Articles tagged as "HIV testing"

Community mobilization programme to increase HIV testing – more work is necessary

Community mobilization for HIV testing uptake: results from a community randomized trial of a theory-based intervention in rural South Africa.

Lippman SA, Neilands TB, MacPhail C, Peacock D, Maman S, Rebombo D, Twine R, Selin A, Leslie HH, Kahn K, Pettifor A. J Acquir Immune Defic Syndr. 2017 Jan 1;74 Suppl 1:S44-S51.

Background: HIV testing uptake in South Africa is below optimal levels. Community mobilization (CM) may increase and sustain demand for HIV testing, however, little rigorous evidence exists regarding the effect of CM interventions on HIV testing and the mechanisms of action.

Methods: We implemented a theory-driven CM intervention in 11 of 22 randomly-selected villages in rural Mpumalanga Province. Cross-sectional surveys including a community mobilization measure were conducted before (n = 1181) and after (n = 1175) a 2-year intervention (2012-2014). We assessed community-level intervention effects on reported HIV testing using multilevel logistic models. We used structural equation models to explore individual-level effects, specifically whether intervention assignment and individual intervention exposure were associated with HIV testing through community mobilization.

Results: Reported testing increased equally in both control and intervention sites: the intervention effect was null in primary analyses. However, the hypothesized pathway, CM, was associated with higher HIV testing in the intervention communities. Every standard deviation increase in village CM score was associated with increased odds of reported HIV testing in intervention village participants (odds ratio: 2.6, P = <0.001) but not control village participants (odds ratio: 1.2, P = 0.53). Structural equation models demonstrate that the intervention affected HIV testing uptake through the individual intervention exposure received and higher personal mobilization scores.

Conclusions: There was no evidence of community-wide gains in HIV testing due to the intervention. However, a significant intervention effect on HIV testing was noted in residents who were personally exposed to the intervention and who evidenced higher community mobilization. Research is needed to understand whether CM interventions can be diffused within communities over time.

Abstract  Full-text [free] access 

Editor’s notes: HIV testing is an integral component of HIV prevention strategies, and essential for achieving the UNAIDS 90-90-90 treatment target. However, testing coverage in many parts of sub-Saharan Africa remains low, particularly among men. Stigma, gender norms, and lack of ‘buy in’ about the benefits of early testing and treatment remain major barriers to testing. 

This cluster-randomised trial of a community mobilization (CM) approach for HIV prevention in South Africa is one of the first to be based around an explicit theoretical model of community change. CM is designed to engage community members and motivate people to achieve a common goal, and has been used successfully in some HIV prevention programmes. The programme focused on young men aged 18-35 years, with an aim to build community support for normative changes that are necessary to tackle social barriers to HIV testing and care. Trial outcomes included gender norms, sexual behaviour and HIV testing uptake. The trial found no overall effect on the uptake of HIV testing – self-reported HIV testing increased significantly in both arms over the two year observation period, with no difference between the programme and control communities. However, CM scores, used to quantify the degree of community engagement, were higher in the programme communities. In addition, individuals with greater exposure to the programme were more likely to report HIV testing. These findings suggest that although the CM programme did have an impact on the individuals exposed to it, the effect did not filter through to the wider community.  

CM strategies are used increasingly in public health programmes, and can be a powerful tool for increasing community awareness and engagement with HIV prevention. The benefit of CM is its ability to diffuse beyond the immediate participants to the community as a whole, to bring about the greatest possible change. However, little is known about why and how these approaches work. As this study illustrates, there is a need to understand more about the underlying mechanisms of change associated with CM, and the factors that contribute to its success.

Africa
South Africa
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Increased risk of death associated with perceived barriers to care at HIV diagnosis in South Africa

Barriers to care and 1-year mortality among newly-diagnosed HIV-infected people in Durban, South Africa.

Bassett IV, Coleman SM, Giddy J, MfamMed, Bogart LM, Chaisson CE, Ross D, Flash MJ, Govender T, Walensky RP, Freedberg KA, Losina E. J Acquir Immune Defic Syndr. 2017 Apr 1;74(4):432-438.  doi: 10.1097/QAI.0000000000001277. 2016 Dec 30. [Epub ahead of print]

Background: Prompt entry into HIV care is often hindered by personal and structural barriers. Our objective was to evaluate the impact of self-perceived barriers to healthcare on 1-year mortality among newly diagnosed HIV-infected individuals in Durban, South Africa.

Methods: Prior to HIV testing at four outpatient sites, adults (≥18y) were surveyed regarding perceived barriers to care including: 1) service delivery; 2) financial; 3) personal health perception; 4) logistical; and 5) structural. We assessed deaths via phone calls and the South African National Population Register. We used multivariable Cox proportional hazards models to determine the association between number of perceived barriers and death within one year.

Results: 1899 HIV-infected participants enrolled. Median age was 33 years (IQR: 27-41y), 49% were female, and median CD4 count was 192/µl (IQR: 72-346/µl). 1057 participants (56%) reported no, 370 (20%) reported 1-3, and 460 (24%) reported >3 barriers to care. By one year, 250 (13%, 95% CI: 12%, 15%) participants died. Adjusting for age, sex, education, baseline CD4 count, distance to clinic, and TB status, participants with 1-3 barriers (adjusted hazard ratio [aHR]: 1.49, 95% CI: 1.06, 2.08) and >3 barriers (aHR: 1.81, 95% CI: 1.35, 2.43) had higher 1-year mortality risk compared to those without barriers.

Conclusions: HIV-infected individuals in South Africa who reported perceived barriers to medical care at diagnosis were more likely to die within one year. Targeted structural interventions such as extended clinic hours, travel vouchers, and streamlined clinic operations may improve linkage to care and ART initiation for these people.

Abstract access  

Editor’s notes: Mortality among people living with HIV remains high in South Africa. Suboptimal engagement in HIV care is noted to be a significant contributor to this, with many deaths occurring before people have even started antiretroviral therapy. Potential barriers to care range from personal, such as perceived good health therefore believing antiretroviral therapy is not necessary, to logistical, such as a lack of transportation, to structural barriers such as busy clinics and long waits for care. Barriers perceived by the patient may also be different to barriers perceived by providers of care.

This study sought to explore self-perceived barriers to care at the time of testing for HIV and their impact on one-year mortality. This was in the context of a trial testing whether or not health system navigators improved linkage to and retention in care. Between 2010 and 2013, adults attending for HIV testing across four clinics in Durban, South Africa enrolled in this trial, completed a baseline questionnaire. This examined self-perceived barriers to care, their emotional health and social support. Participants found to be HIV positive were followed up via phone within 12 months. Limited clinical data was sought from clinic notes. Any reported deaths were confirmed by a national register.

Some 1887 participants were enrolled and subsequently diagnosed with HIV. Some 250 people died by 12 months post enrollment. A myriad of barriers were reported, the most common being associated with personal health, service delivery and structural issues. However, it was the sum of barriers that was predictive of risk. People with one or more perceived barriers had a higher one-year mortality risk compared to people without perceived barriers. Furthermore, it was illustrated that the greater the number of perceived barriers, the greater the risk of mortality. The risk for people with greater than three perceived barriers was double that of people with three or less barriers (22% versus 11%). Interestingly, there was no significant impact of emotional and social support as reported at baseline.

Limitations noted by the authors include a possible overestimation of deaths attributable to HIV, since there were no specific data on the cause of death. Data on co-morbidities (apart from tuberculosis) were also not collected and their potential impact on mortality is not addressed. However, it may be fair to assume that any barriers to HIV care would also extend to affecting access to other forms of healthcare. Overall, the study highlights perceived barriers at diagnosis as plausible factors to address when shaping programmes to improve retention in care. 

Africa
South Africa
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Assisted partner services a safe, effective strategy to identify undiagnosed HIV cases in sub-Saharan Africa

Assisted partner services for HIV in Kenya: a cluster randomised controlled trial.

Cherutich P, Golden MR, Wamuti B, Richardson BA, Asbjornsdottir KH, Otieno FA, Ng'ang'a A, Mutiti PM, Macharia P, Sambai B, Dunbar M, Bukusi D, Farquhar C. Lancet HIV. 2016 Nov 29. pii: S2352-3018(16)30214-4. doi: 10.1016/S2352-3018(16)30214-4. [Epub ahead of print]

Background: Assisted partner services for index patients with HIV infections involves elicitation of information about sex partners and contacting them to ensure that they test for HIV and link to care. Assisted partner services are not widely available in Africa. We aimed to establish whether or not assisted partner services increase HIV testing, diagnoses, and linkage to care among sex partners of people with HIV infections in Kenya.

Methods: In this cluster randomised controlled trial, we recruited non-pregnant adults aged at least 18 years with newly or recently diagnosed HIV without a recent history of intimate partner violence who had not yet or had only recently linked to HIV care from 18 HIV testing services clinics in Kenya. Consenting sites in Kenya were randomly assigned (1:1) by the study statistician (restricted randomisation; balanced distribution in terms of county and proximity to a city) to immediate versus delayed assisted partner services. Primary outcomes were the number of partners tested for HIV, the number who tested HIV positive, and the number enrolled in HIV care, in those who were interviewed at 6 week follow-up. Participants within each cluster were masked to treatment allocation because participants within each cluster received the same intervention. This trial is registered with ClinicalTrials.gov, number NCT01616420.

Findings: Between Aug 12, 2013, and Aug 31, 2015, we randomly allocated 18 clusters to immediate and delayed HIV assisted partner services (nine in each group), enrolling 1305 participants: 625 (48%) in the immediate group and 680 (52%) in the delayed group. 6 weeks after enrolment of index patients, 392 (67%) of 586 partners had tested for HIV in the immediate group and 85 (13%) of 680 had tested in the delayed group (incidence rate ratio 4.8, 95% CI 3.7-6.4). 136 (23%) partners had new HIV diagnoses in the immediate group compared with 28 (4%) in the delayed group (5.0, 3.2-7.9) and 88 (15%) versus 19 (3%) were newly enrolled in care (4.4, 2.6-7.4). Assisted partner services did not increase intimate partner violence (one intimate partner violence event related to partner notification or study procedures occurred in each group).

Interpretation: Assisted partner services are safe and increase HIV testing and case-finding; implementation at the population level could enhance linkage to care and antiretroviral therapy initiation and substantially decrease HIV transmission.

Abstract access  

Editor’s notes: One of the greatest challenges to achieving goals such as the UNAIDS 90:90:90 treatment target is the development of more effective strategies to enable people undiagnosed living with HIV to be tested and engaged with care. One strategy for achieving this in high-income settings, albeit with a very limited evidence base, is assisted partner services. In this approach, health-care workers identify and attempt to contact the sexual partners of people recently diagnosed with HIV. These partners are then encouraged to be tested and engaged with care. This pragmatic cluster randomised study, conducted in Kenya, aimed to assess whether assisted partner services were feasible in a sub-Saharan African setting and if so, to measure the effectiveness in terms of additional individuals testing for HIV, receiving new HIV diagnoses and engaging with care as a result of the programme.

The results were striking, in that six weeks after enrolment almost five times as many partners of index cases in the immediate group (partners contacted  at enrolment) had been tested for HIV compared to the delayed group (partners contacted  six weeks after enrolment). There were five times as many new HIV diagnoses in the immediate group compared to the delayed group. There were also four times as many partners newly engaged with care in the immediate arm compared to the delayed arm. There was also no evidence that the tracing of sexual partners led to an increase in intimate partner violence.

These results illustrate that assisted partner services can make an important contribution to identifying people living with HIV who are undiagnosed, enabling people to get tested and engaged with care in a low-income setting. A major challenge, identified by the study authors, is whether the human resources would be available in already highly stretched settings to implement this strategy. They suggest that task shifting from professional healthcare providers to a less highly educated cadre of workers would be feasible and point to other areas of care such as safe male circumcision and ART delivery, where this has been successfully achieved. 

Africa
Kenya
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Home-based HIV testing more effective than community testing, but fewer linked to care

A comparison of home-based versus outreach event-based community HIV testing in Ugandan fisherfolk communities.

Bogart LM, Wagner GJ, Musoke W, Naigino R, Linnemayr S, Maistrellis E, Klein DJ, Jumamil RB, Mukasa B, Bassett IV, Giordano TP, Wanyenze RK. AIDS Behav. 2016 Nov 29. [Epub ahead of print]

We compared two community-based HIV testing models among fisherfolk in Lake Victoria, Uganda. From May to July 2015, 1364 fisherfolk residents of one island were offered (and 822 received) home-based testing, and 344 fisherfolk on another island were offered testing during eight community mobilization events (outreach event-based testing). Of 207 home-based testing clients identified as HIV-positive (15% of residents), 82 were newly diagnosed, of whom 31 (38%) linked to care within 3 months. Of 41 who screened positive during event-based testing (12% of those tested), 33 were newly diagnosed, of whom 24 (75%) linked to care within 3 months. Testing costs per capita were similar for home-based ($45.09) and event-based testing ($46.99). Compared to event-based testing, home-based testing uncovered a higher number of new HIV cases but was associated with lower linkage to care. Novel community-based test-and-treat programs are needed to ensure timely linkage to care for newly diagnosed fisherfolk.

Abstract access  

Editor’s notes: Regular and reliable HIV testing is necessary to ensure that people who need antiretroviral treatment know their status. When someone tests positive for HIV, it is critical that they are linked to care. This study compares two different types of HIV testing among fisherfolk in Uganda – home-based and community event-based testing. The authors find that home-based testing uncovered more people living with HIV than community event-based testing, but a lower proportion of people were successfully linked to care. The costs of both types of testing were similar. Fewer new people living with HIV were identified through community event-based testing. People who know that they are HIV positive are perhaps more likely to attend such events than people who have not sought to be tested recently, or who are HIV negative. Home-based testing requires less effort from persons receiving a test, and therefore may reach people less likely to test independently. This study further emphasises that linkage to care is a critical step in the HIV treatment cascade.

HIV testing
Africa
Uganda
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At the halfway mark? Community viral suppression in East Africa

Population levels and geographical distribution of HIV RNA in rural Ugandan and Kenyan communities, including serodiscordant couples: a cross-sectional analysis.

Jain V, Petersen ML, Liegler T, Byonanebye DM, Kwarisiima D, Chamie G, Sang N, Black D, Clark TD, Ladai A, Plenty A, Kabami J, Ssemmondo E, Bukusi EA, Cohen CR, Charlebois ED, Kamya MR, Havlir DV. Lancet HIV. 2016 Dec 15. pii: S2352-3018(16)30220-X. doi: 10.1016/S2352-3018(16)30220-X. [Epub ahead of print]

Background: As sub-Saharan Africa transitions to a new era of universal antiretroviral therapy (ART), up-to-date assessments of population-level HIV RNA suppression are needed to inform interventions to optimise ART delivery. We sought to measure population viral load metrics to assess viral suppression and characterise demographic groups and geographical locations with high-level detectable viraemia in east Africa.

Methods: The Sustainable East Africa Research in Community Health (SEARCH) study is a cluster-randomised controlled trial of an HIV test-and-treat strategy in 32 rural communities in Uganda and Kenya, selected on the basis of rural setting, having an approximate population of 10 000 people, and being within the catchment area of a President's Emergency Plan for AIDS Relief-supported HIV clinic. During the baseline population assessment in the SEARCH study, we did baseline HIV testing and HIV RNA measurement. We analysed stable adult (aged 15 years) community residents. We defined viral suppression as a viral load of less than 500 copies per mL. To assess geographical sources of transmission risk, we established the proportion of all adults (both HIV positive and HIV negative) with a detectable viral load (local prevalence of viraemia). We defined transmission risk hotspots as geopolitical subunits within communities with an at least 5% local prevalence of viraemia. We also assessed serodiscordant couples, measuring the proportion of HIV-positive partners with detectable viraemia. The SEARCH study is registered with ClinicalTrials.gov, number NCT01864603.

Findings: Between April 2, 2013, and June 8, 2014, of 303 461 stable residents, we enumerated 274 040 (90.3%), of whom 132 030 (48.2%) were adults. Of these, 117 711 (89.2%) had their HIV status established, of whom 11 964 (10.2%) were HIV positive. Of these, we measured viral load in 8828 (73.8%) people. Viral suppression occurred in 3427 (81.6%) of 4202 HIV-positive adults on ART and 4490 (50.9%) of 8828 HIV-positive adults. Regional viral suppression among HIV-positive adults occurred in 881 (48.2%) of 1827 people in west Uganda, 516 (45.0%) of 1147 in east Uganda, and 3093 (52.8%) of 5854 in Kenya. Transmission risk hotspots occurred in three of 21 parishes in west Uganda and none in east Uganda and in 24 of 26 Kenya geopolitical subunits. In Uganda, 492 (2.9%) of 16 874 couples were serodiscordant: in 287 (58.3%) of these couples, the HIV-positive partner was viraemic (and in 69 [14.0%], viral load was >100 000 copies per mL). In Kenya, 859 (10.0%) of 8616 couples were serodiscordant: in 445 (53.0%) of these couples, the HIV-positive partner was viraemic (and in 129 [15%], viral load was >100 000 copies per mL).

Interpretation: Before the start of the SEARCH trial, 51% of east African HIV-positive adults had viral suppression, reflecting ART scale-up efforts to date. Geographical hotspots of potential HIV transmission risk and detectable viraemia among serodiscordant couples warrant intensified interventions.

Abstract access  

Editor’s notes: Half of all people living with HIV with a valid viral load measurement in these East African communities had viral suppression (<500 copies/mL) at the start of this cluster randomised trial in 2013-14. These results already provided good evidence of the effectiveness and impact of antiretroviral programmes in East Africa. However, at the AIDS conference in July 2016 the study group presented updated results following two years of a universal test and treat (UTT) strategy with expansion of community-based HIV testing services (access abstract here). By this point, the UNAIDS 90-90-90 treatment target had been exceeded in the study communities and, overall, 82% of people living with HIV had viral suppression. 

These results highlight the role of community viral load metrics as indicators of programme impact. What gives rise to more debate is the role of these metrics in estimating the risk of ongoing HIV transmission in the community. Consensus seems to be emerging that the population prevalence of viraemia may be the metric best suited for this purpose. In this study, the estimated population prevalence of viraemia varied quite widely from 0.5 to 14.1% at the level of local communities (of between around 500 and 5000 people). This measure was also used to define several transmission hotspots, based on an arbitrary cut-off of five percent prevalence of viraemia.

Additional research is necessary in different epidemiological contexts to understand the association between these metrics and risk of HIV transmission. There is also some way to go to understand if such metrics can have practical public health implications for HIV prevention. Whether revealing such heterogeneity in transmission risk within generalized epidemics can inform the application of geographically focussed programmes is a question that now should be addressed.

Africa
Kenya, Uganda
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Creating welcoming spaces for men’s active involvement

What do you need to get male partners of pregnant women tested for HIV in resource limited settings? The baby shower cluster randomized trial.

Ezeanolue EE, Obiefune MC, Yang W, Ezeanolue CO, Pharr J, Osuji A, Ogidi AG, Hunt AT, Patel D, Ogedegbe G, Ehiri JE. AIDS Behav. 2016 Dec 8. [Epub ahead of print]

Male partner involvement has the potential to increase uptake of interventions to prevent mother-to-child transmission of HIV (PMTCT). Finding cultural appropriate strategies to promote male partner involvement in PMTCT programs remains an abiding public health challenge. We assessed whether a congregation-based intervention, the Healthy Beginning Initiative (HBI), would lead to increased uptake of HIV testing among male partners of pregnant women during pregnancy. A cluster-randomized controlled trial of forty churches in Southeastern Nigeria randomly assigned to either the HBI (intervention group; IG) or standard of care referral to a health facility (control group; CG) was conducted. Participants in the IG received education and were offered onsite HIV testing. Overall, 2498 male partners enrolled and participated, a participation rate of 88.9%. Results showed that male partners in the IG were 12 times more likely to have had an HIV test compared to male partners of pregnant women in the CG (CG = 37.71% vs. IG = 84.00%; adjusted odds ratio = 11.9; p < .01). Culturally appropriate and community-based interventions can be effective in increasing HIV testing and counseling among male partners of pregnant women.

Abstract  Full-text [free] access

Editor’s notes: Barriers to male partner participation in antenatal care in sub-Saharan Africa include the timing of antenatal services during work hours and negative health care provider attitudes. Importantly, they also include gender norms against male participation that are anchored in deep-seated perceptions that pregnancy is a woman’s affair. This highly successful trial resulted in verified HIV testing by 84% of male partners in the programme group and 38% in the control group, well above the overall HIV testing uptake by males in Nigeria at the time of 23%. What were the elements of the programme that contributed to its success? Critically, it was conducted in communities where religious institutions and their leaders have strong community influence and where nearly 90% of the population attends places of worship. Next, it proposed integrated testing (haemoglobin, malaria, sickle cell genotype, HIV, hepatitis B, and syphilis) to reduce stigma associated with HIV testing. It included the haemoglobin test because men indicated in the formative stages that they wanted this test to find out how strong they were. Then, it engaged the couples publically, with the religious leader inviting all pregnant women and their partners each Sunday to approach the altar for a prayer, accompanied by information about the baby shower programme and the importance of antenatal care. The programme ran baby showers monthly for all participants with the programme group playing an educational game and being offered free integrated HIV testing. The control group was referred to a local health facility for antenatal care and free HIV testing. At baby receptions held every two to three months, the control groups were offered free integrated HIV testing. All in all, HIV testing for male partners was convenient, free, and integrated with other tests that men wanted. It was provided in a family-centred, congregation-based enabling environment that supported men to step forward with their pregnant partners to learn their HIV status. Such a strategy could work in other settings where influential community leaders are prepared to lead the design and implementation of innovative HIV prevention programmes that resonate with community cultural and spiritual values.

Africa
Nigeria
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Community-based HIV testing for MSM: available at an acceptable cost in Europe

Economic evaluation of HIV testing for men who have sex with men in community-based organizations - results from six European cities.

Perelman J, Rosado R, Amri O, Morel S, Rojas Castro D, Chanos S, Cigan B, Lobnik M, Fuertes R, Pichon F, Slaaen Kaye P, Agusti C, Fernandez-Lopez L, Lorente N, Casabona J. AIDS Care. 2016 Dec 27:1-5. doi: 10.1080/09540121.2016.1271392. [Epub ahead of print]

The non-decreasing incidence of HIV among men who have sex with men (MSM) has motivated the emergence of Community Based Voluntary Counselling and Testing (CBVCT) services specifically addressed to MSM. The CBVCT services are characterized by facilitated access and linkage to care, a staff largely constituted by voluntary peers, and private not-for-profit structures outside the formal health system institutions. Encouraging results have been measured about their effectiveness, but these favourable results may have been obtained at high costs, questioning the opportunity to expand the experience. We performed an economic evaluation of HIV testing for MSM at CBVCT services, and compared them across six European cities. We collected retrospective data for six CBVCT services from six cities (Copenhagen, Paris, Lyon, Athens, Lisbon, and Ljubljana), for the year 2014, on the number of HIV tests and HIV reactive tests, and on all expenditures to perform the testing activities. The total costs of CBVCTs varied from 54 390€ per year (Ljubljana) to 245 803€ per year (Athens). The cost per HIV test varied from to 41€ (Athens) to 113€ (Ljubljana). The cost per HIV reactive test varied from 1966€ (Athens) to 9065€ (Ljubljana). Our results show that the benefits of CBVCT services are obtained at an acceptable cost, in comparison with the literature (values, mostly from the USA, range from 1600$ to 16 985$ per HIV reactive test in clinical and non-clinical settings). This result was transversal to several European cities, highlighting that there is a common CBVCT model, the cost of which is comparable regardless of the epidemiological context and prices. The CBVCT services represent an effective and "worth it" experience, to be continued and expanded in future public health strategies towards HIV.

Abstract access

Editor’s notes: Although HIV incidence among some key populations in Europe has declined in recent years, new cases among gay men and other men who have sex with men have steadily increased over the last decade. Among those new cases, over a third are reported late, leading to worse health outcomes for the person, as well as an increased risk of onward transmission. As a result, community-based voluntary counselling and testing has been rolled out in European cities to encouraging results in terms of effectiveness.

In that context, the authors of this paper have carried out an economic evaluation of community-based voluntary counselling and testing programmes in six cities across Europe (Athens, Copenhagen, Lisbon, Lyon, Paris and Ljubljana). They collected total annual costs of running the programmes. They found that the cost per HIV test ranged from €41 in Athens to €113 in Ljubljana and the cost per reactive HIV test ranged from €1966 to €9065 in the same two cities. The authors found that these costs are acceptable compared to those found in the literature.

Oddly, one of the more interesting results found in the article, but not discussed within the text, is the cost per reactive HIV test link to care. This varied in absolute terms (€2297- €20 215) likely due to different linkages to care rates, from 100% in Copenhagen to under 40% in Paris. Given the ultimate aims of testing (which ought to be to improve health outcomes and reduce onward transmission) this is a more important figure than the cost per test. Further research therefore should explore the unit costs further down the treatment cascade resulting from these programmes. These would be, for example, cost per person on treatment and cost per person with a suppressed viral load. 

Europe
Denmark, France, Greece, Portugal, Slovenia
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Is universal antenatal HIV testing still cost-effective?

Should HIV testing for all pregnant women continue? Cost-effectiveness of universal antenatal testing compared to focused approaches across high to very low HIV prevalence settings.

Ishikawa N, Dalal S, Johnson C, Hogan DR, Shimbo T, Shaffer N, Pendse RN, Lo YR, Ghidinelli MN, Baggaley R. J Int AIDS Soc. 2016 Dec 14;19(1):21212. doi: 10.7448/IAS.19.1.21212. eCollection 2016.

Introduction: HIV testing is the entry point for the elimination of mother-to-child transmission of HIV. Decreasing external funding for the HIV response in some low- and middle-income countries has triggered the question of whether a focused approach to HIV testing targeting pregnant women in high-burden areas should be considered. This study aimed at determining and comparing the cost-effectiveness of universal and focused HIV testing approaches for pregnant women across high to very low HIV prevalence settings.

Methods: We conducted a modelling analysis on health and cost outcomes of HIV testing for pregnant women using four country-based case scenarios (Namibia, Kenya, Haiti and Viet Nam) to illustrate high, intermediate, low and very low HIV prevalence settings. We used subnational prevalence data to divide each country into high-, medium- and low-burden areas, and modelled different antenatal and testing coverage in each.

Results: When HIV testing services were only focused in high-burden areas within a country, mother-to-child transmission rates remained high ranging from 18 to 23%, resulting in a 25 to 69% increase in new paediatric HIV infections and increased future treatment costs for children. Universal HIV testing was found to be dominant (i.e. more QALYs gained with less cost) compared to focused approaches in the Namibia, Kenya and Haiti scenarios. The universal approach was also very cost-effective compared to focused approaches, with $ 125 per quality-adjusted life years gained in the Viet Nam-based scenario of very low HIV prevalence. Sensitivity analysis further supported the findings.

Conclusions: Universal approach to antenatal HIV testing achieves the best health outcomes and is cost-saving or cost-effective in the long term across the range of HIV prevalence settings. It is further a prerequisite for quality maternal and child healthcare and for the elimination of mother-to-child transmission of HIV.

Abstract  Full-text [free] access 

Editor’s notes: This paper describes research undertaken to support the consolidated guidelines on HIV testing services, published by World Health Organization in 2015. This analysis was conducted in response to growing questions as to whether focused HIV testing in high prevalence areas can improve value for money in investment for HIV testing.

A model was parameterized to represent four scenarios with high, intermediate, low, and very low HIV prevalence settings (Namibia, Kenya, Haiti, and Viet Nam). Three approaches to HIV testing in antenatal care are considered in comparison with current coverage in each setting. These three approaches were: a very focused approach, a targeted approach, and a universal testing approach for all pregnant women.  The authors estimate the costs and effects of each scenario, including the future costs of treating paediatric HIV for 20 years. Universal testing was found to be cost-saving in Namibia, Kenya and Haiti and was found to be cost-effective in Viet Nam ($125 per QALY gained).  The targeted testing approach was also more cost-effective than current coverage in all settings.

The clear policy implication from this analysis is that HIV testing for pregnant women saves both money and lives in the long term. Universal HIV testing in antenatal care can be regarded as a good investment in almost any HIV prevalence setting. However, it is also important to note that targeted testing was more cost-effective than current coverage in all settings. Countries that are currently struggling to provide testing in antenatal care may need to consider factors other than cost-effectiveness in their planning and strategy for scaling up. This is important in order to address HIV at a national scale.  

Africa, Asia, Latin America
Haiti, Kenya, Namibia, Viet Nam
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Closing the HIV testing gap with partner-delivered self-testing

Promoting partner testing and couples testing through secondary distribution of HIV self-tests: a randomized clinical trial.

Masters SH, Agot K, Obonyo B, Napierala Mavedzenge S, Maman S, Thirumurthy H. PLoS Med. 2016 Nov 8;13(11):e1002166. doi: 10.1371/journal.pmed.1002166. eCollection 2016.

Background: Achieving higher rates of partner HIV testing and couples testing among pregnant and postpartum women in sub-Saharan Africa is essential for the success of combination HIV prevention, including the prevention of mother-to-child transmission. We aimed to determine whether providing multiple HIV self-tests to pregnant and postpartum women for secondary distribution is more effective at promoting partner testing and couples testing than conventional strategies based on invitations to clinic-based testing.

Methods and findings: We conducted a randomized trial in Kisumu, Kenya, between June 11, 2015, and January 15, 2016. Six hundred antenatal and postpartum women aged 18-39 y were randomized to an HIV self-testing (HIVST) group or a comparison group. Participants in the HIVST group were given two oral-fluid-based HIV test kits, instructed on how to use them, and encouraged to distribute a test kit to their male partner or use both kits for testing as a couple. Participants in the comparison group were given an invitation card for clinic-based HIV testing and encouraged to distribute the card to their male partner, a routine practice in many health clinics. The primary outcome was partner testing within 3 mo of enrollment. Among 570 participants analyzed, partner HIV testing was more likely in the HIVST group (90.8%, 258/284) than the comparison group (51.7%, 148/286; difference = 39.1%, 95% CI 32.4% to 45.8%, p < 0.001). Couples testing was also more likely in the HIVST group than the comparison group (75.4% versus 33.2%, difference = 42.1%, 95% CI 34.7% to 49.6%, p < 0.001). No participants reported intimate partner violence due to HIV testing. This study was limited by self-reported outcomes, a common limitation in many studies involving HIVST due to the private manner in which self-tests are meant to be used.

Conclusions: Provision of multiple HIV self-tests to women seeking antenatal and postpartum care was successful in promoting partner testing and couples testing. This approach warrants further consideration as countries develop HIVST policies and seek new ways to increase awareness of HIV status among men and promote couples testing.

Trial registration: ClinicalTrials.gov NCT02386215.

Abstract  Full-text [free] access 

Editor’s notes: Despite scale-up of HIV testing services, two in every five people living with HIV remain undiagnosed. World Health Organization (WHO) has just issued updated guidance on HIV testing services (HTS). In an effort to plug this testing gap, it strengthened the recommendation that HIV self-testing (HIVST) should be offered as one of the approaches to HTS. This paper adds to the body of evidence supporting that recommendation and provides more insight into the specific role of partner-delivered self-testing.     

There are challenges with conducting clinical trials of HIVST, one of which is selecting an appropriate outcome measure. In this trial, the primary outcome was participant report of male partner testing within three months of enrolment. Overall, uptake of male partner testing as reported by the participants was surprisingly high. It is worth noting that the participants and their partners may not have been particularly hard-to-reach groups. Almost all were married. The female participants were frequent testers. On average, they had tested three times in the past year. Most participants also reported that their male partner had tested at least once in the past year. It should also be noted that many women that were screened chose not to participate, so the participants may have to some extent pre-selected themselves as more interested and more likely to benefit from the activity.   

There were very few male partners reported as testing HIV positive during follow-up. This study was not able to determine how effectively people linked to care after HIVST. This is one of a number of research questions that remain around the delivery and impact of HIVST. Many of these are being addressed by the large HIV Self-Testing Africa (STAR) Project (http://hivstar.lshtm.ac.uk/). What seems to be beyond debate now though is that HIVST can and should play a role in helping us to achieve the UNAIDS 90-90-90 treatment target.   

Africa
Kenya
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Dolutegravir in the real world – more intolerance than first thought?

Intolerance of dolutegravir-containing combination antiretroviral therapy regimens in real-life clinical practice.

de Boer MG, van den Berk GE, van Holten N, Oryszcyn JE, Dorama W, Moha DA, Brinkman K. AIDS. 2016 Nov 28;30(18):2831-2834.

Objective: Dolutegravir (DGV) is one of the preferred antiretroviral agents in first-line combination antiretroviral therapy (cART). Though considered to be a well tolerated drug, we aimed to determine the actual rate, timing and detailed motivation of stopping DGV in a real-life clinical setting.

Design: A cohort study including all patients who started DGV in two HIV treatment centers in The Netherlands.

Methods: All cART-naive and cART-experienced patients who had started DGV were identified from the institutional HIV databases. Clinical data, including motivation and timing of discontinuation of DGV, were extracted from the patient files. Factors that potentially influenced discontinuation of DGV were compared between patients who stopped or continued DGV by multivariate and Kaplan-Meier analyses.

Results: In total, 556 patients were included, of whom 102 (18.4%) were cART-naive at initiation of DGV. Median follow-up time was 225 days. Overall, in 85 patients (15.3%), DGV was stopped. In 76 patients (13.7%), this was due to intolerability. Insomnia and sleep disturbance (5.6%), gastrointestinal complaints (4.3%) and neuropsychiatric symptoms such as anxiety, psychosis and depression (4.3%) were the predominant reasons for switching DGV. In regimens that included abacavir, DGV was switched more frequently (adjusted relative risk 1.92, 95% confidence interval 1.09-3.38, P log-rank 0.01). No virologic failures were observed.

Conclusion: A relatively high rate of preliminary discontinuation of DGV due to intolerability was detected in our patient population. In particular, DGV was stopped more frequently if the regimen included abacavir. Multiple factors may explain these unexpected postmarketing observations, which warrant further investigation.

Abstract access  

Editor’s notes: The integrase inhibitor dolutegravir has been billed as a very important milestone in the treatment of HIV. Randomized controlled trials reported that not only was it a highly effective antiviral agent, but it also had a high barrier to resistance. Trial data also suggested an excellent safety profile. Trial participants experienced fewer side effects with dolutegravir use compared to many other drugs. For these reasons, dolutegravir is recommended as one of the preferred options for first-line treatment in European and United States treatment guidelines. In addition, it is increasingly becoming a key component in global efforts to expand access to HIV-positive people in low-income countries.

However, with increased use of dolutegravir beyond clinical trials, evidence is growing to suggest that the incidence of side effects is greater than trial data would predict. This study describes the two-year experience of a cohort spanning two medical centres in the Netherlands. It explores the rate and cause of discontinuation of dolutegravir-containing regimes in both antiretroviral therapy naïve and experienced individuals. Of 556 receiving a dolutegravir-containing regimen, just over 15% stopped its use over two years. Adverse effects were cited as the cause in a sizeable 13%. These rates of discontinuation are over five times higher than was reported from clinical trials. The predominant side effects were sleep disturbance and insomnia. Other reactions included gastrointestinal disturbances, anxiety, depression and general malaise. In terms of factors associated with increased risk of discontinuation, only the concomitant use of abacavir was identified.

These results do not detract from the importance of dolutegravir as an antiretroviral agent. Indeed, it is reassuring that in this cohort no virologic failure occurred as result of its discontinuation. The results instead highlight the need for caution concerning recommendations for dolutegravir as a universal first line agent until further data are accrued from real-world experience.

Europe
Netherlands
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