts, they may drive faster because they feel safer.  Despite some evidence to the contrary, a commonly voiced concern about PrEP is that people who take it will take more risks with their sexual health.  So it is reassuring to see two studies that examine partnership dynamics and condom use among people on antiretroviral therapy (ART) and among men who have been circumcised.

McGrath and Grapsa studied relationships and reported sexual behaviour among 632 people living with HIV and enrolled in an ongoing cohort study in KwaZulu Natal during the period, when only those with lower CD4 counts were eligible for ART.  They interviewed participants every 6 months, in person or by phone, for up to 36 months. This was in order to follow which relationships were formed and which dissolved and to determine how often participants were having sex and how often they were having condomless sex.  The authors clearly document (perhaps unsurprisingly) that many relationships dissolved (192 out of 565 partnerships at some time in the study) or formed (161 out of 132 individuals who were single at some time in the study).  Partnerships dissolved more frequently among people who had only been in a relationship for less than a year; people who drank alcohol and in partnerships where the participant described the relationship as being of “poor quality”.  New partners were more common for people who were younger; had not disclosed their HIV status; drank alcohol or reported having more than 3 lifetime sexual partners at the start of the study.  There was no suggestion that being on ART affected the likelihood of forming or leaving a partnership. This is important for mathematical models of HIV transmission in the era of universal treatment policies.

Sex was more frequently reported in people in more recent partnerships; people who knew their partners’ HIV status and among people who wanted more children.  Sex was less frequent and more often protected by a condom among people who did not trust their partner’s fidelity or where the couple did not live together.  People who were eligible for ART tended to use condoms more regularly during the follow up than people who were still “waiting for treatment”.  Other factors associated with more condom use included more equitable gender norms; HIV status disclosure and not living together.  Condoms were used less often in partnerships that included alcohol, partner violence or where the couple wanted more children.  Overall, the authors estimated that around 5.5% of sex acts were “risky” (that is unprotected with a partner who was HIV negative or where the HIV status was unknown) among those eligible for ART and around 13.2% for those not yet eligible.  Around one third of the participants reported having condomless sex at least once, but in almost half of these, they knew that their partner was also living with HIV.

Taking effective ART regularly means that people living with HIV are no longer infectious once their viral load is reliably suppressed.  However, it is clear that not everyone achieves viral load suppression.  This study provides useful prospective information about partnerships and sexual behaviour in the context of very high HIV transmission.  It is reassuring in showing that on the whole, sexual behaviour seems less risky, even before taking the huge effect of ART into account.  There was no evidence to suggest that risk compensation occurred in those offered ART.

In order to maximize the preventive benefits of ART, it is essential that people are supported to take their medicines regularly.  In crowded urban facilities in high prevalence settings, long waiting times, and challenges in stock management mean that people living with HIV have to be quite determined to negotiate the systems and minimize treatment interruptions.  Although it is national policy in Zambia and some other highly burden countries to provide three-month supplies to people whose HIV is stable and well controlled, McCarthy and colleagues found that less than half of people who should be getting three-month refills were doing so.  They instituted a cluster randomized trial of a quality improvement programme across 16 health facilities in Lusaka.  Each clinic follows around 4-5000 people on ART of whom around 1000 are stable and eligible for three-monthly refills.  The key element was for a focal point in each of the eight intervention clinics to be designated as a quality improvement officer and to be supported with materials to plan and monitor drug stocks and support local changes.  This is to ensure that stable patients did not have to spend long periods in the clinic or go away with less medicine than they needed.  The District Health Management team supported the quality improvement officers when the challenges identified were beyond their responsibilities or capabilities to change.  The programme led to a statistically significant 15% increase in the proportion of appropriate people receiving three-month refills (reaching 69%).  On average the intervention clinics became less congested (35 fewer visits per day compared to the controls) and had shorter waiting times (20 minutes shorter per visit) although these results did not reach statistical significance.

Another study exploring risk compensation was carried out by Shi and colleagues.  The authors used data from recent demographic and health surveys from countries that are part of the scale-up of voluntary medical male circumcision in East and Southern Africa.  Circumcision was most prevalent in Kenya (88% and 94% before and after 2008, when scale-up was pushed) and lowest in Zimbabwe (12% and 11% respectively). Overall condom usage increased in both circumcised and uncircumcised men.  Reports of condom use at last sex averaged around 15-16% before 2008 across the ten countries surveyed and rose to around 21% after 2008.  There was no suggestion that men who were circumcised were any less likely to use a condom than men who were not.  Similarly, there was no suggestion that circumcised men were more likely to have non-cohabiting partners.

The study also highlights big differences between countries, and between different groups.  Even among men with no regular partner, the use of a condom at last sex is often less than 50% with differences as expected also seen by age, education, religion and residence.  Promoting circumcision remains a hugely cost-effective approach to HIV prevention.  This study therefore provides important reassurance that the possibility of risk compensation is not serious for circumcision programmes.  Nonetheless we still have plenty of work to do to reach our targets and prevent HIV.

Does ART change partnership dynamics and HIV risk behaviours among PLWH? A cohort study in KwaZulu-Natal, South Africa.

McGrath N, Grapsa E. AIDS. 2017 Apr 10. doi: 10.1097/QAD.0000000000001502. [Epub ahead of print]

Objective: We explore the impact of antiretroviral therapy (ART) on partnership acquisition and dissolution rates and changes in sexual behaviours among HIV-infected adults.

Design: Using detailed longitudinal data from a prospective cohort of HIV-infected adults with CD4<200 cell/ml (ART-eligible) or CD4>500 cell/ml (pre-ART) conducted in rural KwaZulu-Natal, South Africa, 2009-2012.

Methods: Partnership acquisition and dissolution are explored through survival analysis methods, while generalized linear models were fitted for the sexual behaviour outcomes with interaction terms to allow the association with ART to vary over time. Throughout, the primary comparison of interest for each outcome is differences between the two ART groups.

Results: ART is not associated with partner acquisition or relationship dissolution. During follow-up, the two ART groups do not differ in the odds of being sexually active nor the number of sex acts, while the odds of unprotected sex are significantly lower for partnerships of ART-eligible participants, a0R = 0.26, 95%CI(0.15,0.43). Relationship-level characteristics including cohabitation status and wanting more children with that partner are associated with higher odds and increased frequency of sexual activity, increased odds of unprotected sex; while living with partner, higher relationship quality and longer relationship duration are associated with lower risk of partnership dissolution.

Conclusion: Being on ART was not associated with increased sexual risk behaviours, a reassuring finding given the WHO recommends ART initiation upon HIV diagnosis. The importance of relationship-level characteristics provides evidence that HIV care services should offer routine support for HIV disclosure and sexual risk reduction, and promotion of couples-testing and positive couple-relationships.

Abstract access 

Quality improvement intervention to increase adherence to ART prescription policy at HIV treatment clinics in Lusaka, Zambia: A cluster randomized trial.

McCarthy EA, Subramaniam HL, Prust ML, Prescott MR, Mpasela F, Mwango A, Namonje L, Moyo C, Chibuye B, van den Broek JW, Hehman L, Moberley S. PLoS One. 2017 Apr 18;12(4):e0175534. doi: 10.1371/journal.pone.0175534. eCollection 2017.

Introduction: In urban areas, crowded HIV treatment facilities with long patient wait times can deter patients from attending their clinical appointments and picking up their medications, ultimately disrupting patient care and compromising patient retention and adherence.

Methods: Formative research at eight facilities in Lusaka revealed that only 46% of stable HIV treatment patients were receiving a three-month refill supply of antiretroviral drugs, despite it being national policy for stable adult patients. We designed a quality improvement intervention to improve the operationalization of this policy. We conducted a cluster-randomized controlled trial in sixteen facilities in Lusaka with the primary objective of examining the intervention's impact on the proportion of stable patients receiving three-month refills. The secondary objective was examining whether the quality improvement intervention reduced facility congestion measured through two proxy indicators: daily volume of clinic visits and average clinic wait times for services.

Results: The mean change in the proportion of three-month refills among control facilities from baseline to endline was 10% (from 38% to 48%), compared to a 25% mean change (an increase from 44% to 69%) among intervention facilities. This represents a significant 15% mean difference (95% CI: 2%-29%; P = 0.03) in the change in proportion of patients receiving three-month refills. On average, control facilities had 15 more visits per day in the endline than in the baseline, while intervention facilities had 20 fewer visits per day in endline than in baseline, a mean difference of 35 fewer visits per day (P = 0.1). The change in the mean facility total wait time for intervention facilities dropped 19 minutes between baseline and endline when compared to control facilities (95% CI: -10.2-48.5; P = 0.2).

Conclusion: A more patient-centred service delivery schedule of three-month prescription refills for stable patients is viable. We encourage the expansion of this sustainable intervention in Zambia's urban clinics.

Abstract Full-text [free] access

Evidence that promotion of male circumcision did not lead to sexual risk compensation in prioritized sub-Saharan countries.

Shi CF, Li M, Dushoff J. PLoS One. 2017 Apr 25;12(4):e0175928. doi: 10.1371/journal.pone.0175928. eCollection 2017.

Background: WHO and UNAIDS prioritized 14 eastern and southern African countries with high HIV and low male circumcision prevalence for a voluntary medical male circumcision (VMMC) scale-up in 2007. Because circumcision provides only partial protection against HIV infection to men, the issue of possible risk compensation in response to VMMC campaigns is of particular concern. In this study, we looked at population-level survey data from the countries prioritized by WHO for a VMMC scale-up. We compared the difference in sexual risk behaviours (SRB) between circumcised and uncircumcised men before and after the WHO's official VMMC promotion.

Materials and Methods: Ten countries (Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe) participating in the WHO's VMMC scale-up had available data from the Demographic and Health Surveys (DHS). We used cumulative-link mixed models to investigate interactions between survey period and circumcision status in predicting SRB, in order to evaluate whether the difference between the behavior of the two groups changed before and after the scale-up, while controlling for socio-demographic and knowledge-related covariates. The main responses were condom use at last sex and number of non-cohabiting sexual partners, both in the last 12 months.

Results: There was little change in condom use by circumcised men relative to uncircumcised men from before the VMMC scale up to after the scale up. The relative odds ratio is 1.06 (95% CI, 0.95-1.18; interaction P = 0.310). Similarly, there was little change in the number of non-cohabiting partners in circumcised men (relative to uncircumcised men): the relative odds ratio of increasing the number of partners is 0.95 (95% CI, 0.86-1.05; interaction P = 0.319). Age, religion, education, job, marital status, media use and HIV knowledge also showed statistically significant association with the studied risk behaviours. We also found significant differences among countries, while controlling for covariates.

Conclusions: Overall, we find no evidence of sexual risk compensation in response to VMMC campaigns in countries prioritized by WHO. Changes in relative partner behaviour and the relative odds of condom use were small (and of uncertain sign). In fact, our estimates, though not significant, both suggest slightly less risky behavior. We conclude that sexual risk compensation in response to VMMC campaigns has not been a serious problem to date, but urge continued attention to local context, and to promulgating accurate messages about circumcision within and beyond the VMMC context.

Abstract   Full-text [free] access 

Africa
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Keeping up appearances – the reasons people living with HIV who are not yet ill, give for starting ART

Factors that motivated otherwise healthy HIV-positive young adults to access HIV testing and treatment in South Africa.

Lambert RF, Orrell C, Bangsberg DR, Haberer JE. AIDS Behav. 2017 Feb 11. doi: 10.1007/s10461-017-1704-y. [Epub ahead of print]

The World Health Organization recommends early initiation of HIV antiretroviral therapy (ART) for all those infected with the virus at any CD4 count. Successfully reaching individuals with relatively high CD4 counts depends in large part on healthy individuals seeking testing and treatment; however, little is known about factors motivating this decision. We conducted a qualitative study to explore this issue among 25 young HIV-positive adults (age 18-35) with a CD4 count >350 cells/mm3 who recently started or made the decision to start ART in Gugulethu, South Africa. Using an inductive content analytical approach, we found that most individuals sought testing and treatment early in the disease progression because of a desire to appear healthy thereby avoiding stigma associated with AIDS. Other factors included social support, responsibilities and aspirations, normalcy of having HIV, and accessible services. These findings suggest that maintenance of physical appearance should be included in the development of novel testing and treatment interventions.

Abstract access  

Editor’s notes: A lot has been written on why people delay entry into care, when they are living with HIV. The guidance that all people living with HIV should now start treatment means that many people who are healthy are being offered treatment. The authors of this paper found that in a small sample of people in South Africa, looking healthy mattered. There was a value in the message that ART could maintain health, and in the words of one participant in their study, to ‘remain beautiful’. In addition, other positive anticipated results of taking ART emerged from the data. Young people saw the benefit in maintaining their health so they can help their family in the future, for example. However, despite the positive messages on appearance and a future role for the family and society, many concerns remained. Participants wanted privacy to live with HIV without others knowing. Fears of stigma, fears of an altered appearance and faltering strength haunted participants. The authors stress the value of the positive messaging of ART as an aid to sustaining a healthy appearance. They suggest that this messaging could be used to encourage people to start ART promptly. 

Africa
South Africa
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Measuring adherence – a promising approach with caregivers of children living with HIV

Improved adherence to antiretroviral therapy observed among HIV-infected children whose caregivers had positive beliefs in medicine in sub-Saharan Africa.

Abongomera G, Cook A, Musiime V, Chabala C, Lamorde M, Abach J, Thomason M, Mulenga V, Kekitiinwa A, Colebunders R, Kityo C, Walker AS, Gibb DM. AIDS Behav. 2017 Feb;21(2):441-449. doi: 10.1007/s10461-016-1582-8.

A high level of adherence to antiretroviral treatment is essential for optimal clinical outcomes in HIV infection, but measuring adherence is difficult. We investigated whether responses to a questionnaire eliciting caregiver beliefs in medicines were associated with adherence of their child (median age 2.8 years), and whether this in turn was associated with viral suppression. We used the validated beliefs in medicine questionnaire (BMQ) to measure caregiver beliefs, and medication event monitoring system caps to measure adherence. We found significant associations between BMQ scores and adherence, and between adherence and viral suppression. Among children initiating antiretroviral therapy (ART), we also found significant associations between BMQ 'necessity' scores, and BMQ 'necessity-concerns' scores, and later viral suppression. This suggests that the BMQ may be a valuable tool when used alongside other adherence measures, and that it remains important to keep caregivers well informed about the long-term necessity of their child's ART.

Abstract  Full-text [free] access 

Editor’s notes: How we measure adherence to antiretroviral therapy has long been a challenge within HIV clinical care. We need to know who is struggling with their HIV treatment so that we can provide support to improve their treatment taking behaviour before treatment resistance and other complex clinical problems take hold. This can be an especially relevant concern for children who will need to take HIV treatment throughout their lives. The analysis within this paper proffers a relatively accessible means to identify families who are more likely to encounter adherence problems. This potentially allows people to receive pre-emptive support before clinical problems arise. 

The authors tested their hypothesis that the children of caregivers who had concerns about the overuse and associated toxicity of medicine and/or had strong beliefs in divine intervention as curative, relative to their belief in the necessity of medicines, would be less likely to be virally suppressed. Such beliefs were measured in a validated ‘belief in medicine’ questionnaire. Although this was used within a clinical trial setting it is potentially simple enough to feasibly be used in more general clinical settings. This measure could identify particular ‘at-risk’ caregiver groups to inform not only the provision of tailored adherence support but also at which critical time points such support should be delivered.

Africa
Uganda, Zambia
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A cohort-based approach to the HIV treatment cascade finds linkage the major bottleneck

From HIV infection to therapeutic response: a population-based longitudinal HIV cascade-of-care study in KwaZulu-Natal, South Africa.

Haber N, Tanser F, Bor J, Naidu K, Mutevedzi T, Herbst K, Porter K, Pillay D, Barnighausen T. Lancet HIV. 2017 Jan 30. pii: S2352-3018(16)30224-7. doi: 10.1016/S2352-3018(16)30224-7. [Epub ahead of print]

Background: Standard approaches to estimation of losses in the HIV cascade of care are typically cross-sectional and do not include the population stages before linkage to clinical care. We used individual-level longitudinal cascade data, transition by transition, including population stages, both to identify the health-system losses in the cascade and to show the differences in inference between standard methods and the longitudinal approach.

Methods: We used non-parametric survival analysis to estimate a longitudinal HIV care cascade for a large population of people with HIV residing in rural KwaZulu-Natal, South Africa. We linked data from a longitudinal population health surveillance (which is maintained by the Africa Health Research Institute) with patient records from the local public-sector HIV treatment programme (contained in an electronic clinical HIV treatment and care database, ARTemis). We followed up all people who had been newly detected as having HIV between Jan 1, 2006, and Dec 31, 2011, across six cascade stages: three population stages (first positive HIV test, HIV status knowledge, and linkage to care) and three clinical stages (eligibility for antiretroviral therapy [ART], initiation of ART, and therapeutic response). We compared our estimates to cross-sectional cascades in the same population. We estimated the cumulative incidence of reaching a particular cascade stage at a specific time with Kaplan-Meier survival analysis.

Findings: Our population consisted of 5205 individuals with HIV who were followed up for 24 031 person-years. We recorded 598 deaths. 4539 individuals gained knowledge of their positive HIV status, 2818 were linked to care, 2151 became eligible for ART, 1839 began ART, and 1456 had successful responses to therapy. We used Kaplan-Meier survival analysis to adjust for censorship due to the end of data collection, and found that 8 years after testing positive in the population health surveillance, 16% had died. Among living patients, 82% knew their HIV status, 45% were linked to care, 39% were eligible for ART, 35% initiated ART, and 33% had reached therapeutic response. Median times to transition for these cascade stages were 52 months, 52 months, 20 months, 3 months, and 9 months, respectively. Compared with the population stages in the cascade, the transitions across the clinical stages were fast. Over calendar time, rates of linkage to care have decreased and patients presenting for the first time for care were, on average, healthier.

Interpretation: HIV programmes should focus on linkage to care as the most important bottleneck in the cascade. Cascade estimation should be longitudinal rather than cross-sectional and start with the population stages preceding clinical care.

Abstract access  

Editor’s notes: The HIV treatment cascade outlines the stages required to effectively treat HIV, starting with HIV testing and ending with viral suppression. The cascade has become a widely-used framework to evaluate the performance of HIV care programmes, to measure progress towards universal treatment coverage, and to identify gaps in care. However, methods for constructing the HIV treatment cascade vary considerably. The majority of cascade analyses rely on cross-sectional data obtained from different sources. The authors present the first analysis of the HIV treatment cascade that follows individuals longitudinally from the time of HIV infection across all stages of the cascade. By linking data from a demographic surveillance system with electronic clinical records, they are able to describe the cascade for a large population-based cohort of people living with HIV in rural KwaZulu-Natal, South Africa.  They demonstrate that, once people became eligible for ART, the rates of ART initiation, and of viral suppression after initiation, were high. Half of individuals started ART within three months of becoming eligible, and 94% of people on therapy achieved virologic suppression. In addition, retention in care improved over time. However, a key finding is that rates of HIV diagnosis and linkage to care worsened over time, and less than 50% of people had linked to care within eight years of HIV infection, despite 82% being aware of their status. As illustrated by cascade analyses in other settings, increasing linkage to care remains a major challenge for reaching the UNAIDS 90-90-90 treatment target in sub-Saharan Africa.  

In addition to highlighting linkage as the most important bottleneck in the HIV care cascade in this part of rural KwaZulu-Natal, the study illustrates some of the weaknesses in traditional cascade analyses based on cross-sectional data. The cross-sectional cascade is constructed from snapshots of different groups of people in a particular moment in time, rather than describing what happens to the same group of people over time. The authors illustrate how a cross-sectional analysis can give a misleading impression of improvement in the cascade over time, because it fails to take account of changes in the population. The longitudinal cascade, by following the same group of people, provides important insights into the true progression of the cascade over time, and identification of losses along each stage. However, the individual-level longitudinal data necessary for this type of analysis requires a large investment in data collection, and is unlikely to be feasible in most resource-limited settings.

Africa
South Africa
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Adolescents and PMTCT services: where are the gaps?

PMTCT service uptake among adolescents and adult women attending antenatal care in selected health facilities in Zimbabwe.

Musarandega R, Machekano R, Chideme M, Muchuchuti C, Mushavi A, Mahomva A, Guay L. J Acquir Immune Defic Syndr. 2017 Feb 20. doi: 10.1097/QAI.0000000000001327. [Epub ahead of print]

Background: Age-disaggregated analyses of prevention of mother-to-child transmission (PMTCT) program data to assess the uptake of HIV services by pregnant adolescent women are limited but are critical to understanding the unique needs of this vulnerable, high risk population.

Methods: We conducted a retrospective analysis of patient-level PMTCT data collected from 2011 to 2013 in 36 health facilities in 5 districts of Zimbabwe using an electronic database. We compared uptake proportions for PMTCT services between adolescent (< 19 years) and adult (> 19 years) women. Multivariable binomial regression analysis was used to estimate the association of the women's age group with each PMTCT service indicator.

Results: The study analysed data from 22 215 women aged 12 to 50 years (22.5% adolescents). Adolescents were more likely to present to ANC before 14 weeks gestational age compared to older women (adjusted relative risk (aRR)=1.34; 95% confidence interval (CI): 1.22-1.47) with equally low rates of completion of four ANC visits. Adolescents were less likely to present with known HIV status (aRR=0.34; 95% CI: 0.29-0.41) but equally likely to be HIV tested in ANC. HIV prevalence was 5.5% in adolescents versus 20.1% in adults. While > 84% of both HIV-positive groups received ARVs for PMTCT, 44% of eligible adolescents were initiated on ART versus 51.3% of eligible adults, though not statistically significant.

Conclusions: Pregnant adolescents must be a priority for primary HIV prevention services and expanded HIV treatment services among pregnant women to achieve an AIDS-free generation in Zimbabwe and similar high HIV burden countries.

Abstract access  

Editor’s notes: Young women continue to be a key population at risk of acquiring HIV, and contribute approximately one-third of all new infections in sub-Saharan Africa. Young women face multiple legal, economic and social vulnerabilities that place them not only at higher risk of acquiring HIV but may also have an impact on their ability to access antenatal care (ANC) services and programmes to prevent mother-to-child HIV transmission (PMTCT) if they get pregnant. This in turn has implications for the goal of eliminating paediatric HIV infection.

This retrospective study compared the uptake of PMTCT services between adolescents (people aged 19 years and below) and older women accessing ANC in 36 public sector services across Zimbabwe. The study was conducted between 2011 and 2013, when PMTCT guidelines recommended Option A. Option A called for life-long antiretroviral therapy (ART) for women who were ART-eligible based on immunological or clinical criteria; or, for people ineligible, zidovudine monotherapy through pregnancy followed by single dose nevirapine at the onset of labour. It is no longer formally recommended by World Health Organization (WHO), although it is still used in some countries.      

Nearly a quarter of all women were adolescents and over 80% were on their first pregnancy or primigravid. Adolescent women were 34% more likely to attend their first ANC visit by 14 weeks of gestational age compared to adult women. But among both groups, only about 10% attended their first ANC visit in the first trimester and less than 40% attended the four antenatal visits recommended by WHO. Notably, knowledge of HIV status prior to the first ANC attendance was 66% lower in adolescent women, even after adjusting for parity and facility type, with only 3.1% aware of their HIV status. In addition, the proportion of women who were known HIV-positive and taking ART was also lower, although this may be due partly to fewer adolescents being eligible for ART. The uptake of HIV testing (over 95%) and uptake of zidovudine prophylaxis was high among all women. However, there was a suggestion that adolescents were less likely than older women to start ART if they were eligible, although this was not statistically significant. Indeed, several studies in the region have demonstrated lower levels of ART initiation among pregnant adolescents compared to older women.  

Older women would have been more likely to have undergone HIV testing in previous pregnancies. However, even after adjusting for parity, this study demonstrates that adolescents are less likely to have previously accessed HIV testing. Common barriers to testing highlighted by other studies include lack of information, unavailability of HIV testing services, unfriendly HIV testing environments in health facilities and the need for parental consent. Lack of knowledge of HIV status prior to pregnancy is also a missed opportunity for family planning, and initiation of ART prior to pregnancy. The substantial difference in HIV prevalence among adolescents compared to older women highlights the critical need for implementing prevention programmes such as pre-exposure prophylaxis among young women in high HIV prevalence settings. While adolescents are less likely to be tested for HIV in the general population than adults, this study illustrates that when HIV testing is offered in appropriate, supportive environments, uptake is high.

Overall, the uptake of HIV testing and of prophylaxis were high, demonstrating the potential for eliminating infections in children. A major limitation is that this analysis was limited to women who had sought antenatal care. Promoting early ANC attendance is important to allow early ART initiation, to reduce the risk of intrauterine HIV transmission. Following a positive HIV test result, particular attention is necessary to ensure linkage to care and support for sustained adherence to ART.

Africa
Zimbabwe
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Thai PrEP Open-label study illustrates better adherence in people at higher risk of HIV

Factors associated with the uptake of and adherence to HIV pre-exposure prophylaxis in people who have injected drugs: an observational, open-label extension of the Bangkok Tenofovir Study.

Martin M, Vanichseni S, Suntharasamai P, Sangkum U, Mock PA, Chaipung B, Worrajittanon D, Leethochawalit M, Chiamwongpaet S, Kittimunkong S, Gvetadze RJ, McNicholl JM, Paxton LA, Curlin ME, Holtz TH, Samandari T, Choopanya K, on behalf of the Bangkok Tenofovir Study Group. Lancet HIV. 2017 Feb;4(2):e59-e66. doi: 10.1016/S2352-3018(16)30207-7. Epub 2016 Nov 18.

Background: Results of the randomised, double-blind, placebo-controlled Bangkok Tenofovir Study (BTS) showed that taking tenofovir daily as pre-exposure prophylaxis (PrEP) can reduce the risk of HIV infection by 49% in people who inject drugs. In an extension to the trial, participants were offered 1 year of open-label tenofovir. We aimed to examine the demographic characteristics, drug use, and risk behaviours associated with participants' uptake of and adherence to PrEP.

Methods: In this observational, open-label extension of the BTS (NCT00119106), non-pregnant, non-breastfeeding, HIV-negative BTS participants, all of whom were current or previous injecting drug users at the time of enrolment in the BTS, were offered daily oral tenofovir (300 mg) for 1 year at 17 Bangkok Metropolitan Administration drug-treatment clinics. Participant demographics, drug use, and risk behaviours were assessed at baseline and every 3 months using an audio computer-assisted self-interview. HIV testing was done monthly and serum creatinine was assessed every 3 months. We used logistic regression to examine factors associated with the decision to take daily tenofovir as PrEP, the decision to return for at least one PrEP follow-up visit, and greater than 90% adherence to PrEP.

Findings: Between Aug 1, 2013, and Aug 31, 2014, 1348 (58%) of the 2306 surviving BTS participants returned to the clinics, 33 of whom were excluded because they had HIV (n=27) or grade 2-4 creatinine results (n=6). 798 (61%) of the 1315 eligible participants chose to start open-label PrEP and were followed up for a median of 335 days (IQR 0-364). 339 (42%) participants completed 12 months of follow-up; 220 (28%) did not return for any follow-up visits. Participants who were 30 years or older (odds ratio [OR] 1.8, 95% CI 1.4-2.2; p<0.0001), injected heroin (OR 1.5, 1.1-2.1; p=0.007), or had been in prison (OR 1.7, 1.3-2.1; p<0.0001) during the randomised trial were more likely to choose PrEP than were those without these characteristics. Participants who reported injecting heroin or being in prison during the 3 months before open-label enrolment were more likely to return for at least one open-label follow-up visit than those who did not report injecting heroin (OR 3.0, 95 % CI 1.3-7.3; p=0.01) or being in prison (OR 2.3, 1.4-3.7; p=0.0007). Participants who injected midazolam or were in prison during open-label follow-up were more likely to be greater than 90% adherent than were those who did not inject midazolam (OR 2.2, 95% CI 1.2-4.3; p=0.02) or were not in prison (OR 4.7, 3.1-7.2; p<0.0001). One participant tested positive for HIV, yielding an HIV incidence of 2.1 (95% CI 0.05-11.7) per 1000 person-years. No serious adverse events related to tenofovir use were reported.

Interpretation: More than 60% of returning, eligible BTS participants started PrEP, which indicates that a substantial proportion of PWID who are knowledgeable about PrEP might be interested in taking it. Participants who had injected heroin or been in prison were more likely to choose to take PrEP, suggesting that participants based their decision to take PrEP, at least in part, on their perceived risk of incident HIV infection.

Abstract access  

Editor’s notes: Following the clinical trials assessing the efficacy of oral pre-exposure prophylaxis (PrEP) for HIV prevention, several of the trial teams and others have undertaken open-label extension and implementation studies. These were conducted to investigate the ‘real-world’ delivery of PrEP among key populations in various settings throughout the world. This paper presents the open-label study following the Bangkok Tenofovir Study (BTS) where oral PrEP was offered to participants, people who inject (or injected) drugs, for one year in the BTS study clinics. Unique to this study was the element of observed daily dosing at the clinics where participants were required to attend in order to access their PrEP. Results of the study are largely in line with reports from other similar studies, where people with more HIV-associated risk factors tended to adhere better and were more likely to take up and use PrEP. Interestingly, having a casual partner was not associated with better adherence, however, the number of casual partners reported by participants decreased during the study period, and there was no observed increase in other risky behaviours such as injecting drug use or sharing needles. One other additional point of note was the relatively higher adherence seen among prisoners and other incarcerated people which could point to consistent and easy access as a strong motivator to take PrEP. These results are an important contribution to the growing body of evidence around PrEP implementation which seems to suggest that people with a higher risk will be appropriately self-selecting for uptake of the programme. 

Asia
Thailand
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Psychological distress and HIV after financial meltdown in Zimbabwe

Prevalence and associations of psychological distress, HIV Infection and HIV care service utilization in East Zimbabwe.

Tlhajoane M, Eaton JW, Takaruza A, Rhead R, Maswera R, Schur N, Sherr L, Nyamukapa C, Gregson S. AIDS Behav. 2017 Feb 13. doi: 10.1007/s10461-017-1705-x. [Epub ahead of print]

The correlation between mental health and sexual risk behaviours for HIV infection remains largely unknown in low and middle income settings. The present study determined the prevalence of psychological distress (PD) in a sub-Saharan African population with a generalized HIV epidemic, and investigated associations with HIV acquisition risk and uptake of HIV services using data from a cross-sectional survey of 13,252 adults. PD was measured using the Shona Symptom Questionnaire. Logistic regression was used to measure associations between PD and hypothesized covariates. The prevalence of PD was 4.5% (95% CI 3.9-5.1%) among men, and 12.9% (95% CI 12.2-13.6%) among women. PD was associated with sexual risk behaviours for HIV infection and HIV-infected individuals were more likely to suffer from PD. Amongst those initiated on anti-retroviral therapy, individuals with PD were less likely to adhere to treatment (91 vs. 96%; age- and site-type-adjusted odds ratio = 0.38; 95% CI 0.15, 0.99). Integrated HIV and mental health services may enhance HIV care and treatment outcomes in high HIV-prevalence populations in sub-Saharan Africa.

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Editor’s notes: Psychological distress can lead to increased use of alcohol and drugs, sexual risk behaviour, and hence increased risk of HIV acquisition. In rural Manicaland, the fifth survey round of an open population cohort measured psychological distress for the first time in 2009-2011, following the Zimbabwe hyperinflation crisis of 2008-2009.

Psychological distress was highly prevalent, especially among women, as was HIV infection. Overall, HIV prevalence was 12.7% in men and 18.3% in women. Psychological distress and HIV were also clearly associated. Among people with psychological distress HIV prevalence was 18.8% for men and 27.2% for women, compared to 12.4% and 17.1% for men and women respectively without psychological distress.

People living with HIV (identified by anonymous testing) who had psychological distress were more likely to have had an HIV test than people without psychological distress, although this could be reversed to mean that people with HIV who knew their status were more likely to have psychological distress than people who did not. If diagnosed and on antiretroviral therapy, people with psychological distress also had poorer adherence, supporting findings of other studies.

A main challenge to interpreting these results is a lack of information on poverty and how it may have impacted both psychological distress and risk of HIV acquisition. Only one survey round used the Shona Symptom Questionnaire so the study is essentially a cross-sectional survey. Women with psychological distress were more likely to have transactional sex, engage in sex work and not use condoms, but it is not clear that these behaviours were consequences of psychological distress. Instead, both the behaviours and the distress could have been caused by poverty constraints and lack of options. The only economic variables measured were time of year (as a proxy for food availability) and employment status (employed/unemployed). Being employed was associated with lower risk of psychological distress for women, but had no effect for men.

Africa
Zimbabwe
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Treatment of depression at antiretroviral initiation could have a considerable impact on mortality

Depression at antiretroviral therapy initiation and clinical outcomes among a cohort of Tanzanian women living with HIV.

Sudfeld CR, Kaaya S, Gunaratna NS, Mugusi F, Fawzi WW, Aboud S, Smith Fawzi. AIDS. 2017 Jan 14;31(2):263-271. doi: 10.1097/QAD.0000000000001323.

Objective: The objective of the study was to assess the relationship of depression at antiretroviral therapy (ART) initiation with mortality and clinical outcomes among Tanzanian women living with HIV.

Design: We conducted a prospective cohort study of 1487 women who initiated ART in Dar es Salaam, Tanzania.

Methods: Symptoms of depression and anxiety were assessed using a Tanzanian-adapted and validated version of the Hopkins Symptom Checklist. Participants attended monthly clinic visits during the first 2 years of ART and CD4 T-cell counts were assessed every 4 months. Proportional hazard models were used to assess the relationship of depression with mortality and clinical outcomes.

Results: Symptoms consistent with depression were prevalent among 57.8% of women at ART initiation. After multivariate adjustment, including social support and stigma, depression at ART initiation was associated with increased risk of mortality [hazard ratio (HR): 1.92; 95% confidence interval (CI): 1.15-3.20; P = 0.01] and incidence of severe anemia (hemoglobin <8.5 g/dl; HR: 1.59; 95% CI: 1.07-2.37; P = 0.02). Under the assumption of causality, we estimate 36.1% (95% CI: 13.6-55.1%) of deaths among the study cohort were attributable to depression and its consequences. Depression was not significantly associated with trajectory of CD4 T-cell reconstitution or the risk of immunologic failure (P values >0.05).

Conclusion: Elimination of depression may reduce mortality during the first 2 years of ART by one-third in our study cohort. Randomized trials and rigorous implementation studies are needed to evaluate the individual and population-level effects of integrated mental health interventions and HIV treatment approaches in resource-limited settings.

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Editor’s notes: People living with HIV are more than twice as likely to have depression than the general population, in both high- and low-income settings. Many studies in high-income countries have illustrated that depression is associated with poor HIV-associated outcomes. There have been relatively few longitudinal studies on this from low-income settings. This study, among women in Tanzania living with HIV, found that over half had symptoms consistent with depression at ART initiation, and this was associated with a two-fold risk of mortality. The results suggest that effective programmes which address depression, such as problem-solving therapy or cognitive behaviour therapy, at ART initiation, could have a considerable impact on mortality. There is a need to evaluate appropriate mental health programmes integrated with HIV strategies in resource-limited settings that address the specific needs of different populations of people living with HIV, such as children and adolescents   

Africa
United Republic of Tanzania
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Outcomes on ART among children and adolescents in Latin America

Mortality in children with human immunodeficiency virus initiating treatment: a six-cohort study in Latin America.

Luque MT, Jenkins CA, Shepherd BE, Padgett D, Rouzier V, Succi RC, Machado DM, McGowan CC, Vermund SH, Pinto JA. J Pediatr. 2017 Jan 9. pii: S0022-3476(16)31433-0. doi: 10.1016/j.jpeds.2016.12.034. [Epub ahead of print]

Objectives: To assess the risks of and factors associated with mortality, loss to follow-up, and changing regimens after children with HIV infected perinatally initiate combination antiretroviral therapy (cART) in Latin America and the Caribbean.

Study design: This 1997-2013 retrospective cohort study included 1174 antiretroviral therapy-naive, perinatally infected children who started cART when they were younger than 18 years of age (median 4.7 years; IQR 1.7-8.8) at 1 of 6 cohorts from Argentina, Brazil, Haiti, and Honduras, within the Caribbean, Central and South America Network for HIV Epidemiology. Median follow-up was 5.6 years (IQR 2.3-9.3). Study outcomes were all-cause mortality, loss to follow-up, and major changes/interruption/stopping of cART. We used Cox proportional hazards models stratified by site to examine the association between predictors and times to death or changing regimens.

Results: Only 52% started cART at younger than 5 years of age; 19% began a protease inhibitor. At cART initiation, median CD4 count was 472 cells/mm3 (IQR 201-902); median CD4% was 16% (IQR 10-23). Probability of death was high in the first year of cART: 0.06 (95% CI 0.04-0.07). Five years after cART initiation, the cumulative mortality incidence was 0.12 (95% CI 0.10-0.14). Cumulative incidences for loss to follow-up and regimen change after 5 years were 0.16 (95% 0.14-0.18) and 0.30 (95% 0.26-0.34), respectively. Younger children had the greatest risk of mortality, whereas older children had the greatest risk of being lost to follow-up or changing regimens.

Conclusions: Innovative clinical and community approaches are needed for quality improvement in the pediatric care of HIV in the Americas.

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Editor’s notes: Despite the dramatic declines in mortality with antiretroviral therapy (ART), mortality rates among children living with HIV still remain substantially higher than in the general paediatric population in high-income settings, such as in the United States of America. Mortality rates after ART initiation are even higher in sub-Saharan Africa, likely because children initiate ART at older ages and at more advanced stages of disease. There are, however, no data available for Latin America and the Caribbean, which has had a mostly stable epidemic with a slowly declining adult HIV incidence over the past decade.

In this retrospective cohort study, the authors investigate mortality, loss-to-follow-up (LTFU) and regimen change among children who acquired HIV in the perinatal period from Argentina, Haiti, Honduras and Brazil. They initiated ART aged below 18 years. About half of all children started ART aged over five years, and a third had clinical AIDS by the time they initiated ART. This would suggest that paediatric HIV programmes in this region face similar challenges to those seen in African programmes, including failure of prevention of mother-to-child HIV transmission (PMTCT) programmes and late diagnosis of children.

As expected, a low baseline CD4 count and clinical AIDS at baseline were both associated with an increased risk of mortality. Importantly, younger age at starting ART was also associated with an increased hazard of death, as was being an adolescent (although the association was weaker). The most likely reason for this is that the youngest children placed on ART may have been initiated following presentation with fast-progressing disease, and would therefore have a higher risk of death than comparatively healthier and stable older children. The higher risk of death among the adolescents likely reflects delayed diagnosis of slow-progressors in adolescence.   

Another important finding was the significantly higher risk of LTFU and regimen change in adolescents compared to younger children. This finding, also noted in African and high-income setting cohorts, highlights the challenges of retaining adolescents in care, addressing treatment fatigue, and possibly increased risk of attrition from care during transitioning from paediatric to adult services. 

In summary, HIV care outcomes in children in Latin America and the Caribbean appear to be similar to those reported in other settings. Together, they highlight the pressing need for strengthening prevention of mother-to-child HIV transmission programmes, particularly follow-up and prompt testing of HIV-exposed infants. It also emphasizes the need for innovative approaches to support children to stay in care and maintain long-term adherence. 

Latin America
Argentina, Brazil, Haiti, Honduras
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HIV Self-testing acceptable to vocational students in South Africa

High acceptability of HIV self-testing among technical vocational education and training college students in Gauteng and North West province: what are the implications for the scale up in South Africa?

Mokgatle MM, Madiba S. PLoS One. 2017 Jan 31;12(1):e0169765. doi: 10.1371/journal.pone.0169765. eCollection 2017.

Background: Although HIV self-testing (HIVST) is globally accepted as an important complement to existing HIV testing approaches, South Africa has lagged behind in its adoption. As a result, data on the acceptability and uptake of HIVST is limited. The study investigated the acceptability of HIVST among students in Technical Vocational Education and Training (TVET) colleges in two provinces in South Africa.

Methods: A cross-sectional survey using a self-administered structured questionnaire was used to collect data among 3662 students recruited from 13 TVET colleges.

Results: The mean age of the students was 21.9 years. The majority (80.9%) were sexually active; while 66.1% reported that they had one sexual partner, and 33.9% had two or more sexual partners in the past year, and 66.5% used condoms during the last sexual act. Three-quarters tested for HIV in the past year but less than half knew about HIVST prior to the survey. The acceptability of HIVST was high; about three-quarters showed a willingness to purchase a self-test kit and a majority would self-test with partners. Acceptability of HIVST was associated with being sexually active (OR = 1.73, p = 0.02, confidence interval (CI): 1.08-2.75), having ever been tested for HIV (OR = 1.74, p = 0.001, CI: 1.26-2.38), and having multiple sexual partners (OR = 0.61, p = 0.01, CI: 0.42-0.88). Three-quarters would confirm test results at a local health facility. In terms of counselling, telephone hotlines were acceptable to only 39.9%, and less than half felt that test-kit leaflets would provide sufficient information to self-test.

Interpretations: The high acceptability of HIVST among the students calls for extensive planning and preparation for the scaling up of HIVST in South Africa. In addition, campaigns similar to those conducted to promote HIV counselling and testing (HCT) should be considered to educate communities about HIVST.

Abstract  Full-text [free] access  

Editor’s notes: The percentage of people living with HIV who know their status (the first 90 of the UNAIDS 90:90:90 treatment target) has been consistently well below the stated target in national HIV treatment cascades. HIV self-testing is an exciting strategy being used to increase the uptake of testing, and has recently been adopted in South Africa. This study had two aims; firstly to assess the participants attitudes to currently available HIV counselling and testing services and secondly to assess the level of acceptability of HIV self-testing. The study population were students in technical and vocational education and training colleges in South Africa.

Among people who had not tested for HIV in the past year, reasons given for non-uptake of testing (other than a low perception of risk) included a fear of stigma associated with a positive test or a lack of comfort with testing in a hospital setting. Less than half of participants had heard of HIV self-testing, but when the concept was explained to them, around 80% expressed a willingness to use it if it was available, and 70% were willing to purchase the self-test kit. These results are consistent with other studies of HIV self-testing uptake and acceptability in sub-Saharan Africa.

The stated willingness of participants to present at a clinic for a confirmatory test is encouraging. However, this may not reflect actual behaviour, especially in a setting where there is currently no plan or system to link people with positive HIV self-test results to a clinic for confirmatory testing. However, the drive to improve counselling and linkage around self-testing needs to be balanced against the fundamental principle for HIV self-testing to allow choice for users to test without the need for a health worker to be present, and the privacy associated with this. Further work may include assessing acceptability of using remote services to complement HIV self-testing such as telephone hotlines or other counselling strategies. 

Africa
South Africa
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