Articles tagged as "Kenya"

Silent transfers result in underestimation of retention on ART

Retention in care and patient-reported reasons for undocumented transfer or stopping care among HIV-infected patients on antiretroviral therapy in eastern Africa: application of a sampling-based approach.

Geng EH, Odeny TA, Lyamuya R, Nakiwogga-Muwanga A, Diero L, Bwana M, Braitstein P, Somi G, Kambugu A, Bukusi E, Wenger M, Neilands TB, Glidden DV, Wools-Kaloustian K, Yiannoutsos C, Martin J, East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium. Clin Infect Dis. 2016 Apr 1;62(7):935-44. doi: 10.1093/cid/civ1004. Epub 2015 Dec 17.

Background: Improving the implementation of the global response to human immunodeficiency virus requires understanding retention after starting antiretroviral therapy (ART), but loss to follow-up undermines assessment of the magnitude of and reasons for stopping care.

Methods: We evaluated adults starting ART over 2.5 years in 14 clinics in Uganda, Tanzania, and Kenya. We traced a random sample of patients lost to follow-up and incorporated updated information in weighted competing risks estimates of retention. Reasons for nonreturn were surveyed.

Results: Among 18 081 patients, 3150 (18%) were lost to follow-up and 579 (18%) were traced. Of 497 (86%) with ascertained vital status, 340 (69%) were alive and, in 278 (82%) cases, updated care status was obtained. Among all patients initiating ART, weighted estimates incorporating tracing outcomes found that 2 years after ART, 69% were in care at their original clinic, 14% transferred (4% official and 10% unofficial), 6% were alive but out of care, 6% died in care (<60 days after last visit), and 6% died out of care (≥60 days after last visit). Among lost patients found in care elsewhere, structural barriers (eg, transportation) were most prevalent (65%), followed by clinic-based (eg, waiting times) (33%) and psychosocial (eg, stigma) (27%). Among patients not in care elsewhere, psychosocial barriers were most prevalent (76%), followed by structural (51%) and clinic based (15%).

Conclusions: Accounting for outcomes among those lost to follow-up yields a more informative assessment of retention. Structural barriers contribute most to silent transfers, whereas psychological and social barriers tend to result in longer-term care discontinuation.

Abstract access 

Editor’s notes: The authors explore outcomes by tracing a sample of people who were lost to follow-up from antiretroviral therapy (ART) clinics. They collected data on reasons provided by patients for undocumented transfer out, or stopping ART. The findings are important, both to be able to critically evaluate the success of ART programmes (and individual clinics) in retaining people in care, and to identify barriers to retention which may be amenable to change. Consistent with findings elsewhere, the most common outcome among “lost” ART clinic attendees was “silent” (unofficial) transfer to another clinic, which, in this three-country study, accounted for a 10% underestimation of retention in care over two years. This highlights the pressing need for improved electronic medical record systems with centralised identification, in order to be able to track individuals between facilities so that accurate retention data can be collated.

As ART programmes move towards universal immediate initiation, the rate of stopping care (or transferring) will likely increase. In this study, 22% of people who had stopped care gave “I felt well” as a reason. The need for programmes to respond to the structural, psychological and social barriers identified will become even more important. 

Africa
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What works to link people living with HIV to care - a review

Facilitators and barriers in HIV linkage to care interventions: a qualitative evidence review.

Tso LS, Best J, Beanland R, Doherty M, Lackey M, Ma Q, Hall BJ, Yang B, Tucker JD. AIDS. 2016 Apr 6. [Epub ahead of print]

Objective: To synthesize qualitative evidence on linkage to care interventions for people living with HIV.

Design: Systematic literature review.

Methods: We searched nineteen databases for studies reporting qualitative evidence on linkage interventions. Data extraction and thematic analysis were used to synthesize findings. Quality was assessed using the CASP tool and certainty of evidence was evaluated using the CERQual approach.

Results: Twenty-five studies from eleven countries focused on adults (24 studies), adolescents (8 studies), and pregnant women (4 Facilitators included community-level factors (i.e. task-shifting, mobile outreach, integrated HIV and primary services, supportive cessation programs for substance users, active referrals, and dedicated case management teams) and individual-level factors (encouragement of peers/family and positive interactions with healthcare providers in transitioning into care). One key barrier for people living with HIV was perceived inability of providers to ensure confidentiality as part of linkage to care interventions. Providers reported difficulties navigating procedures across disparate facilities and having limited resources for linkage to care interventions.

Conclusions: Our findings extend the literature by highlighting the importance of task-shifting, mobile outreach, and integrated HIV and primary services. Both community and individual level factors may increase the feasibility and acceptability of HIV linkage to care interventions. These findings may inform policies to increase the reach of HIV services available in communities.

Abstract access  

Editor’s notes: As the authors of this paper observe, most evaluations of linkage to care programmes have focused on quantitative assessment. This useful paper provides a thorough overview of the findings from 25 studies which used qualitative methods for assessment. Linkage-to- care programmes feasible in different country settings were identified in this review.  The authors also highlight gaps, most notably a lack of information on linkage-to-care programmes for men. They also note the need for longitudinal assessments that look at changes over time.

This paper is a useful synthesis of findings. But it is also an excellent example of how to carry out a systematic review of qualitative research. The description of the qualitative meta-synthesis the authors performed adds additional value to this paper. 

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What works to link people living with HIV to care - a review

Facilitators and barriers in HIV linkage to care interventions: a qualitative evidence review.

Tso LS, Best J, Beanland R, Doherty M, Lackey M, Ma Q, Hall BJ, Yang B, Tucker JD. AIDS. 2016 Apr 6. [Epub ahead of print]

Objective: To synthesize qualitative evidence on linkage to care interventions for people living with HIV.

Design: Systematic literature review.

Methods: We searched nineteen databases for studies reporting qualitative evidence on linkage interventions. Data extraction and thematic analysis were used to synthesize findings. Quality was assessed using the CASP tool and certainty of evidence was evaluated using the CERQual approach.

Results: Twenty-five studies from eleven countries focused on adults (24 studies), adolescents (8 studies), and pregnant women (4 Facilitators included community-level factors (i.e. task-shifting, mobile outreach, integrated HIV and primary services, supportive cessation programs for substance users, active referrals, and dedicated case management teams) and individual-level factors (encouragement of peers/family and positive interactions with healthcare providers in transitioning into care). One key barrier for people living with HIV was perceived inability of providers to ensure confidentiality as part of linkage to care interventions. Providers reported difficulties navigating procedures across disparate facilities and having limited resources for linkage to care interventions.

Conclusions: Our findings extend the literature by highlighting the importance of task-shifting, mobile outreach, and integrated HIV and primary services. Both community and individual level factors may increase the feasibility and acceptability of HIV linkage to care interventions. These findings may inform policies to increase the reach of HIV services available in communities.

Abstract access  

Editor’s notes: As the authors of this paper observe, most evaluations of linkage to care programmes have focused on quantitative assessment. This useful paper provides a thorough overview of the findings from 25 studies which used qualitative methods for assessment. Linkage-to- care programmes feasible in different country settings were identified in this review.  The authors also highlight gaps, most notably a lack of information on linkage-to-care programmes for men. They also note the need for longitudinal assessments that look at changes over time.

This paper is a useful synthesis of findings. But it is also an excellent example of how to carry out a systematic review of qualitative research. The description of the qualitative meta-synthesis the authors performed adds additional value to this paper. 

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Strengthening PMTCT implementation through systems engineering

Impact of a systems engineering intervention on PMTCT service delivery in Cote d'Ivoire, Kenya, Mozambique: a cluster randomized trial.

Rustagi AS, Gimbel S, Nduati R, Cuembelo MF, Wasserheit JN, Farquhar C, Gloyd S, Sherr K, with input from the SST. J Acquir Immune Defic Syndr. 2016 Apr 14. [Epub ahead of print]

Background: Efficacious interventions to prevent mother-to-child HIV transmission (PMTCT) have not translated well into effective programs. Prior studies of systems engineering applications to PMTCT lacked comparison groups or randomization.

Methods: Thirty-six health facilities in Cote d'Ivoire, Kenya, and Mozambique were randomized to usual care or a systems engineering intervention, stratified by country and volume. The intervention guided facility staff to iteratively identify and then rectify barriers to PMTCT implementation. Registry data quantified coverage of HIV testing during first antenatal care visit, antiretrovirals (ARVs) for HIV-positive pregnant women, and screening HIV-exposed infants (HEI) for HIV by 6-8 weeks. We compared the change between baseline (January 2013-January 2014) and post-intervention (January-March 2015) periods using t-tests. All analyses were intent-to-treat.

Results: ARV coverage increased 3-fold (+13.3 percentage points [95% CI: 0.5, 26.0] in intervention vs. +4.1 [-12.6, 20.7] in control facilities) and HEI screening increased 17-fold (+11.6 [-2.6, 25.7] in intervention vs. +0.7 [-12.9, 14.4] in control facilities). In pre-specified sub-group analyses, ARV coverage increased significantly in Kenya (+20.9 [-3.1, 44.9] in intervention vs. -21.2 [-52.7, 10.4] in controls; p=0.02). HEI screening increased significantly in Mozambique (+23.1 [10.3, 35.8] in intervention vs. +3.7 [-13.1, 20.6] in controls; p=0.04). HIV testing did not differ significantly between arms.

Conclusions: In this first randomized trial of systems engineering to improve PMTCT, we saw substantially larger improvements in ARV coverage and HEI screening in intervention facilities compared to controls, which were significant in pre-specified sub-groups. Systems engineering could strengthen PMTCT service delivery and protect infants from HIV.

Abstract access

Editor’s notes: Systems engineering is an interdisciplinary approach to optimise complex processes or systems. In this randomised trial of a systems engineering approach to improving prevention  of mother-to-child HIV transmission programmes, the study programme was a five-step, iterative package of systems analysis and quality improvement tools. In lay terms, the systems engineering activity helped facility staff understand implementation barriers to prevention of mother-to-child transmission programme service delivery, identify bottlenecks and patient dropout along the cascade and develop a facility-specific microintervention to address these issues. This was then repeated in a quality improvement iterative cycle with the overall aim to improve the flow of mother-infant pairs through the prevention of mother-to-child HIV transmission cascade. Study findings suggest that a systems engineering approach could markedly increase antiretroviral therapy coverage and HIV-exposed infant screening in prevention of mother-to-child HIV transmission programmes.  Further studies evaluating a systems engineering approach in the context of programmatic HIV care, especially in resource-poor settings, are required.

Africa
Côte d'Ivoire, Kenya, Mozambique
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Greater HIV-free survival for infants when the father attends antenatal care

Male partner participation in antenatal clinic services is associated with improved HIV-free survival among infants in Nairobi, Kenya: a prospective cohort study.

Aluisio AR, Bosire R, Betz B, Gatuguta A, Kiarie JN, Nduati R, John-Stewart G, Farquhar C. J Acquir Immune Defic Syndr. 2016 Apr 26. [Epub ahead of print]

Objective: This prospective study investigated the relationship between male antenatal clinics (ANC) involvement and infant HIV-free survival.

Methods: From 2009-2013, HIV-infected pregnant women were enrolled from six antenatal clinics (ANC) in Nairobi, Kenya and followed with their infants until six weeks postpartum. Male partners were encouraged to attend antenatally through invitation letters. Males who failed to attend had questionnaires sent for self-completion postnatally. Multivariate regression was used to identify correlates of male attendance. The role of male involvement in infant outcomes of HIV infection, mortality and HIV-free survival were examined.

Results: Among 830 enrolled women, 519 (62.5%) consented to male participation and 136 (26.2%) men attended the ANC. For the 383 (73.8%) women whose partners failed to attend, 63 (16.4%) were surveyed via outreach. In multivariate analysis, male report of prior HIV testing was associated with maternal ANC attendance (aOR=3.7; 95% CI:1.5-8.9, p=0.003). Thirty-five (6.6%) of 501 infants acquired HIV or died by six weeks of life. HIV-free survival was significantly greater among infants born to women with partner attendance (97.7%) than those without (91.3%) (p=0.01). Infants lacking male ANC engagement had an approximately 4-fold higher risk of death or infection compared to those born to women with partner attendance (HR=3.95, 95% CI:1.21-12.89, p=0.023). Adjusting for antiretroviral use, the risk of death or infection remained significantly greater for infants born to mothers without male participation (aHR=3.79, 95% CI:1.15-12.42, p=0.028).

Conclusions: Male ANC attendance was associated with improved infant HIV-free survival. Promotion of male HIV testing and engagement in ANC/PMTCT services may improve infant outcomes.

Abstract access  

Editor’s notes: Male partners of pregnant women are usually not involved in antenatal care in Africa, and this is now recognised as a missed opportunity. In addition to providing an opportunity to offer HIV testing and counselling to men, prevention of mother-to-child HIV transmission is easier with the acceptance and support of the male partner. This study investigated whether involving the male partner was associated with improved infant survival and reduced mother-to-child HIV transmission.

Men who had previously tested for HIV, especially as a couple, and who knew their partner’s status were more likely to attend antenatal care. Notably, 14% of men who did not attend the ANC did not know that mother-to-child HIV transmission is preventable.  

Six weeks after birth, infants born to women living with HIV, whose fathers had been involved in ANC care had greater HIV-free survival than infants whose fathers had not been involved. However, male involvement was rare. Over a quarter of women who had a male partner did not want him to be involved, and of the partners who were encouraged to come via letter, only a quarter did attend.

The results should be interpreted cautiously as it is not possible to disentangle the characteristics that prompted male involvement from the effect of prior counselling and testing on willingness to be involved in antenatal care. Men who attended antenatal care may have been more supportive to their partner. Mixed-methods research may help to identify the process and how outcomes can be improved. Overall, the results support investment in programmes aimed at enhancing male HIV testing and ANC engagement to improve infant health outcomes. 

Africa
Kenya
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Stopping PrEP use due to changes in partnership dynamics and life events could increase HIV risk

When and why women might suspend PrEP use according to perceived seasons of risk: implications for PrEP-specific risk-reduction counselling.

Namey E, Agot K, Ahmed K, Odhiambo J, Skhosana J, Guest G, Corneli A. Cult Health Sex. 2016 Apr 19:1-11. [Epub ahead of print]

Oral pre-exposure prophylaxis (PrEP) using the antiretroviral drug emtricitabine/tenofovir disoproxil fumarate (Truvada) has been shown to dramatically reduce the risk of HIV acquisition for women at higher risk of infection if taken daily. Understanding when and why women would intentionally stop using an efficacious oral PrEP drug within the context of their 'normal' daily lives is essential for delivering effective PrEP risk-reduction counselling. As part of a larger study, we conducted 60 qualitative interviews with women at higher risk of HIV in Bondo, Kenya, and Pretoria, South Africa. Participants charted their sexual contacts over the previous six months, indicated whether they would have taken PrEP if available and discussed whether and why they would have suspended PrEP use. Nearly all participants said they would have used PrEP in the previous six months; half indicated they would have suspended PrEP use at some point. Participants' reasons for an extended break from PrEP were related to partnership dynamics (e.g., perceived low risk of a stable partner) and phases of life (e.g., trying to conceive). Life events (e.g., holidays and travel) could prompt shorter breaks in PrEP use. These circumstances may or may not correspond to actual contexts of lower risk, highlighting the importance of tailored PrEP risk-reduction counselling.

 Abstract access 

Editor’s notes: This paper presents findings from a qualitative study that aimed to understand why and when women would stop using oral PrEP in the context of their everyday lives. The study included 30 semi-structured interviews with women in Kenya and 30 with women in South Africa.  All were participants in a larger study exploring PrEP and risk compensation who were HIV negative (aged between 18 and 35 years).

The authors found that nearly all women would have taken PrEP six months before the interview. Reasons for stopping PrEP use due to partnership dynamics included the absence of a partner, the end of a relationship, infrequent sex, marriage and stable or faithful relationships. Phases of life which would stop women using PrEP included trying to conceive, pregnancy and older age.  Life events such as illness, stressful events, travelling and festivals affected PrEP use.

The authors provided a number of suggestions for counsellors to support women to assess risk and need to use PrEP. This could include information on the HIV-infection risk due to the difficulty of negotiating condom use. The authors also suggested the use of couples counselling and male engagement strategies. The authors recommended that counsellors should counsel that risk may increase during travel and holidays. Such suggestions highlight the usefulness of this study in understanding why women would stop PrEP use.

Africa
Kenya, South Africa
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Addressing alcohol use can improve structural factors in the lives of sex workers

The impact of an alcohol harm reduction intervention on interpersonal violence and engagement in sex work among female sex workers in Mombasa, Kenya: Results from a randomized controlled trial.

Parcesepe AM, KL LE, Martin SL, Green S, Sinkele W, Suchindran C, Speizer IS, Mwarogo P, Kingola N. Drug Alcohol Depend. 2016 Apr 1;161:21-8. doi: 10.1016/j.drugalcdep.2015.12.037. Epub 2016 Jan 22.

Aims: To evaluate whether an alcohol harm reduction intervention was associated with reduced interpersonal violence or engagement in sex work among female sex workers (FSWs) in Mombasa, Kenya.

Design: Randomized controlled trial.

Setting: HIV prevention drop-in centers in Mombasa, Kenya.

Participants: 818 women 18 or older in Mombasa who visited HIV prevention drop-in centers, were moderate-risk drinkers and engaged in transactional sex in past six months (410 and 408 in intervention and control arms, respectively).

Intervention: 6 session alcohol harm reduction intervention.

Comparator: 6 session non-alcohol related nutrition intervention.

Measurements: In-person interviews were conducted at enrollment, immediately post-intervention and 6-months post-intervention. General linear mixed models examined associations between intervention assignment and recent violence (physical violence, verbal abuse, and being robbed in the past 30 days) from paying and non-paying sex partners and engagement in sex work in the past 30 days.

Findings: The alcohol intervention was associated with statistically significant decreases in physical violence from paying partners at 6 months post-intervention and verbal abuse from paying partners immediately post-intervention and 6-months post-intervention. Those assigned to the alcohol intervention had significantly reduced odds of engaging in sex work immediately post-intervention and 6-months post-intervention.

Conclusions: The alcohol intervention was associated with reductions in some forms of violence and with reductions in engagement in sex work among FSWs in Mombasa, Kenya.

Abstract access  

Editor’s notes: Modifying structural drivers, such as alcohol, violence, or socio-economic status is a challenging but necessary component of developing sustainable, effective solutions to the HIV epidemic. This study presents findings from an individually randomised trial, where female sex workers were randomised to receive an individual-level programme focused on alcohol and substance use, and to assess non-alcohol associated outcomes of violence, and indirectly economic vulnerability. While the programme did not produce persistent effects at six months for all components, it very usefully demonstrated how addressing alcohol use, a structural factor central to sex workers’ lives, can potentially also improve non-alcohol associated outcomes. These included experiences of violence, economic status, and even ability to reduce time spent in sex work. Alcohol harm reduction programming should be integrated into HIV prevention programming with female sex workers, regardless of HIV status.

Africa
Kenya
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Intimate partner violence among female sex workers living with HIV must be addressed to improve their wellbeing and reduce onward transmission of HIV

A prospective cohort study of intimate partner violence and unprotected sex in HIV-positive female sex workers in Mombasa, Kenya.

Wilson KS, Deya R, Yuhas K, Simoni J, Vander Stoep A, Shafi J, Jaoko W, Hughes JP, Richardson BA, McClelland RS. AIDS Behav. 2016 Apr 19. [Epub ahead of print]

We conducted a prospective cohort study to test the hypothesis that intimate partner violence (IPV) is associated with unprotected sex in HIV-positive female sex workers in Mombasa, Kenya. Women completed monthly visits and quarterly examinations. Any IPV in the past year was defined as ≥1 act of physical, sexual, or emotional violence by the current or most recent emotional partner ('index partner'). Unprotected sex with any partner was measured by self-report and prostate specific antigen (PSA) test. Recent IPV was associated with significantly higher risk of unprotected sex (adjusted relative risk [aRR] 1.91, 95 % CI 1.32, 2.78, p = 0.001) and PSA (aRR 1.54, 95 % CI 1.17, 2.04, p = 0.002) after adjusting for age, alcohol use, and sexual violence by someone besides the index partner. Addressing IPV in comprehensive HIV programs for HIV-positive women in this key population is important to improve wellbeing and reduce risk of sexual transmission of HIV.

Abstract access  

Editor’s notes: Intimate partner violence (IPV) is the most common form of gender-based violence globally. A recent systematic review reported high prevalence of IPV in sub-Saharan Africa, ranging from 30% to 66% among ever partnered women. Negative outcomes associated with IPV include increased risk of HIV infection and there are multiple pathways through which IPV may increase the risk of HIV infection in women. These include reduced sexual relationship power and ability to negotiate condom, and more risky sexual behaviour. Furthermore, IPV may be a marker of relationships with men who have a history of violent behaviour and may be at increased risk of HIV themselves. Women living with HIV are also at increased risk of IPV, which in turn can increase the risk of condomless sex and onward transmission of HIV.

Female sex workers are a key population disproportionately affected by violence, substance abuse and HIV. This longitudinal study of female sex workers in Kenya found a significant association between IPV and condomless sex. It highlights the value of using both self-reported behavioural and biological markers of sexual behaviour to gain a more complete understanding of the relationship between IPV and risky sexual behaviour. Comprehensive HIV programmes must address IPV to improve both the health and well-being of women living with HIV and to reduce sexual transmission of HIV. 

Africa
Kenya
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Profound effect of ART on mortality through reduction of opportunistic infections

Incidence of opportunistic infections and the impact of antiretroviral therapy among HIV-infected adults in low and middle income countries: a systematic review and meta-analysis. 

Low A, Gavriilidis G, Larke N, Lajoie MR, Drouin O, Stover J, Muhe L, Easterbrook P. Clin Infect Dis. 2016 Mar 6. pii: ciw125. [Epub ahead of print]

Background: To understand regional burdens and inform delivery of health services, we conducted a systematic review and meta-analysis to evaluate the effect of antiretroviral therapy (ART) on incidence of key opportunistic infections (OIs) in HIV-infected adults in low and middle-income countries (LMIC).

Methods: Eligible studies describing the cumulative incidence of OIs and proportion on ART from 1990 to November 2013 were identified using multiple databases. Summary incident risks for the ART-naive period, and during and after the first year of ART, were calculated using random effects meta-analyses. Summary estimates from ART subgroups were compared using meta-regression. The number of OI cases and associated costs averted if ART was initiated at CD4 ≥200 cells/µl was estimated using UNAIDS country estimates and global average OI treatment cost per case.

Results: We identified 7965 citations, and included 126 studies describing 491 608 HIV-infected persons. In ART-naive patients, summary risk was highest (>5%) for oral candidiasis, tuberculosis, herpes zoster, and bacterial pneumonia. The reduction in incidence was greatest for all OIs during the first 12 months of ART (range 57-91%) except for tuberculosis, and was largest for oral candidiasis, PCP and toxoplasmosis. Earlier ART was estimated to have averted 857 828 cases in 2013 (95% confidence interval [CI], 828 032-874 853), with cost savings of $46.7 million (95% CI, 43.8-49.4).

Conclusions: There was a major reduction in risk for most OIs with ART use in LMICs, with the greatest effect seen in the first year of treatment. ART has resulted in substantial cost savings from OIs averted.

Abstract  Full-text [free] access

Editor’s notes: Opportunistic infections (OIs) remain the major cause of HIV-associated mortality. OIs account for substantially higher mortality in low and middle income countries (LMICs) compared to high income countries (HICs).

This paper describes the results of a systematic review and meta-analysis including about 500 000 people on ART in LMICs across three regions (sub-Saharan Africa, Asia, and Latin America). These large numbers enabled the investigators to look at the effect of ART on the incidence of key OIs during and after the first year of treatment.

Not surprisingly they found that the effect of ART reduced the risk of all OIs during the first year after ART initiation, although the reduction was less for tuberculosis. The authors attribute this to the occurrence of tuberculosis across a wide range of CD4 cell counts, a smaller effect of early immune restoration and the contribution of TB as a manifestation of immune reconstitution syndrome during the first months after ART initiation. Beyond one year after ART initiation, the reduction in tuberculosis was greater.

They conclude that the effect of ART on the incidence of most HIV-associated OIs is the key reason for the global decline in HIV-associated mortality. However, a significant proportion of HIV-positive persons still continue to present with advanced disease. Besides timely ART initiation, additional measures such as CTX prophylaxis, screening for TB and cryptococcal disease, and the use of isoniazid and fluconazole prophylaxis should be considered for late presenters. 

Africa, Asia, Latin America
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Combining community-based HIV testing methods to achieve high testing coverage

A hybrid mobile approach for population-wide HIV testing in rural east Africa: an observational study. 

Chamie G, Clark TD, Kabami J, Kadede K, Ssemmondo E, Steinfeld R, Lavoy G, Kwarisiima D, Sang N, Jain V, Thirumurthy H, Liegler T, Balzer LB, Petersen ML, Cohen CR, Bukusi EA, Kamya MR, Havlir DV, Charlebois ED. Lancet HIV. 2016 Mar;3(3):e111-9. doi: 10.1016/S2352-3018(15)00251-9. Epub 2016 Jan 26.

Background: Despite large investments in HIV testing, only an estimated 45% of HIV-infected people in sub-Saharan Africa know their HIV status. Optimum methods for maximising population-level testing remain unknown. We sought to show the effectiveness of a hybrid mobile HIV testing approach at achieving population-wide testing coverage.

Methods: We enumerated adult (≥15 years) residents of 32 communities in Uganda (n=20) and Kenya (n=12) using a door-to-door census. Stable residence was defined as living in the community for at least 6 months in the past year. In each community, we did 2 week multiple-disease community health campaigns (CHCs) that included HIV testing, counselling, and referral to care if HIV infected; people who did not participate in the CHCs were approached for home-based testing (HBT) for 1-2 months within the 1-6 months after the CHC. We measured population HIV testing coverage and predictors of testing via HBT rather than CHC and non-testing.

Findings: From April 2, 2013, to June 8, 2014, 168 772 adult residents were enumerated in the door-to-door census. HIV testing was achieved in 131 307 (89%) of 146 906 adults with stable residence. 13 043 of 136 033 (9.6%, 95% CI 9.4-9.8) adults with and without stable residence had HIV; median CD4 count was 514 cells per µL (IQR 355-703). Among 131 307 adults with stable residence tested, 56 106 (43%) reported no previous testing. Among 13 043 HIV-infected adults, 4932 (38%) were unaware of their status. Among 105 170 CHC attendees with stable residence 104 635 (99%) accepted HIV testing. Of 131 307 adults with stable residence tested, 104 635 (80%; range 60-93% across communities) tested via CHCs. In multivariable analyses of adults with stable residence, predictors of non-testing included being male (risk ratio [RR] 1.52, 95% CI 1.48-1.56), single marital status (1.70, 1.66-1.75), age 30-39 years (1.58, 1.52-1.65 vs 15-19 years), residence in Kenya (1.46, 1.41-1.50), and migration out of the community for at least 1 month in the past year (1.60, 1.53-1.68). Compared with unemployed people, testing for HIV was more common among farmers (RR 0.73, 95% CI 0.67-0.79) and students (0.73, 0.69-0.77); and compared with people with no education, testing was more common in those with primary education (0.84, 0.80-0.89).

Interpretation: A hybrid, mobile approach of multiple-disease CHCs followed by HBT allowed for flexibility at the community and individual level to help reach testing coverage goals. Men and mobile populations remain challenges for universal testing.

Abstract access

Editor’s notes: Achieving high levels of HIV testing coverage remains a challenge in many parts of sub-Saharan Africa. Conventional facility-based HIV testing models are insufficient to achieve the UNAIDS 90-90-90 targets and maximise the prevention benefits of treatment. This study was able to achieve extremely high levels of HIV testing coverage in a short period of time by strategically combining two community-based testing approaches. By offering testing through multiple-disease community health campaigns (CHC), followed by focused home-based testing (HBT) for individuals who did not attend the CHCs, nearly 90% of adult stable residents accepted HIV testing. This near-universal coverage was achieved in all 32 communities (range 84%‒95%) across two countries, in a variety of settings with different rates of HIV prevalence and of previous testing. Testing uptake in the CHCs varied considerably across the communities (52%‒82%), demonstrating the value of this hybrid approach to expand coverage. Non-stable residents, who were 13% of the population, had low rates of testing uptake (22%). High rates of mobility remain a particular challenge for universal HIV testing coverage, and additional strategies are necessary to engage this group. A potential limitation of a focused approach to HBT is the need for community enumeration.  Still the results illustrate that achieving high HIV testing coverage is feasible with a combination of community-based approaches.

Africa
Kenya, Uganda
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