Articles tagged as "HIV testing"

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

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

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

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

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

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

Trial registration: NCT01509508.

Abstract  Full-text [free] access 

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

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

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

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

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

South Africa
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HIV treatment during acute infection can lead to false negative HIV antibody tests

Initiation of antiretroviral therapy during acute HIV-1 infection leads to a high rate of nonreactive HIV serology.

de Souza MS, Pinyakorn S, Akapirat S, Pattanachaiwit S, Fletcher JL, Chomchey N, Kroon ED, Ubolyam S, Michael NL, Robb ML, Phanuphak P, Kim JH, Phanuphak N, Ananworanich J. Clin Infect Dis. 2016 Aug 15;63(4):555-61. doi: 10.1093/cid/ciw365. Epub 2016 Jun 17.

Background: Third- and fourth-generation immunoassays (IAs) are widely used in the diagnosis of human immunodeficiency virus (HIV) infection. Antiretroviral therapy (ART) during acute HIV infection (AHI) may impact HIV-specific antibodies, with failure to develop antibody or seroreversion. We report on the ability of diagnostic tests to detect HIV-specific antibodies in Thai participants initiating ART during AHI.

Methods: Participants with detectable plasma HIV RNA but nonreactive HIV-specific immunoglobulin G, enrolled in an AHI study, were offered immediate initiation of ART. Participants were tested at initiation and at 12 and 24 weeks following treatment using standard second-, third-, and fourth-generation IAs and Western blot (WB).

Results: Participants (N = 234) initiating ART at a median of 19 days (range, 1-62 days) from HIV exposure demonstrated different frequencies of reactivity prior to and following 24 weeks of ART depending on the IA. Third-generation IA nonreactivity prior to ART was 48%, which decreased to 4% following ART (P < .001). Fourth-generation IA nonreactivity was 18% prior to ART and 17% following ART (P = .720). Negative WB results were observed in 89% and 12% of participants prior to and following 24 weeks of ART, respectively (P < .001). Seroreversion to nonreactivity during ART was observed to at least one of the tests in 20% of participants, with fourth-generation IA demonstrating the highest frequency (11%) of seroreversion.

Conclusions: HIV-specific antibodies may fail to develop and, when detected, may decline when ART is initiated during AHI. Although fourth-generation IA was the most sensitive at detecting AHI prior to ART, third-generation IA was the most sensitive during treatment.

Clinical trials registration: NCT00796146 and NCT00796263.

Abstract access  

Editor’s notes: Antibodies to HIV become detectable around three weeks after HIV infection. Fourth generation HIV tests detect both HIV antibodies and the p24 HIV antigen, and can therefore detect HIV infection earlier than second and third-generation tests, which are based on detection of antibodies. Fourth generation tests therefore allow for earlier initiation of antiretroviral therapy (ART) relative to second- and third-generation HIV tests.

There have been sporadic reports of seroreversion from being HIV antibody positive to negative, or failure to seroconvert to being HIV antibody positive, following initiation of ART, particularly from paediatric populations. This study examined the impact of ART initiation during acute HIV infection on HIV diagnostic test results. Although the fourth-generation HIV test was the most sensitive at detecting acute HIV infection, it also had the highest frequency of seroreversion. Conversely, third generation HIV tests were positive prior to the start of ART in just over half of participants, compared to nearly all by 12 weeks after ART initiation. Notably, the Western blot, which was historically used as a confirmatory test for HIV, had high rates of non-reactivity in acute infection and 12% of tests were negative at 24 weeks after treatment, demonstrating that this test is not informative as a confirmatory assay in the context of acutely-treated HIV infection.   

The recent WHO guidelines recommend ART for all HIV-positive people regardless of age and disease stage.  Initiating ART as early as possible following HIV infection has also been recommended as a means to limit the size of the viral reservoir and improve prognosis. It is therefore likely that increasing numbers of individuals will start ART during early infection. There may be instances where individuals on ART may retest either due to doubts about results, or when they relocate to other HIV services. Clinicians need to be aware of the possibility of false-negative HIV antibody tests among people taking ART, particularly among individuals who initiated treatment during acute infection.    

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

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

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

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

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

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

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

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

Abstract  Full-text [free] access 

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

Latin America
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Systematic review finds that the evidence for the impact of HCT on HIV acquisition is limited but scale-up remains vital to facilitate other proven interventions

The effect of HIV counselling and testing on HIV acquisition in sub-Saharan Africa: a systematic review.

Rosenberg NE, Hauser BM, Ryan J, Miller WC. Sex Transm Infect. 2016 Aug 16. pii: sextrans-2016-052651. doi: 10.1136/sextrans-2016-052651. [Epub ahead of print]

Objectives: Annually, millions of people in sub-Saharan Africa (SSA) receive HIV counselling and testing (HCT), a service designed to inform persons of their HIV status and, if HIV uninfected, reduce HIV acquisition risk. However, the impact of HCT on HIV acquisition has not been systematically evaluated. We conducted a systematic review to assess this relationship in SSA.

Methods: We searched for articles from SSA meeting the following criteria: an HIV-uninfected population, HCT as an exposure, longitudinal design and an HIV acquisition endpoint. Three sets of comparisons were assessed and divided into strata: sites receiving HCT versus sites not receiving HCT (Strata A), persons receiving HCT versus persons not receiving HCT (Strata B) and persons receiving couple HCT (cHCT) versus persons receiving individual HCT (Strata C).

Results: We reviewed 1635 abstracts; eight met all inclusion criteria. Strata A consisted of one cluster randomised trial with a non-significant trend towards HCT being harmful: incidence rate ratio (IRR): 1.4. Strata B consisted of five observational studies with non-significant unadjusted IRRs from 0.6 to 1.3. Strata C consisted of two studies. Both displayed trends towards cHCT being more protective than individual HCT (IRRs: 0.3-0.5). All studies had at least one design limitation.

Conclusions: In spite of intensive scale-up of HCT in SSA, few well-designed studies have assessed the prevention impacts of HCT. The limited body of evidence suggests that individual HCT does not have a consistent impact on HIV acquisition, and cHCT is more protective than individual HCT.

Abstract access  

Editor’s notes: Although it is plausible that knowing that you are HIV-negative might be an incentive for safer behaviour and thus reduce the risk of HIV acquisition, previous studies have not been conclusive.  HIV counselling and testing (HCT) is an integral part of other prevention and treatment activities (e.g. voluntary medical male circumcision (VMMC) or pre-exposure prophylaxis (PreP)). The findings from this systematic review suggest that with the available evidence individual HCT does not consistently have a protective or harmful effect on HIV acquisition. Couples’ HCT may be protective but the authors caution against a simplistic interpretation, reminding us of limited evidence including imprecise estimates and possibilities of bias. There were just two studies on couples’ HCT and convincing evidence of benefit was only seen in the study which compared couples’ HCT with individual HCT. There could be systematic differences between people who sought couples’ versus individual HCT (who may be unable or unwilling to take up a couples programme). While couples’ HCT may be suited to some people and be protective for them, the wider applicability may be more limited. The authors describe the methodological challenges of measuring the impact of an HCT activity on HIV acquisition, including the fact that large cohorts need to be effectively followed for long periods. In addition, randomised comparisons with no HCT are not possible because of ethical barriers to withholding HCT. Another challenge the authors cite is that both the primary exposure (HCT) and the primary outcome (HIV acquisition) require an HIV test. Arguably, this could be circumvented by offering anonymised remote (eg laboratory) HIV testing to determine HIV acquisition, rather than point-of-care tests where results would be immediately available. The final message from this paper is that although convincing evidence for reduction in HIV acquisition from HCT is not apparent, it’s scale-up must continue. HCT is the gateway to other proven activities for both prevention and treatment.

HIV testing
Rwanda, South Africa, Uganda, Zimbabwe
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‘Scared of going there’ – barriers to HIV treatment for pregnant women in Tanzania

Stigma, facility constraints, and personal disbelief: why women disengage from HIV care during and after pregnancy in Morogoro region, Tanzania.

McMahon SA, Kennedy CE, Winch PJ, Kombe M, Killewo J, Kilewo C. AIDS Behav. 2016 Aug 17. [Epub ahead of print]

Millions of children are living with HIV in sub-Saharan Africa, and the primary mode of these childhood infections is mother-to-child transmission. While existing interventions can virtually eliminate such transmission, in low- and middle-income settings, only 63% of pregnant women living with HIV accessed medicines necessary to prevent transmission. In Tanzania, HIV prevalence among pregnant women is 3.2%. Understanding why HIV-positive women disengage from care during and after pregnancy can inform efforts to reduce the impact of HIV on mothers and young children. Informed by the tenets of Grounded Theory, we conducted qualitative interviews with 40 seropositive postpartum women who had disengaged from care to prevent mother-to-child transmission (PMTCT). Nearly all women described antiretroviral treatment (ART) as ultimately beneficial but effectively inaccessible given concerns related to stigma. Many women also described how their feelings of health and vitality coupled with concerns about side effects underscored a desire to forgo ART until they deemed it immediately necessary. Relatively fewer women described not knowing or forgetting that they needed to continue their treatment regimens. We present a theory of PMTCT disengagement outlining primary and ancillary barriers. This study is among the first to examine disengagement by interviewing women who had actually discontinued care. We urge that a combination of intervention approaches such as mother-to-mother support groups, electronic medical records with same-day tracing, task shifting, and mobile technology be adapted, implemented, and evaluated within the Tanzanian setting.

Abstract access  

Editor’s notes: The push for universal access to antiretroviral therapy for everyone living with HIV faces many obstacles.  In many parts of the world, pregnant women are offered HIV testing as a part of antenatal care. Treatment is then offered if a woman is found to be HIV-positive. Many women accept this care, having been provided with the information that this is beneficial for their baby and also themselves. Some women who accept treatment take themselves out of care. This can be detrimental not only for the HIV status of their baby, but also for their general antenatal care. As the authors of this paper note, there is a growing body of literature that describes losses to care from the provider perspective. There are also a number of papers about women who have accepted care, who describe why others refuse treatment.  It is unusual to find detailed findings from interviews with women who have dropped out of or refused HIV treatment while pregnant. While the findings are not particularly surprising, the authors of this paper have captured the individual reasons why the 40 women interviewed in their study, left or never entered care. The reasons given underline the challenge of ‘prompt treatment’. Many women were not ready for immediate treatment.  Fears of the clinic layout ‘betraying’ a woman’s status are described. So too are the negative attitudes of health providers as well as family and community members. The authors provide an excellent example of how good qualitative research, conducted and analysed in an exemplary manner, offers valuable insights. This paper provides valuable information on an often hidden minority of women who are not ready or able ‘to test and treat’.

United Republic of Tanzania
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Using HIV infrastructure to test for other diseases can reach many people at a low cost

Cost and efficiency of a hybrid mobile multi-disease testing approach with high HIV testing coverage in East Africa.

Chang W, Chamie G, Mwai D, Clark TD, Thirumurthy H, Charlebois ED, Petersen M, Kabami J, Ssemmondo E, Kadede K, Kwarisiima D, Sang N, Bukusi EA, Cohen CR, Kamya M, Havlir DV, Kahn JG. J Acquir Immune Defic Syndr. 2016 Jul 29. [Epub ahead of print]

Background: In 2013-14, we achieved 89% adult HIV testing coverage using a hybrid testing approach in 32 communities in Uganda and Kenya (SEARCH: NCT01864603). To inform scalability, we sought to determine: 1) overall cost and efficiency of this approach; and 2) costs associated with point-of-care (POC) CD4 testing, multi-disease services, and community mobilization.

Methods: We applied micro-costing methods to estimate costs of population-wide HIV testing in 12 SEARCH Trial communities. Main intervention components of the hybrid approach are census, multi-disease community health campaigns (CHC), and home-based testing (HBT) for CHC non-attendees. POC CD4 tests were provided for all HIV-infected participants. Data were extracted from expenditure records, activity registers, staff interviews, and time and motion logs.

Results: The mean cost per adult tested for HIV was $20.5 (range: $17.1 - $32.1) [2014 US$], including a POC CD4 test at $16 per HIV+ person identified. Cost per adult tested for HIV was $13.8 at CHC vs. $31.7 via HBT. The cost per HIV+ adult identified was $231 ($87 - $1245), with variability due mainly to HIV prevalence among persons tested (i.e., HIV positivity rate). The marginal costs of multi-disease testing at CHCs were $1.16/person for hypertension and diabetes, and $0.90 for malaria. Community mobilization constituted 15.3% of total costs.

Conclusions: The hybrid testing approach achieved very high HIV testing coverage, with POC CD4, at costs similar to previously reported mobile, home-based, or venue-based HIV testing approaches in sub-Saharan Africa. By leveraging HIV infrastructure, multi-disease services were offered at low marginal costs.

Abstract access 

Editor’s notes: Ensuring high rates of HIV testing is critical to managing the HIV epidemic in many countries. With a positive diagnosis, recent WHO recommendations suggest that people living with HIV can immediately be put onto treatment which improves their own health, alongside reducing the chance that they will pass on infection to others. There are many different ways to carry out HIV testing, and this study looks at the differences in costs between community health campaigns (which also test for other diseases including hypertension and diabetes), and home-based testing. This paper estimates that it was less costly to carry out a HIV test through a multi-disease community programme than home-based testing. The authors suggest that because of the robust infrastructure that has been developed for HIV testing in Uganda and Kenya, the additional cost for testing for other diseases is very low. There has been some criticism that the response to the HIV epidemic has been at the expense of reducing ill-health from other conditions. Using HIV infrastructure to support testing for diseases like hypertension and diabetes is a good way to counter these criticisms, and improve the overall health of the population. 

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

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

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

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

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

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

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

Abstract access

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

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

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

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

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

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Showing they care: lay-counsellors, home-based testing and the value of follow-up support

How home HIV testing and counselling with follow-up support achieves high testing coverage and linkage to treatment and prevention: a qualitative analysis from Uganda.

Ware NC, Wyatt MA, Asiimwe S, Turyamureeba B, Tumwesigye E, van Rooyen H, Barnabas RV, Celum CL. J Int AIDS Soc. 2016 Jun 28;19(1):20929. doi: 10.7448/IAS.19.1.20929. eCollection 2016.

Introduction: The successes of HIV treatment scale-up and the availability of new prevention tools have raised hopes that the epidemic can finally be controlled and ended. Reduction in HIV incidence and control of the epidemic requires high testing rates at population levels, followed by linkage to treatment or prevention. As effective linkage strategies are identified, it becomes important to understand how these strategies work. We use qualitative data from The Linkages Study, a recent community intervention trial of community-based testing with linkage interventions in sub-Saharan Africa, to show how lay counsellor home HIV testing and counselling (home HTC) with follow-up support leads to linkage to clinic-based HIV treatment and medical male circumcision services.

Methods: We conducted 99 semi-structured individual interviews with study participants and three focus groups with 16 lay counsellors in Kabwohe, Sheema District, Uganda. The participant sample included both HIV+ men and women (N=47) and HIV-uncircumcised men (N=52). Interview and focus group audio-recordings were translated and transcribed. Each transcript was summarized. The summaries were analyzed inductively to identify emergent themes. Thematic concepts were grouped to develop general constructs and framing propositional statements.

Results: Trial participants expressed interest in linking to clinic-based services at testing, but faced obstacles that eroded their initial enthusiasm. Follow-up support by lay counsellors intervened to restore interest and inspire action. Together, home HTC and follow-up support improved morale, created a desire to reciprocate, and provided reassurance that services were trustworthy. In different ways, these functions built links to the health service system. They worked to strengthen individuals' general sense of capability, while making the idea of accessing services more manageable and familiar, thus reducing linkage barriers.

Conclusions: Home HTC with follow-up support leads to linkage by building "social bridges," interpersonal connections established and developed through repeated face-to-face contact between counsellors and prospective users of HIV treatment and male circumcision services. Social bridges link communities to the service system, inspiring individuals to overcome obstacles and access care.

Abstract  Full-text [free] access 

Editor’s notes: How can people be encouraged once they have received a positive HIV-test result to link and stay in treatment? This is a crucial question as the momentum for everyone living with HIV to be on antiretroviral therapy grows.  The authors of this paper demonstrate clearly and succinctly the value of personal contact in supporting people to test and the link to care. Lay-counsellors paying visits to people’s homes provided the encouragement to help some people to link to care. The home visits were seen by people visited as a sign that ‘someone cared’.  The personal attention and information provided promoted trust. The visits also created a sense of obligation: the person visited felt they should do something in return to please the counsellor.

Increasing numbers of people living with HIV does not necessarily mean that it is easier for someone coping with a positive-test result to link to care. We should not underestimate the continued burden that an HIV-positive test result places on individuals.  Many barriers remain both to testing and sustaining a link to care. The authors of this paper provide examples of how to overcome some of those barriers. However, while this paper provides encouraging findings on the value of the home-based activity, the findings also pose a challenge. Can such follow-up support services, which demand more than a single visit, be provided widely enough to benefit all people who need such attention and support? 

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The HIV prevention cascade – a new approach to guide HIV prevention programmes

Providing a conceptual framework for HIV prevention cascades and assessing feasibility of empirical measurement with data from east Zimbabwe: a case study.

Garnett GP, Hallett TB, Takaruza A, Hargreaves J, Rhead R, Warren M, Nyamukapa C, Gregson S. Lancet HIV. 2016 Jul;3(7):e297-306. doi: 10.1016/S2352-3018(16)30039-X.

Background: The HIV treatment cascade illustrates the steps required for successful treatment and is a powerful advocacy and monitoring tool. Similar cascades for people susceptible to infection could improve HIV prevention programming. We aim to show the feasibility of using cascade models to monitor prevention programmes.

Methods: Conceptual prevention cascades are described taking intervention-centric and client-centric perspectives to look at supply, demand, and efficacy of interventions. Data from two rounds of a population-based study in east Zimbabwe are used to derive the values of steps for cascades for voluntary medical male circumcision (VMMC) and for partner reduction or condom use driven by HIV testing and counselling (HTC).

Findings: In 2009 to 2011 the availability of circumcision services was negligible, but by 2012 to 2013 about a third of the population had access. However, where it was available only 12% of eligible men sought to be circumcised leading to an increase in circumcision prevalence from 3.1% to 6.9%. Of uninfected men, 85.3% did not perceive themselves to be at risk of acquiring HIV. The proportions of men and women tested for HIV increased from 27.5% to 56.6% and from 61.1% to 79.6%, respectively, with 30.4% of men tested self-reporting reduced sexual partner numbers and 12.8% reporting increased condom use.

Interpretation: Prevention cascades can be populated to inform HIV prevention programmes. In eastern Zimbabwe programmes need to provide greater access to circumcision services and the design and implementation of associated demand creation activities. Whereas, HTC services need to consider how to increase reductions in partner numbers or increased condom use or should not be considered as contributing to prevention services for the HIV-negative adults.

Abstract  Full-text [free] access 

Editor’s notes: UNAIDS has set an ambitious goal of reducing new adult HIV infections below 500 000 per year by 2020. Achieving this goal relies on increased coverage of primary HIV prevention programmes, including pre-exposure prophylaxis and voluntary medical male circumcision (VMMC). The HIV treatment cascade is a well known tool to monitor the performance of services for people living with HIV, and to identify gaps in care. An HIV prevention cascade could provide a similarly useful tool to inform prevention programmes. The tool would define the steps necessary for an effective HIV prevention programme, estimating the proportion of people lost at each step, and hence identifying the barriers to effective HIV prevention in populations. The authors propose a framework for HIV prevention cascades, differentiating between availability, uptake, adherence, and efficacy.  The framework would estimate the proportion of the population protected by a given strategy or combination of strategies. Population survey data from rural Zimbabwe are used to illustrate the prevention cascade for VMMC and behaviour change driven by HIV testing and counselling (HTC). These data are used to highlight the barriers impacting on reducing HIV incidence. As the authors acknowledge, there are limitations to the cascade approach for HIV prevention. The cascade is more difficult to define and to estimate for HIV prevention than for HIV treatment. In order for the cascade to be useful, it is necessary to have a good understanding of who is at risk of acquiring HIV.  However, the prevention needs of HIV negative adults change over time as people move in and out of risk. Although the authors illustrate the use of the cascade for an individual programme, it is more difficult to assess the combined effect of several prevention strategies. Still, the cascade approach may provide a useful tool to help guide HIV prevention efforts, by identifying gaps and prioritising areas for action.

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

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

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

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

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

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

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

Abstract  Full-text [free] access 

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

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

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

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

South Africa
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