Articles tagged as "People living with HIV"

Living with HIV on the move: migrant workers in north India

Complex routes into HIV care for migrant workers: a qualitative study from north India.

Rai T, Lambert HS, Ward H. AIDS Care. 2015 Nov 26:1-6. [Epub ahead of print]

Migrant workers are designated a bridge population in the spread of HIV and therefore if infected, should be diagnosed and treated early. This study examined pathways to HIV diagnosis and access to care for rural-to-urban circular migrant workers and partners of migrants in northern India, identifying structural, social and individual level factors that shaped their journeys into care. We conducted a qualitative study using in-depth interviews with HIV-positive men (n = 20) and women (n = 13) with a history of circular migration, recruited from an antiretroviral therapy centre in one district of Uttar Pradesh, north India. Migrants and partners of migrants faced a complex series of obstacles to accessing HIV testing and care. Employment insecurity, lack of entitlement to sick pay or subsidised healthcare at destination and the household's economic reliance on their migration-based livelihood led many men to continue working until they became incapacitated by HIV-related morbidity. During periods of deteriorating health they often exhausted their savings on private treatments focused on symptom management, and sought HIV testing and treatment at a public hospital only following a medical or financial emergency. Wives of migrants had generally been diagnosed following their husbands' diagnosis or death, with access to testing and treatment mediated via family members. For some, a delay in disclosure of husband's HIV status led to delays in their own testing. Diagnosing and treating HIV infection early is important in slowing down the spread of the epidemic and targeting those at greatest risk should be a priority. However, despite targeted campaigns, circumstances associated with migration may prevent migrant workers and their partners from accessing testing and treatment until they become sick. The insecurity of migrant work, the dominance of private healthcare and gender differences in health-seeking behaviour delay early diagnosis and treatment initiation.

Abstract access

Editor’s notes: Migrant workers who move for work in their own country face challenges in accessing health care and social support. In a country as large and diverse as India internal migration can be particularly taxing. For people living with HIV, or who acquire HIV while migrating for work, the challenges can be immense. This paper sets out concisely the issues these migrants face, trying to access information, treatment and support both in the place they move to and at home. The authors explain how migrant men might delay treatment because of their need to work, and perhaps also to keep their HIV-status secret. For the wives of migrants, this delay can severely affect their own access to health care. Free antiretroviral therapy is available, but as the authors suggest, many migrant workers do not know that. This lack of knowledge highlights the importance of providing better support for migrant workers. Support for access to free, or at least affordable, health care is something many migrant workers require; for migrant workers living with HIV that support is essential.

Asia
India
  • share
0 comments.

Can children recognise HIV-associated symptoms in their carers? Evaluation of a verbal assessment tool for children in South Africa.

Measuring child awareness for adult symptomatic HIV using a verbal assessment tool: concordance between adult-child dyads on adult HIV-associated symptoms and illnesses.

Becker E, Kuo C, Operario D, Moshabela M, Cluver L. Sex Transm Infect. 2015 Nov;91(7):528-33. doi: 10.1136/sextrans-2014-051728. Epub 2015 Jan 13.

Objectives: This study assessed children's awareness for adult HIV-associated symptoms and illnesses using a verbal assessment tool by analysing inter-rater reliability between adult-child dyads. This study also evaluated sociodemographic and household characteristics associated with child awareness of adult symptomatic HIV.

Methods: A cross-sectional survey using a representative community sample of adult-child dyads (N=2477 dyads) was conducted in KwaZulu-Natal, South Africa. Analyses focused on a subsample (n=673 adult-child dyads) who completed verbal assessment interviews for symptomatic HIV. We used an existing validated verbal autopsy approach, originally designed to determine AIDS-related deaths by adult proxy reporters. We adapted this approach for use by child proxy reporters for reporting on HIV-associated symptoms and illnesses among living adults. Analyses assessed whether children could reliably report on adult HIV-associated symptoms and illnesses and adult provisional HIV status.

Results: Adult-child pairs concurred above the 65th percentile for 9 of the 10 HIV-associated symptoms and illnesses with sensitivities ranging from 10% to 100% and specificities ranging from 20% to 100%. Concordant reporting between adult-child dyads for the adult's provisional HIV status was 72% (sensitivity=68%, specificity=73%). Children were more likely to reliably match adult's reports of provisional HIV status when they lived in households with more household members, and households with more robust socioeconomic indicators including access to potable water, food security and television.

Conclusions: Children demonstrate awareness of HIV-associated symptoms and illnesses experienced by adults in their household. Children in households with greater socioeconomic resources and more household members were more likely to reliably report on the adult's provisional HIV status.

Abstract Full-text [free] access

Editor’s notes: This study tested a new tool for assessing whether children who are caring for adults living with HIV in their household are able to recognise HIV-associated symptoms and illnesses. The study was conducted with households in one rural and one urban site in KwaZulu-Natal, South Africa. The authors report on the analysis of results from a sub-sample of 673 dyads, composed of one adult and one child living in the same household. With the help of researchers, children aged 10-17, completed a verbal tool that was adapted for this study from a previous ‘verbal autopsy’ tool used to assess AIDS-associated deaths. The adult in each of the dyads also completed an adult version of the study’s adapted tool. The tool contained questions on ten symptoms and illnesses associated with HIV. Some of these strongly indicate HIV presence when found in a combination of two or more (e.g. TB; oral candidiasis; diarrhoea; herpes). Children-adult responses were compared in each dyad and tested for concurrency and sensibility. Overall, children and adult responses matched for more than 65% for nine out of ten of the symptoms/illnesses listed. There were variations in reliable matching depending on symptoms/illnesses. Some symptoms may have been harder for children to report on behalf of the adult, for example, constant diarrhoea. The tool used with the children may be useful for improving our understanding of the issues faced by young carers in households where some members are living with HIV. The tool may also help to understand strategies put in place by young carers looking after an adult with HIV-associated illnesses.

Africa
South Africa
  • share
0 comments.

Assessing the risk of HIV in older age in South Africa

HIV after 40 in rural South Africa: a life course approach to HIV vulnerability among middle aged and older adults.

Mojola SA, Williams J, Angotti N, Gomez-Olive FX. Soc Sci Med. 2015 Oct;143:204-12. doi: 10.1016/j.socscimed.2015.08.023. Epub 2015 Aug 17.

South Africa has the highest number of people living with HIV in the world (over 6 million) as well as a rapidly aging population, with 15% of the population aged 50 and over. High HIV prevalence in rural former apartheid homeland areas suggests substantial aging with HIV and acquisition of HIV at older ages. We develop a life course approach to HIV vulnerability, highlighting the rise and fall of risk and protection as people age, as well as the role of contextual density in shaping HIV vulnerability. Using this approach, we draw on an innovative multi-method data set collected within the Agincourt Health and Demographic Surveillance System in South Africa, combining survey data with 60 nested life history interviews and 9 community focus group interviews. We examine HIV risk and protective factors among adults aged 40-80, as well as how and why these factors vary among people at older ages.

Abstract access

Editor’s notes: A growing body of work is documenting the importance of HIV in older age in East and southern Africa. This paper is a valuable addition to the literature. The authors look at how the risk of HIV infection, and the impact of living with HIV, affects women and men aged 40-80 years old. Forty is a relatively young age for a study of older people, but the age span covered by this paper does allow the authors to trace HIV vulnerability for people actively engaged in migrant labour to when they settle, as they age into their 60s and 70s. The finding that risk of HIV-infection and vulnerability to the impact of HIV vary across the life course, is not new. But the findings presented in this paper provide a compelling picture of changing risk. Indeed, the possibility that men in their 60s might be at particular risk of acquiring HIV because of their wives diminishing interest in sex highlights the importance of not assuming only people under 50 are ‘sexually active’. The authors also illustrate the risk that older women face who may prefer to remain celibate but cannot always refuse to have sexual intercourse with their husbands. One notable finding is that older men with a pension are attractive partners for younger women in what the authors describe as a poverty stricken area. The mixture of quantitative and qualitative data the authors use provide both breadth and depth to the findings presented making this both an interesting and informative paper.

Africa
South Africa
  • share
0 comments.

Relatedness, communication, and care of children living with HIV in eastern Uganda

Communication in the context of family caregiving: an exploratory study of Ugandan children on antiretroviral therapy.

Kajubi P, Katahoire AR, Kyaddondo D, Whyte SR. J Biosoc Sci. 2015 Oct 28:1-22. [Epub ahead of print]

It is important to consider the complexities of family dynamics when deciding when and how to communicate with HIV-infected children about their illness and treatment. Previous research has focused on providers' and caregivers' perspectives on whether, when and how to disclose HIV/AIDS diagnosis and treatment to HIV-infected children. From the perspective of HIV-infected children, communication does not mean just giving information about illness and treatment, but also encompasses emotional and material care. This paper places communication within the broader framework of caregiving in family situations. This exploratory study was conducted in Jinja district, Uganda, between November 2011 and December 2012. Through participant observation and in-depth interviews, communication by, and with, HIV-infected children in the context of family situations was explored from the perspectives of 29 HIV-infected children aged 8-17 years on antiretroviral therapy (ART) using content thematic analysis. Children's communication with caregivers about their illness and treatment varied depending on whom they were living with and the nature of caregiving. Although a mother's care was considered best, children described others who cared 'like a mother'. For some, caregiving was distributed among several relatives and non-relatives, while others felt they had hardly anyone to care for them. Caregiving from the children's perspective involved emotional support, expressed verbally and explicitly in messages of concern, encouragement conveyed in reminders to take medicines, attention when sick and confidential conversations about the challenges of having HIV and taking ART. Caregiving was also communicated implicitly in acts of provision of food/drinks to take with medicines, counting pills to confirm they had taken the medicines and accompanying children to treatment centres. Children's communication about their health and medicines and the care they received was to a large extent shaped by the nature of their relatedness to their caregivers, the extent to which caregiving was dispersed among several people and who else in the household was infected with HIV and on medication.

Abstract access 

Editor’s notes: The majority of children who acquire HIV are infected perinatally. This makes HIV unique among paediatric conditions to the extent that mothers may be ill or deceased. The family plays a vital role in the treatment and care of children, including individuals living with HIV. The family context is an important consideration when supporting children to adhere to care. It also affects decisions on how and when to communicate with children about their illness and treatment. The authors argue that for children living with HIV, communication is not just the transmission of factual information, but also the conveying of concern, feelings of affection and implicit messages of support, as well as their opposites. This is particularly important in the context of loss and family disruption; stigma and discrimination; and dislocation from siblings and other family when children are cared for by new carers.

This qualitative paper draws on ethnographic data collected between 2011 and 2012 in eastern Uganda through in-depth interviews and participant observation. A total of 29 children living with HIV aged between eight and 17 years and on ART were followed up for one year. Children were purposively sampled to include different ages, sexes and family status (residence, orphan status), education levels and disclosure statuses.

The study draws on the concept of ‘relatedness’ in order to understand the meaning of communication in the context of family caregiving. It highlights that communication by, and with children living with HIV, extends beyond the transmission of information to being structured around a much broader relationship of care. This has important implications for treatment centres as the person that a child lives with may not always be their main caregiver. This framing incorporates a broader understanding of caregiving to include both emotional and material support which may be delivered both explicitly and implicitly through words and deeds.

Africa
Uganda
  • share
0 comments.

Some success in improving infant-feeding practices in South Africa

Effect of an integrated community-based package for maternal and newborn care on feeding patterns during the first 12 weeks of life: a cluster-randomized trial in a South African township.

Ijumba P, Doherty T, Jackson D, Tomlinson M, Sanders D, Swanevelder S, Persson LA. Public Health Nutr. 2015 Oct;18(14):2660-8. doi: 10.1017/S1368980015000099. Epub 2015 Feb 9.

Objective: To analyse the effect of community-based counselling on feeding patterns during the first 12 weeks after birth, and to study whether the effect differs by maternal HIV status, educational level or household wealth.

Design: Cluster-randomized trial with fifteen clusters in each arm to evaluate an integrated package providing two pregnancy and five postnatal home visits delivered by community health workers. Infant feeding data were collected using 24 h recall of nineteen food and fluid items.

Setting: A township near Durban, South Africa.

Subjects: Pregnant women (1894 intervention and 2243 control) aged 17 years or more.

Results: Twelve weeks after birth, 1629 (intervention) and 1865 (control) mother-infant pairs were available for analysis. Socio-economic conditions differed slightly across intervention groups, which were considered in the analyses. There was no effect on early initiation of breast-feeding. At 12 weeks of age the intervention doubled exclusive breast-feeding (OR=2.29; 95 % CI 1.80, 2.92), increased exclusive formula-feeding (OR=1.70; 95 % CI 1.28, 2.27), increased predominant breast-feeding (OR=1.71; 95 % CI 1.34, 2.19), decreased mixed formula-feeding (OR=0.68; 95 % CI 0.55, 0.83) and decreased mixed breast-feeding (OR=0.54; 95 % CI 0.44, 0.67). The effect on exclusive breast-feeding at 12 weeks was stronger among HIV-negative mothers than HIV-positive mothers (P=0.01), while the effect on mixed formula-feeding was significant only among HIV-positive mothers (P=0.03). The effect on exclusive feeding was not different by household wealth or maternal education levels.

Conclusions: A perinatal intervention package delivered by community health workers was effective in increasing exclusive breast-feeding, exclusive formula-feeding and decreasing mixed feeding.

Abstract access 

Editor’s notes: This trial assesses the provision of an integrated package of motivational interviewing-based counselling during home visits by systematically supervised, remunerated full-time community health workers on breastfeeding practices. It found stronger effects among HIV negative mothers than mothers living with HIV. This is particularly important in the context of a setting where exclusive breast feeding is practised by only 8% of mothers and where messages have been mixed about the safety of breastfeeding among mothers living with HIV. The smaller effect among mothers living with HIV may be a legacy of the free provision of formula to these mothers from 2002 to 2011, and cultural feeding practices. Exit interviews with the community health workers revealed that no mothers had exclusively breast-fed their babies, and this may have influenced their delivery of the programme. Further work is necessary to communicate messages on the need for exclusive breast feeding among mothers living with HIV.

Avoid TB deaths
Africa
South Africa
  • share
0 comments.

Intimate partner violence and uptake and adherence of HIV treatment

Intimate partner violence and engagement in HIV care and treatment among women: a systematic review and meta-analysis.

Hatcher AM, Smout EM, Turan JM, Christofides N, Stockl H. AIDS. 2015 Sep 5. [Epub ahead of print]

Objective: We aimed to estimate the odds of engagement in HIV care and treatment among HIV-positive women reporting intimate partner violence (IPV).

Design: We systematically reviewed the literature on the association between IPV and engagement in care. Data sources included searches of electronic databases (PubMed, Web of Science, CINAHL and PsychoInfo), hand searches and citation tracking.

Methods: Two reviewers screened 757 full-text articles, extracted data and independently appraised study quality. Included studies were peer-reviewed and assessed IPV alongside engagement in care outcomes: antiretroviral treatment (ART) use; self-reported ART adherence; viral suppression; retention in HIV care. Odds ratios (ORs) were pooled using random effects meta-analysis.

Results: Thirteen cross-sectional studies among HIV-positive women were included. Measurement of IPV varied, with most studies defining a 'case' as any history of physical and/or sexual IPV. Meta-analysis of five studies showed IPV to be significantly associated with lower ART use [OR 0.79, 95% confidence interval (95% CI) 0.64-0.97]. IPV was associated with poorer self-reported ART adherence in seven studies (OR 0.48, 95% CI 0.30-0.75) and lower odds of viral load suppression in seven studies (OR 0.64, 95% CI 0.46-0.90). Lack of longitudinal data and measurement considerations should temper interpretation of these results.

Conclusion: IPV is associated with lower ART use, half the odds of self-reported ART adherence and significantly worsened viral suppression among women. To ensure the health of HIV-positive women, it is essential for clinical programmes to address conditions that impact engagement in care and treatment. IPV is one such condition, and its association with declines in ART use and adherence requires urgent attention.

Abstract access 

Editor’s notes: Intimate partner violence (IPV) is prevalent globally (30%). It has been associated with HIV infection and also with progression to AIDS among women living with HIV. However it is unclear how intimate partner violence may impact on HIV-associated health. This study examined associations between violence exposure and uptake of HIV treatment and care services. The authors conducted a systematic review and meta-analyses. From an initial search of 621 studies, 13 were included in these analyses: 12 were conducted in the United States of America and one in Haiti. All were cross-sectional. Measurement of intimate partner violence varied from a single question to validated scales. Some 11 measured lifetime IPV and two measured recent intimate partner violence, in the past 12 months.

Meta-analysis suggests intimate partner violence is associated with significantly lower odds of (i) current ART use (ii) self-reported adherence and (iii) worsened viral load suppression. There was insufficient data to measure retention in HIV care. These analyses suggest that uptake and adherence to ART is a key pathway through which intimate partner violence may negatively influence HIV-associated health of women. Further research is necessary, in low and middle income settings, and among key populations. Future studies should develop and test programmes to address intimate partner violence within HIV clinical care. 

Latin America, Northern America
Haiti, United States of America
  • share
0 comments.

Better integration of programmes against alcohol use necessary at every step of the HIV treatment cascade

The impact of alcohol use and related disorders on the HIV continuum of care: a systematic review: alcohol and the HIV continuum of care.

Vagenas P, Azar MM, Copenhaver MM, Springer SA, Molina PE, Altice FL. Curr HIV/AIDS Rep. 2015 Sep 28. [Epub ahead of print]

Alcohol use is highly prevalent globally with numerous negative consequences to human health, including HIV progression, in people living with HIV (PLH). The HIV continuum of care, or treatment cascade, represents a sequence of targets for intervention that can result in viral suppression, which ultimately benefits individuals and society. The extent to which alcohol impacts each step in the cascade, however, has not been systematically examined. International targets for HIV treatment as prevention aim for 90% of PLH to be diagnosed, 90% of them to be prescribed with antiretroviral therapy (ART), and 90% to achieve viral suppression; currently, only 20% of PLH are virally suppressed. This systematic review, from 2010 through May 2015, found 53 clinical research papers examining the impact of alcohol use on each step of the HIV treatment cascade. These studies were mostly cross-sectional or cohort studies and from all income settings. Most (77 %) found a negative association between alcohol consumption on one or more stages of the treatment cascade. Lack of consistency in measurement, however, reduced the ability to draw consistent conclusions. Nonetheless, the strong negative correlations suggest that problematic alcohol consumption should be targeted, preferably using evidence-based behavioral and pharmacological interventions, to indirectly increase the proportion of PLH achieving viral suppression, to achieve treatment as prevention mandates, and to reduce HIV transmission.

Abstract access 

Editor’s notes: This systematic review examined the impact of alcohol consumption on each step of the HIV treatment cascade. This covered HIV diagnosis, linkage to care, retention in care, ART initiation and adherence, and sustained virologic suppression. Overall, there was an association between alcohol consumption and negative consequences on various steps of the treatment cascade. The majority of studies focused on the effect of alcohol use disorders and ART adherence, and on viral suppression. There was fairly consistent evidence of reduced adherence among people with alcohol use disorders. Key findings of this review include the lack of consistency in studies of alcohol consumption. Many studies are not using standardised, validated, measures such as the AUDIT, and there is the lack of studies on the association of alcohol use with earlier stages of the cascade, including testing uptake and linkage to care. Further studies in this area would be useful, to identify whether programmes focused on problematic alcohol use are necessary at HIV testing centres.

  • share
0 comments.

Food insecurity among people living with HIV in the United States: time for structural level policy changes?

Food insecurity, chronic illness, and gentrification in the San Francisco Bay Area: an example of structural violence in United States public policy.

Whittle HJ, Palar K, Hufstedler LL, Seligman HK, Frongillo EA, Weiser SD. Soc Sci Med. 2015 Aug 20;143:154-161. doi: 10.1016/j.socscimed.2015.08.027. [Epub ahead of print]

Food insecurity continues to be a major challenge in the United States, affecting 49 million individuals. Quantitative studies show that food insecurity has serious negative health impacts among individuals suffering from chronic illnesses, including people living with HIV/AIDS (PLHIV). Formulating effective interventions and policies to combat these health effects requires an in-depth understanding of the lived experience and structural drivers of food insecurity. Few studies, however, have elucidated these phenomena among people living with chronic illnesses in resource-rich settings, including in the United States. Here we sought to explore the experiences and structural determinants of food insecurity among a group of low-income PLHIV in the San Francisco Bay Area. Thirty-four semi-structured in-depth interviews were conducted with low-income PLHIV receiving food assistance from a local non-profit in San Francisco and Alameda County, California, between April and June 2014. Interview transcripts were coded and analysed according to content analysis methods following an inductive-deductive approach. The lived experience of food insecurity among participants included periods of insufficient quantity of food and resultant hunger, as well as long-term struggles with quality of food that led to concerns about the poor health effects of a cheap diet. Participants also reported procuring food using personally and socially unacceptable strategies, including long-term dependence on friends, family, and charity; stealing food; exchanging sex for food; and selling controlled substances. Food insecurity often arose from the need to pay high rents exacerbated by gentrification while receiving limited disability income-a situation resulting in large part from the convergence of long-standing urban policies amenable to gentrification and an outdated disability policy that constrains financial viability. The experiences of food insecurity described by participants in this study can be understood as a form of structural violence, motivating the need for structural interventions at the policy level that extend beyond food-specific solutions.

Abstract access 

Editor’s notes: Studies in the United States of America have demonstrated a high prevalence of food insecurity among low-income people living with HIV. Despite this high prevalence, little is known about the precise structural mechanisms by which food insecurity is distributed across low and high income participants, particularly among people living with HIV. This paper begins to fill that knowledge gap.  Using in-depth interviews among a group of low-income people living with HIV residing in the San Francisco Bay area, this study sought to investigate questions around how food insecurity manifests among certain groups in the population. Three themes relevant to the lived experience of food insecurity emerged from the interviews. The first being periods of significant food shortage where hunger or the anticipation of hunger was a serious source of anxiety for participants. The second was around the perceived poor quality of food where participants were unable to afford a diet that they believed to be sufficiently healthy. They considered this to be detrimental to both their general and HIV-associated health. This led to a third theme: participants using a multitude of resourceful strategies in order to procure food. Some of the strategies they found personally uncomfortable or they perceived as socially unacceptable. A relevant theme around structural determinants of food security that also emerged was the disparity between rent payments and the disability income which participants received. In particular, rising rents due to an influx of people who benefited from the technology boom, alongside gentrification taking place in the San Francisco area made it particularly difficult for low income people living with HIV to afford to live in the city. In order to be able to purchase food which they considered as high priority they would have to ration their money and avoid buying items they considered as less of a necessity (for example, entertainment, travel or toiletries). This is particularly exacerbated by the issue of monthly disability payments being low relative to the cost of living. The findings presented in this paper suggest certain structural activities in order to prevent the adverse effects of food insecurity such as sexual risk, sub-optimal ART adherence and poor clinical outcomes for people living with HIV. There were two suggested measures. The first was protecting vulnerable populations from the market effects of urban regeneration through better state subsidies in housing. The second was helping state-dependent individuals afford an adequate and sufficiently healthy diet by reassessing the amount disbursed through the disability income.

In summary, the authors describe low-income people living with HIV participants who often found themselves pushed into situations of indignity, shame and poor health by large-scale economic forces beyond their control. Without funds to purchase food with adequate nutritional content, they often fell into absolute hunger or had poor diets that prompted concerns about their physical health. Despite the United States of America being a high income country with one of the highest GDP per capita, food insecurity continues to be a challenge. Only broad structural approaches with policy changes can help chronically ill and vulnerable individuals escape both indignities and negative health consequences of food insecurity in the 21st century. 

Northern America
United States of America
  • share
0 comments.

In which settings is Xpert® MTB/RIF and LED microscopy screening for Tuberculosis for people living with HIV cost-effective?

Screening for tuberculosis among adults newly diagnosed with HIV in sub-Saharan Africa: a cost-effectiveness analysis.

Zwerling AA, Sahu M, Ngwira LG, Khundi M, Harawa T, Corbett EL, Chaisson RE, Dowdy DW. J Acquir Immune Defic Syndr. 2015 Sep 1;70(1):83-90. doi: 10.1097/QAI.0000000000000712.

Objective: New tools, including light-emitting diode (LED) fluorescence microscopy and the molecular assay Xpert® MTB/RIF, offer increased sensitivity for tuberculosis (TB) in persons with HIV but come with higher costs. Using operational data from rural Malawi, we explored the potential cost-effectiveness of on-demand screening for TB in low-income countries of sub-Saharan Africa.

Design and methods: Costs were empirically collected in 4 clinics and in 1 hospital using a microcosting approach, through direct interview and observation from the national TB program perspective. Using decision analysis, newly diagnosed persons with HIV were modeled as being screened by 1 of the 3 strategies: Xpert®, LED, or standard of care (ie, at the discretion of the treating physician).

Results: Cost-effectiveness of TB screening among persons newly diagnosed with HIV was largely determined by 2 factors: prevalence of active TB among patients newly diagnosed with HIV and volume of testing. In facilities screening at least 50 people with a 6.5% prevalence of TB, or at least 500 people with a 2.5% TB prevalence, Xpert® is likely to be cost-effective. At lower prevalence-including that observed in Malawi-LED microscopy may be the preferred strategy, whereas in settings of lower TB prevalence or small numbers of eligible patients, no screening may be reasonable (such that resources can be deployed elsewhere).

Conclusions: TB screening at the point of HIV diagnosis may be cost-effective in low-income countries of sub-Saharan Africa, but only if a relatively large population with high prevalence of TB can be identified for screening.

Abstract access 

Editor’s notes: This study provides guidance on when screening people newly diagnosed with HIV for tuberculosis (TB) using Xpert® MTB/RIF or LED microscopy is likely to be cost-effective. Previous studies suggest that both TB screening technologies may be cost-effective, but that cost-effectiveness will depend on how tests are implemented. In highly resource constrained settings, the affordability of TB screening, particularly using Xpert® MTB/RIF, remains a concern. It therefore may not be feasible to place screening equipment at all locations, and more guidance is required on the types of setting where these investments may have the most benefit.

The study finds that two factors are particularly important in the choice of TB screening at any specific site. First, the authors find that test volumes are critical to cost-effectiveness. This finding supports earlier studies from South Africa prior to Xpert® MTB/RIF roll-out – that suggest that ‘economies of scale’ drive the unit costs per test. The authors of this study add to this previous evidence by providing a detailed example from a low income setting. Second, on the effect side, TB prevalence is found to be a key driver of cost-effectiveness.

The authors provide an illustration of a simple approach and model that can be used by countries to select the different TB screening tests required. It should be noted however, that the authors are not able to fully consider some factors that may have an important impact on the cost-effectiveness of TB screening, due to data scarcity. For example, the extent and speed to which people are appropriately treated for TB under each option (including the standard of care). This has been shown to be an important consideration in other studies investigating the cost-effectiveness of Xpert® MTB/RIF. It should also be noted that the study determines cost-effectiveness using an approach that may not fully reflect financial constraints. Therefore additional analyses, using local data, are still required before applying the study’s results in different settings.  

Africa
Malawi
  • share
0 comments.

Awareness of HIV status and risk among key populations in India

HIV care continuum among men who have sex with men and people who inject drugs in India: barriers to successful engagement.

Mehta SH, Lucas GM, Solomon S, Srikrishnan AS, McFall AM, Dhingra N, Nandagopal P, Kumar MS, Celentano DD, Solomon SS. Clin Infect Dis. 2015 Aug 6. pii: civ669. [Epub ahead of print]

Background: We characterize the HIV care continuum for men who have sex with men (MSM) and people who inject drugs (PWID) across India.

Methods: We recruited 12 022 MSM and 14 481 PWID across 26 Indian cities using respondent-driven sampling (9/2012-12/2013). Participants were ≥18 years and either 1) self-identified as male and reported sex with a man in the prior year (MSM); or 2) reported injection drug use in the prior 2 years (PWID). Correlates of awareness of HIV positive status were characterized using multi-level logistic regression.

Results: 1146 MSM were HIV-infected of whom a median 30% were aware of their HIV positive status, 23% were linked to care, 22% were retained pre-ART, 16% initiated ART, 16% were currently on ART, and 10% had suppressed VL. There was site variability (awareness range: 0-90%; suppressed VL range: 0-58%). 2906 PWID were HIV-infected of whom a median 41% were aware, 36% linked to care, 31% were retained pre-ART, 20% initiated ART, 18% were currently on ART, and 15% had suppressed VL. Similar site variability was observed (awareness range: 2-93%; suppressed VL range: 0-47%). Factors significantly associated with awareness were region, older age, being married (MSM) or female (PWID), other service utilization (PWID), more lifetime sexual partners (MSM) and needle sharing (PWID). Ongoing injection drug use (PWID) and alcohol (MSM) were associated with lower awareness.

Conclusions: In this large sample, the major barrier to HIV care engagement was awareness of HIV positive status. Efforts should focus on linking HIV testing to other essential services.

Abstract access 

Editor’s notes: The UNAIDS target of 90-90-90 (90% of HIV positive individuals knowing their status, 90% of people being on ART and 90% of people on ART being virally suppressed) applies to all people living with HIV, including people in key populations who can be hard to reach in some settings. In India, declines in HIV prevalence have been seen among women attending antenatal clinics, but not in the key populations of gay men and other men who have sex with men and people who inject drugs. In this large, community-based, study of gay men and other men who have sex with men and people who inject drugs across India, the majority of people living with HIV (70% of gay men and other men who have sex with men and 59% of people who inject drugs) were unaware of their HIV status. Of people who were aware of their status, the proportions receiving sustained ART were relatively low (68% of gay men and other men who have sex with men and 52% of people who inject drugs). Notably, among people on ART, levels of viral suppression were high and comparable to that in high-income settings. The study highlights awareness of HIV status as the primary barrier to HIV care in these populations, and the importance of integrating HIV testing across healthcare services for vulnerable populations, using same-day rapid tests to maximise linkage-to-care. However, to have a real impact on outcomes across the HIV care continuum, additional strategies will be necessary. These are needed together with large-scale public policy changes to modify the broader social environment – such as decriminalisation of same-sex behaviour.

Asia
India
  • share
0 comments.