Articles tagged as "People living with HIV"

Immediate initiation of HIV treatment is cost-effective, but needs a large portion of health system spending

Changing HIV treatment eligibility under health system constraints in sub-Saharan Africa: Investment needs, population health gains, and cost-effectiveness.

Hontelez JA, Chang AY, Ogbuoji O, Vlas SJ, Barnighausen T, Atun R. AIDS. 2016 Jun 29. [Epub ahead of print]

Objective: We estimated the investment need, population health gains, and cost-effectiveness of different policy options for scaling-up prevention and treatment of HIV in the 10 countries that currently comprise 80% of all people living with HIV in sub-Saharan Africa (Ethiopia, Kenya, Malawi, Mozambique, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe).

Design: We adapted the established STDSIM model, to capture the health system dynamics: demand-side and supply-side constraints in the delivery of antiretroviral treatment (ART).

Methods: We compared different scenarios of supply-side (i.e. health system capacity) and demand-side (i.e. health seeking behavior) constraints, and determined the impact of changing guidelines to ART eligibility at any CD4 cell count within these constraints.

Results: Continuing current scale-up would require US$178 billion by 2050. Changing guidelines to ART at any CD4 cell count is cost-effective under all constraints tested in the model, especially in demand-side constrained health systems because earlier initiation prevents loss to follow-up of patients not yet eligible. Changing guidelines under current demand-side constraints would avert 1.8 million infections at US$208 per life-year saved.

Conclusions: Treatment eligibility at any CD4 cell count would be cost-effective, even under health system constraints. Excessive loss to follow up and mortality in patients not eligible for treatment can be avoided by changing guidelines in demand-side constrained systems. The financial obligation for sustaining the AIDS response in sub-Saharan Africa over the next 35 years is substantial, and requires strong, long-term commitment of policy makers and donors to continue to allocate substantial parts of their budgets.

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Editor’s notes: Recent WHO guidelines recommend that everyone who is diagnosed as HIV positive should be allowed to start treatment immediately, a change to the former guideline where their CD4 count (a measure of disease progression) was the main criteria for starting treatment. This paper uses a model to look at the costs and benefits of changing to this immediate treatment regimen in the sub-Saharan African countries most affected by the epidemic. The authors find that allowing all HIV people living with HIV to access treatment is cost-effective, and this finding does not change when the model assumptions are varied. However, the impact of this change on the health system budgets in these countries is very substantial, and the authors suggest that a large commitment is necessary from policymakers and donors to sustain this response as short-term spending will not be enough to make an impact.

Africa
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Antiretroviral therapy: being reborn into uncertainty

What will become of me if they take this away? Zimbabwean women's perceptions of "free" ART.

Gona CM, McGee E, DeMarco R. J Assoc Nurses AIDS Care. 2016 May 13. pii: S1055-3290(16)30040-1. doi: 10.1016/j.jana.2016.05.001. [Epub ahead of print]

The evolution of antiretroviral therapies (ART) has redefined HIV infection from a life-threatening disease to a chronic manageable condition. Despite ART, HIV infection remains a serious health burden in Zimbabwe, particularly among women of reproductive age. In this interpretive phenomenology study, we interviewed 17 women with advanced HIV infection to uncover and understand their experiences of living with HIV infection in the ART era. Two themes (knowing the restorative power of ART and the heavy burden of being infected with HIV) reflected the women's experiences. ART brought physical and mental relief, but did not change the sobering reality of poverty or the challenges posed by the infective nature of HIV. The heavily donor-funded Zimbabwean ART program has been a success story, but there is uncertainty over its long-term sustainability. In resource-limited countries, clinicians and other stakeholders should continue to focus on HIV prevention as the cornerstone of HIV programming.

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Editor’s notes: In Zimbabwe, as in much of sub-Saharan Africa, women are disproportionately affected by HIV infection. In 2013, women comprised 59% of adults living with HIV. Between 2007 and 2010, women accounted for 64% of people enrolled on ART in the country. Currently only 77% of women in clinical need of ART have access to it with most accessing it through a government and donor-funded ‘cost-free’ programme.  For women in Zimbabwe, living with HIV infection, normal life not only depends on the assurance of uninterrupted access to ART, but also the ability to get married and bear children.

The authors of this paper report on Zimbabwean women’s experiences of living with HIV infection while on ART. The study was nested within an ongoing clinical trial. Women were interviewed through in-depth, individual, face-to-face, open-ended interviews. 

The authors identify a number of important implications of the findings of this study. First, many women, in addition to concerns about their health, also had to contend with the effects of extreme poverty and gender inequality. For HIV treatment programmes to be successful, health care providers and policy makers should incorporate poverty reduction and gender equity components. Second, funding provisions should be put in place to ensure continued supplies of medications in order to reduce the reliance on external donor funding. Third, there is a need to clarify and strengthen policies regarding the continuation of treatment after the completion of a clinical trial to ensure participants’ continued access. Fourth, given the ability of ART to transform HIV into a chronic disease, reproductive health service provision should be prioritized to enable people living with HIV to have children if they wish. Further, and particularly in the light of these challenges, HIV prevention should be centralised as a focal point of HIV programming in order to reduce HIV incidence.

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

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

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

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

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

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

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

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

Africa
Lesotho, Malawi, Swaziland
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Perceived stigma may lead to increased experienced stigma among people living with HIV

A transactional approach to relationships over time between perceived HIV stigma and the psychological and physical well-being of people with HIV.

Miller CT, Solomon SE, Varni SE, Hodge JJ, Knapp FA, Bunn JY. Soc Sci Med. 2016 Jun 16;162:97-105. doi: 10.1016/j.socscimed.2016.06.025. [Epub ahead of print]

Rationale: Cross-sectional studies demonstrate that perceived discrimination is related to the psychological and physical well-being of stigmatized people. The theoretical and empirical foci of most of this research is on how racial discrimination undermines well-being. The present study takes a transactional approach to examine people with HIV, a potentially concealable stigma.

Hypothesis: The transactional approach posits that even as discrimination adversely affects the psychological well-being of people with HIV, psychological distress also makes them more sensitive to perceiving that they may be or have been stigmatized, and may increase the chances that other people actually do stigmatize them.

Methods: This hypothesis was tested in a longitudinal study in which 216 New England residents with HIV were recruited to complete measures of perceived HIV stigma and well-being across three time points, approximately 90 days apart. This study also expanded on past research by assessing anticipated and internalized stigma as well as perceived discrimination.

Results: Results indicated that all of these aspects of HIV stigma prospectively predicted psychological distress, thriving, and physical well-being. Equally important, psychological distress and thriving also prospectively predicted all three aspects of HIV stigma, but physical well-being did not.

Conclusion: These findings suggest that people with HIV are ensnared in a cycle in which experiences of stigma and reduced psychological well-being mutually reinforce each other.

Abstract access

Editor’s notes: Stigma can act as a barrier to the delivery and uptake of HIV care. This study investigated the transactional approach to understanding stigma. The authors sought to determine whether psychological stress due to perceptions of discrimination causes people living with HIV to be more sensitive to perceiving stigma. Then in turn whether this makes it more likely that they will be stigmatized. The authors examined data from a longitudinal study of 216 participants in New England in the United States. The study was embedded within a larger study protocol that sought to answer a broad range of research questions. Participants responded to a questionnaire which asked questions about participants’ perceived stigma based on the HIV Stigma Scale developed by Berger and colleagues in 2001. The authors used three subscales to measure enacted, anticipated, and internalized stigma. Participants responded to questions on a 5-point subscale of strongly disagree (scored as 1) to strongly agree (scored as 5) to questions about the three different types of stigma. The authors analysed associations between perceived, internalized, and experienced stigma. The authors concluded that understanding the transactional relationship between HIV-associated stigma and psychological stress is important for developing and implementing effective HIV-associated stigma programmes. Perceptions of stigma may lead to increases in perceived and experienced stigma among people living with HIV. This study suggests that future programmes that seek to address HIV-associated stigma should incorporate an understanding of the transactional relationship between psychological stress and perceived and experienced stigma.

Northern America
United States of America
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Viral load testing is more cost-effective than CD4 testing

Laboratory monitoring of antiretroviral therapy for HIV infection: cost-effectiveness and budget impact of current and novel strategies.

Ouattara EN, Robine M, Eholie SP, MacLean RL, Moh R, Losina E, Gabillard D, Paltiel AD, Danel C, Walensky RP, Anglaret X, Freedberg KA. Clin Infect Dis. 2016 Jun 1;62(11):1454-62. doi: 10.1093/cid/ciw117. Epub 2016 Mar 1.

Background: Optimal laboratory monitoring of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) remains controversial. We evaluated current and novel monitoring strategies in Cote d'Ivoire, West Africa.

Methods: We used the Cost-Effectiveness of Preventing AIDS Complications -International model to compare clinical outcomes, cost-effectiveness, and budget impact of 11 ART monitoring strategies varying by type (CD4 and/or viral load [VL]) and frequency. We included "adaptive" strategies (biannual then annual monitoring for patients on ART/suppressed). Mean CD4 count at ART initiation was 154/µL. Laboratory test costs were CD4=$11 and VL=$33. The standard of care (SOC; biannual CD4) was the comparator. We assessed cost-effectiveness relative to Cote d'Ivoire's 2013 per capita GDP ($1500).

Results: Discounted life expectancy was 16.69 years for SOC, 16.97 years with VL confirmation of immunologic failure, and 17.25 years for adaptive VL. Mean time on failed first-line ART was 3.7 years for SOC and <0.9 years for all routine/adaptive VL strategies. VL failure confirmation was cost-saving compared with SOC. Adaptive VL had an incremental cost-effectiveness ratio (ICER) of $4100/year of life saved compared with VL confirmation and increased the 5-year budget by $310/patient compared with SOC. Adaptive VL achieved an ICER <1x GDP if second-line ART and VL costs simultaneously decreased to $156 and $13, respectively.

Conclusions: VL confirmation of immunologic failure is more effective and less costly than CD4 monitoring in Cote d'Ivoire. Adaptive VL monitoring reduces time on failing ART, is cost-effective, and should become standard in Cote d'Ivoire and similar settings.

Abstract access 

Editor’s notes: Monitoring whether or not people are able to effectively use HIV antiretroviral therapy (ART) to supress viral load is important to maintaining individual and population health. There are two ways to monitor whether or not people are able to adhere to ART, assessing CD4 cell count or viral load. These tests require different amounts of expensive laboratory resources. This paper explores 11 ways in which ART regimens can be monitored in Cote d’Ivoire to assess the potential impact and cost-effectiveness of different strategies compared to current care (twice-yearly CD4 tests). The authors estimate that adding viral load failure confirmation to current practice would be cost saving. Adaptive viral load monitoring is found to be cost-effective. This approach involves decreasing monitoring from twice-annually to annually among people who present with suppressed viral loads for one year. In many countries, viral load monitoring is not generally available. This research is important because it illustrates that viral load monitoring strategies can be cost saving compared to CD4 counts, in line with WHO recommendations. 

Africa
Côte d'Ivoire
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Improved survival with lymphoma in the antiretroviral therapy era

Evolution of HIV-associated lymphoma over 3 decades.

Ramaswami R, Chia G, Dalla Pria A, Pinato DJ, Parker K, Nelson M, Bower M. J Acquir Immune Defic Syndr. 2016 Jun 1;72(2):177-83. doi: 10.1097/QAI.0000000000000946.

Introduction: The emergence of combined antiretroviral therapy (cART) and improvements in the management of opportunistic infections have altered the HIV epidemic over the last 30 years. We aimed to assess changes to the biology and outcomes of HIV-associated lymphomas over this period at the national center for HIV oncology in the United Kingdom.

Methods: Clinical characteristics at lymphoma diagnosis have been prospectively collected since 1986, along with details of lymphoma treatment and outcomes. The clinical features and outcomes were compared between 3 decades: pre-cART decade (1986-1995), early-cART decade (1996-2005), and late-cART decade (2006-2015).

Results: A total of 615 patients with HIV-associated lymphoma were included in the study: 158 patients in the pre-cART era, 200 patients in the early-cART era, and 257 patients in the late-cART era. In more recent decades, patients were older (P < 0.0001) and had higher CD4 cell counts (P < 0.0001) at lymphoma diagnosis. Over time, there has also been a shift in lymphoma histological subtypes, with an increase in lymphoma subtypes associated with moderate immunosuppression. The overall survival for patients with HIV-associated lymphoma has dramatically improved over the 3 decades (P < 0.0001).

Conclusion: Over the last 30 years, the clinical demographic of HIV-associated lymphomas has evolved, and the outcomes have improved.

Abstract access

Editor’s notes: Lymphomas are the second most common malignancy after Kaposi’s sarcoma among people living with HIV in Europe, Australia and northern America. This study examined how the biology and rates of survival have changed since combination antiretroviral therapy (cART) became available.

People living with HIV and diagnosed with lymphoma over the past thirty years in a specialist oncology centre in the United Kingdom were included in the study. The mean age at diagnosis of lymphoma increased over time, most likely reflecting improvement in life expectancy with cART. As would be expected, the mean CD4 count and the proportion of people with a suppressed viral load at lymphoma diagnosis increased, while proportion with an AIDS-defining illness before lymphoma diagnosis declined significantly.  

This study demonstrated a shift of the histological subtypes of lymphoma that are associated with less severe immunosuppression, for example the proportion of primary CNS lymphoma (PCNSL) and diffuse large B-cell lymphoma (DLBCL), which are associated with severe immunosuppression, declined, while the proportion of Burkitt’s lymphoma and Hodgkin’s lymphoma (associated with less profound immunosuppression) increased.

A key finding of this study was the significantly improved overall survival of people with lymphoma. The improved survival is not explained by changes in histological subtypes of lymphoma over time, as improvement in prognosis was observed for each histological subtype. The substantial improvement in overall survival is attributable to a number of factors. They include the availability of cART, attention to opportunistic infection prophylaxis, improved supportive care for people undergoing lymphoma treatment as well as improved modalities of lymphoma treatment. Such modalities include efficacious drugs that can be safely co-administered with cART, e.g., rituximab, novel agents and use of autologous stem cell transplants.  

Europe
United Kingdom
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Partner’s knowledge of HIV suppression among male couples in San Francisco

Relationship dynamics and partner beliefs about viral suppression: a longitudinal study of male couples living with HIV/AIDS (the duo project).

Conroy AA, Gamarel KE, Neilands TB, Dilworth SE, Darbes LA, Johnson MO. AIDS Behav. 2016 May 5. [Epub ahead of print]

Accurate beliefs about partners' viral suppression are important for HIV prevention and care. We fit multilevel mixed effects logistic regression models to examine associations between partners' viral suppression beliefs and objective HIV RNA viral load tests, and whether relationship dynamics were associated with accurate viral suppression beliefs over time. Male couples (N = 266 couples) with at least one HIV-positive partner on antiretroviral therapy completed five assessments over 2 years. Half of the 407 HIV-positive partners were virally suppressed. Of the 40% who had inaccurate viral load beliefs, 80% assumed their partner was suppressed. The odds of having accurate viral load beliefs decreased over time (OR = 0.83; p = 0.042). Within-couple differences in dyadic adjustment (OR = 0.66; p < 0.01) and commitment (OR = 0.82; p = 0.022) were negatively associated with accurate viral load beliefs. Beliefs about a partner's viral load may factor into sexual decision-making and social support. Couple-based approaches are warranted to improve knowledge of partners' viral load.

Abstract access

Editor’s notes: This study with male couples in San Francisco examined how accurate a partner’s knowledge about their partner’s viral load status was, and if this changes over time. The study was the first of its kind. The research team enrolled 266 male couples where at least one of the couple was HIV-positive and on ART for >30 days. Most couples (72%) were seroconcordant (both HIV-positive) and 28% were serodiscordant. Participants were mostly white, middle-aged men with low-income levels. Eighty percent were living with their partner. The couples had been together on average 6.6 years. Thus, this sample may differ substantially from other studies with gay men and other men who have sex with men. Approximately 50% of men living with HIV on ART were virally suppressed at each of three visits. However, between 24% (visit one) and 40% (visit three) of men had inaccurate knowledge about their partner’s viral suppression, with most of these people wrongly believing their partner’s viral load to be suppressed when it was not. Surprisingly, these results were similar among serodiscordant and seroconcordant couples. Results did not differ significantly according to most relationship characteristics (relationship satisfaction; commitment; intimacy; equality; constructive communication).

The results are interesting because inaccuracy in partner’s beliefs about viral load suppression may translate into poor decision making around the safety of condomless anal intercourse. In addition, having accurate knowledge of partner viral suppression is important for the provision of social support associate with HIV care and treatment. Qualitative studies are necessary to understand why many men in this study had an inaccurate knowledge about their partner’s viral suppression. And why this inaccuracy increased over time. Understanding these issues and how they translate to other populations will be useful for developing programmes among male couples to reduce HIV transmission and increase partner’s social support associated with HIV care and treatment. 

Northern America
United States of America
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Sex on the move

Exploring the relationship between population mobility and HIV risk: evidence from Tanzania.

Deane KD, Samwell Ngalya P, Boniface L, Bulugu G, Urassa M. Glob Public Health. 2016 May 27:1-16. [Epub ahead of print]

Migration and population mobility has long been regarded as an important structural driver of HIV. Following initial concerns regarding the spatial spread of the disease, mobile populations are viewed to engage in higher levels of risky sexual behaviours than non-mobile groups. However, beyond the case studies of mineworkers and truck drivers, the statistical evidence is inconclusive, suggesting that the relationship between mobility and risk is not well understood. This study investigated how engaging in specific livelihoods that involve mobility influences sexual behaviour and HIV risk. A qualitative research project, including focus groups and in-depth interviews with key mobile groups, was conducted in Northern Tanzania. The findings show that the patterns and conditions of moving related to the requirements of each different economic activity influence the nature of relationships that mobile groups have whilst away, how and where local sexual networks are accessed, and the practicalities of having sex. This has further implications for condom use. Risk behaviours are also shaped by local sexual norms related to transactional sex, emphasising that the roles of mobility and gender are interrelated, overlapping and difficult to disentangle.

Abstract access  

Editor’s notes: Case studies with truck drivers and mineworkers have clearly shown a relationship between migration, mobility and HIV risk in sub-Saharan Africa. It remains unclear to what extent findings from these case studies can be extrapolated across all mobile populations. Evidence from studies in other populations is inconclusive, inconsistent and in some cases contradictory. This, in part is due to the limitations of the statistical frameworks used which tend to reduce migration to an abstract individual variable and fail to recognise migration as a dynamic socio-economic phenomenon. These frameworks may also inadequately reflect the variability of migratory behaviour offering limited policy conclusions for addressing HIV risk arising from migration or population mobility.

This qualitative study was conducted in North-western Tanzania in a population in which 60% of men and 43% of women were classified as mobile. Data were collected through focus group discussions and individual interviews with both female and male farmers and maize traders.

The findings of this study suggest that patterns and conditions of moving can influence the nature of sexual relationships that mobile individuals have while away. The findings offer important insights for future, more nuanced statistical work. This would include considering why people move, where they go, patterns of movement, the specific economic activities in which they engage, and where they stay while they are away. The findings also highlight the importance of situating the risk behaviours of mobile individuals within the sexual norms and practices around sex and exchange, and particularly transactional sex. The authors note that being mobile may exacerbate gendered and economic inequalities making the relative influences of mobility and sexual norms difficult to disentangle. This further highlights the value of HIV prevention programmes being specifically tailored to the specific needs of mobile populations.

Africa
United Republic of Tanzania
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Inequalities in access to health care for older people living with HIV in South Africa

Health expenditure and catastrophic spending among older adults living with HIV.

Negin J, Randell M, Raban MZ, Nyirenda M, Kalula S, Madurai L, Kowal P. Glob Public Health. 2016 Apr 30:1-15. [Epub ahead of print]

Introduction: The burden of HIV is increasing among adults aged over 50, who generally experience increased risk of comorbid illnesses and poorer financial protection. We compared patterns of health utilisation and expenditure among HIV-positive and HIV-negative adults over 50.

Methods: Data were drawn from the Study on global AGEing and adult health in South Africa with analysis focusing on individual and household-level data of 147 HIV-positive and 2725 HIV-negative respondents.

Results: HIV-positive respondents reported lower utilisation of private health-care facilities (11.8%) than HIV-negative respondents (25.0%) (p = .03) and generally had more negative attitudes towards health system responsiveness than HIV-negative counterparts. Less than 10% of HIV-positive and HIV-negative respondents experienced catastrophic health expenditure (CHE). Women (OR 1.8; p < .001) and respondents from rural settings (OR 2.9; p < .01) had higher odds of CHE than men or respondents in urban settings. Over half the respondents in both groups indicated that they had received free health care.

Conclusions: These findings suggest that although HIV-positive and HIV-negative older adults in South Africa are protected to some extent from CHE, inequalities still exist in access to and quality of care available at health-care services - which can inform South Africa's development of a national health insurance scheme.

Abstract access

Editor’s notes: The study provides a valuable overview of the health expenditures of HIV-positive and negative older people (50 years and older) in South Africa. It should be noted that the data used in this analysis are from 2007-2008. Therefore, it is likely that some things may have changed as anti-retroviral therapy has become more available. Perhaps some of the negative experiences reported by people living with HIV may have changed. However, it is likely that waiting times in clinics and concerns about drug-stockouts, may not have changed. Nearly a decade on, the number of people in need of HIV-associated care, and the resulting burden on the health service remain immense. The authors point to the valuable role of the social security system in reducing the financial impact of HIV, and mitigating catastrophic health expenditures. 

The authors have produced an important paper, highlighting some of the inequities in health care access. Many of these inequities are likely to have persisted. It would be invaluable to have a similar analysis of more recent data in order to chart progress. 

Africa
South Africa
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Botswana within reach of UNAIDS 90-90-90 treatment target

Botswana's progress toward achieving the 2020 UNAIDS 90-90-90 antiretroviral therapy and virological suppression goals: a population-based survey.

Gaolathe T, Wirth KE, Holme MP, Makhema J, Moyo S, Chakalisa U, Yankinda EK, Lei Q, Mmalane M, Novitsky V, Okui L, van Widenfelt E, Powis KM, Khan N, Bennett K, Bussmann H, Dryden-Peterson S, Lebelonyane R, El-Halabi S, Mills LA, Marukutira T, Wang R, Tchetgen EJ, DeGruttola V, Essex M, Lockman S, Botswana Combination Prevention Project study team. Lancet HIV. 2016 May;3(5):e221-30. doi: 10.1016/S2352-3018(16)00037-0. Epub 2016 Mar 24.

Background: HIV programmes face challenges achieving high rates of HIV testing and treatment needed to optimise health and to reduce transmission. We used data from the Botswana Combination Prevention Project study survey to assess Botswana's progress toward achieving UNAIDS targets for 2020: 90% of all people living with HIV knowing their status, 90% of these receiving sustained antiretroviral therapy (ART), and 90% of those having virological suppression (90-90-90).

Methods: A population-based sample of individuals was recruited and interviewed in 30 rural and periurban communities from Oct 30, 2013, to Nov 24, 2015, as part of a large, ongoing community-randomised trial designed to assess the effect of a combination prevention package on HIV incidence. A random sample of about 20% of households in each community was selected. Consenting household residents aged 16-64 years who were Botswana citizens or spouses of citizens responded to a questionnaire and had blood drawn for HIV testing in the absence of documentation of positive HIV status. Viral load testing was done in all HIV-infected participants, irrespective of treatment status. We used modified Poisson generalised estimating equations to obtain prevalence ratios, corresponding Huber robust SEs, and 95% Wald CIs to examine associations between individual sociodemographic factors and a binary outcome indicating achievement of the three individual and combined overall 90-90-90 targets. The study is registered at ClinicalTrials.gov, number NCT01965470.

Findings: 81% of enumerated eligible household members took part in the survey (10% refused and 9% were absent). Among 12 610 participants surveyed, 3596 (29%) were infected with HIV, and 2995 (83.3%, 95% CI 81.4-85.2) of these individuals already knew their HIV status. Among those who knew their HIV status, 2617 (87.4%, 95% CI 85.8-89.0) were receiving ART (95% of those eligible by national guidelines, and 73% of all infected people). Of the 2609 individuals receiving ART with a viral load measurement, 2517 (96.5%, 95% CI 96.0-97.0) had viral load of 400 copies per mL or less. Overall, 70.2% (95% CI 67.5-73.0) of HIV-infected people had virological suppression, close to the UNAIDS target of 73%.

Interpretation: UNAIDS 90-90-90 targets are achievable even in resource-constrained settings with high HIV burden.

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 HIV-positive people being virally suppressed. 

This study estimated coverage of HIV diagnosis, antiretroviral therapy and viral suppression among 30 communities in Botswana, a country with a high HIV prevalence (~ 25%), to assess the country’s progress towards the UNAIDS treatment target. They found that overall, about 70% of people living with HIV had viral suppression (defined in this analysis as having a viral load of less than HIV RNA 400 copies per mL), close to the UNAIDS target of 73%. However, there is still substantial ongoing transmission (demonstrated by an HIV incidence of 1.4% per year in 2013). The authors attribute this mainly to the 30% of people living with HIV that remain unsuppressed (undiagnosed, or not on treatment, or not virally suppressed because of poor adherence or drug resistance). They also acknowledge that other factors such as the complexities of sexual networks, risk behaviour patterns, and biological factors may play a role.

Interestingly the authors found very high proportions of viral suppression. Nearly 97% of people on ART were virally suppressed. The authors also found that younger age was the strongest predictor of not reaching the ultimate target (diagnosed, on treatment and being virally suppressed). People living with HIV aged 20-29 years old were about 50% less likely to be virally suppressed compared with people 60 years and older. Young people living with HIV aged between 16-19 years old were 60% less likely to be virally suppressed. This emphasizes again the need for focussed programmes for adolescents and young people.

Botswana has reached this level of coverage even when the criterion for initiating antiretroviral therapy was a CD4 cell count below 350 cells per μL, even before moving to providing treatment for everyone diagnosed with HIV. The authors conclude that the high proportions of HIV testing, antiretroviral therapy and viral suppression provide good evidence that the UNAIDS treatment target is achievable.

Africa
Botswana
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