Articles tagged as "Malawi"

Expanding ART access: increasing costs

The HIV treatment gap: estimates of the financial resources needed versus available for scale-up of antiretroviral therapy in 97 countries from 2015 to 2020.

Dutta A, Barker C, Kallarakal A. PLoS Med. 2015 Nov 24;12(11):e1001907. doi: 10.1371/journal.pmed.1001907. eCollection 2015.

Background: The World Health Organization (WHO) released revised guidelines in 2015 recommending that all people living with HIV, regardless of CD4 count, initiate antiretroviral therapy (ART) upon diagnosis. However, few studies have projected the global resources needed for rapid scale-up of ART. Under the Health Policy Project, we conducted modeling analyses for 97 countries to estimate eligibility for and numbers on ART from 2015 to 2020, along with the facility-level financial resources required. We compared the estimated financial requirements to estimated funding available.

Methods and findings: Current coverage levels and future need for treatment were based on country-specific epidemiological and demographic data. Simulated annual numbers of individuals on treatment were derived from three scenarios: (1) continuation of countries' current policies of eligibility for ART, (2) universal adoption of aspects of the WHO 2013 eligibility guidelines, and (3) expanded eligibility as per the WHO 2015 guidelines and meeting the Joint United Nations Programme on HIV/AIDS "90-90-90" ART targets. We modeled uncertainty in the annual resource requirements for antiretroviral drugs, laboratory tests, and facility-level personnel and overhead.

We estimate that 25.7 (95% CI 25.5, 26.0) million adults and 1.57 (95% CI 1.55, 1.60) million children could receive ART by 2020 if countries maintain current eligibility plans and increase coverage based on historical rates, which may be ambitious. If countries uniformly adopt aspects of the WHO 2013 guidelines, 26.5 (95% CI 26.0 27.0) million adults and 1.53 (95% CI 1.52, 1.55) million children could be on ART by 2020. Under the 90-90-90 scenario, 30.4 (95% CI 30.1, 30.7) million adults and 1.68 (95% CI 1.63, 1.73) million children could receive treatment by 2020. The facility-level financial resources needed for scaling up ART in these countries from 2015 to 2020 are estimated to be US$45.8 (95% CI 45.4, 46.2) billion under the current scenario, US$48.7 (95% CI 47.8, 49.6) billion under the WHO 2013 scenario, and US$52.5 (95% CI 51.4, 53.6) billion under the 90-90-90 scenario. After projecting recent external and domestic funding trends, the estimated 6-y financing gap ranges from US$19.8 billion to US$25.0 billion, depending on the costing scenario and the U.S. President's Emergency Plan for AIDS Relief contribution level, with the gap for ART commodities alone ranging from US$14.0 to US$16.8 billion. The study is limited by excluding above-facility and other costs essential to ART service delivery and by the availability and quality of country- and region-specific data.

Conclusions: The projected number of people receiving ART across three scenarios suggests that countries are unlikely to meet the 90-90-90 treatment target (81% of people living with HIV on ART by 2020) unless they adopt a test-and-offer approach and increase ART coverage. Our results suggest that future resource needs for ART scale-up are smaller than stated elsewhere but still significantly threaten the sustainability of the global HIV response without additional resource mobilization from domestic or innovative financing sources or efficiency gains. As the world moves towards adopting the WHO 2015 guidelines, advances in technology, including the introduction of lower-cost, highly effective antiretroviral regimens, whose value are assessed here, may prove to be "game changers" that allow more people to be on ART with the resources available.

Abstract Full-text [free] access

Editor’s notes: This is a complex and important paper that seeks to understand the financial requirements necessary to: a) continue countries’ current policies of eligibility for ART, b) roll out universal adoption of certain aspects of WHO 2013 eligibility guidelines, and c) expand eligibility as per WHO 2015 guidelines and meeting the Joint United Nations Programme on HIV/AIDS ‘90-90-90’ targets.

The authors estimated the number of adults and children eligible for and receiving HIV treatment, as well as the cost of providing ART in 97 countries across six regions, covering different income levels. They estimated that 25.7 million adults and 1.57 million children could receive ART by 2020 if countries maintain the current eligibility strategies. If countries adopted WHO 2013 eligibility guidelines, 26.5 million adults and 1.53 million children would be on ART by 2020, and if they adopted the 90-90-90 scenario, 30.4 million adults and 1.68 million children could receive treatment by then. The financial resources necessary for this scale up are estimated to be US$ 45.8 billion under current eligibility, US$ 48.7 billion under WHO 2013 scenario and US$ 52.5 billion under the 90-90-90 scenario. The estimated funding gap for the six year period ranges between US$ 20 and US$ 25 billion. In this study, the costs of commodities were taken directly from data collated by other organisations.  No empirical cost estimates of service delivery were made.  Nor was there an attempt to understand the cost implications of the development synergies and social and programme enablers that may be needed to increase the number of people living with HIV knowing their status.  The new WHO recommendations need to be actively pursued if we are to meet targets, rather than passively continuing with “business as usual”. 

Nonetheless, the findings of this study highlight the gap between guidelines written by WHO and very real programmatic obstacles on the ground. There is evidence to suggest that universal test-and-treat strategies could lead to substantially improved health outcomes at the population level, as well as potentially being cost-saving in the long-term. However, as the authors have illustrated, it would require increased levels of funding. What needs to be explored further now is how to overcome the logistical hurdles of rolling out such an initiative. Changing systems and practices is costly and takes time. Health workers will have to be retrained, data collection strategies will have to be revised. Expanding treatment may also mean increasing the number of health staff working on this initiative, which has an opportunity cost that may reverberate in other parts of the health system. Substantially altering health service provision, particularly in weak health systems, may have knock-on effects with unexpected and unintended consequences.

WHO guidelines serve a vital purpose of giving us a goal to aim for. But studies like this one help us know if and how we can get there. 

Africa, Asia, Europe, Latin America, Oceania
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Vulnerabilities of children living with HIV positive adults

Children living with HIV-infected adults: estimates for 23 countries in sub-Saharan Africa.

Short SE, Goldberg RE. PLoS One. 2015 Nov 17; 10(11): e0142580.

Background: In sub-Saharan Africa many children live in extreme poverty and experience a burden of illness and disease that is disproportionately high. The emergence of HIV and AIDS has only exacerbated long-standing challenges to improving children's health in the region, with recent cohorts experiencing pediatric AIDS and high levels of orphan status, situations which are monitored globally and receive much policy and research attention. Children's health, however, can be affected also by living with HIV-infected adults, through associated exposure to infectious diseases and the diversion of household resources away from them. While long recognized, far less research has focused on characterizing this distinct and vulnerable population of HIV-affected children.

Methods: Using Demographic and Health Survey data from 23 countries collected between 2003 and 2011, we estimate the percentage of children living in a household with at least one HIV-infected adult. We assess overlaps with orphan status and investigate the relationship between children and the adults who are infected in their households.

Results: The population of children living in a household with at least one HIV-infected adult is substantial where HIV prevalence is high; in Southern Africa, the percentage exceeded 10% in all countries and reached as high as 36%. This population is largely distinct from the orphan population. Among children living in households with tested, HIV-infected adults, most live with parents, often mothers, who are infected; nonetheless, in most countries over 20% live in households with at least one infected adult who is not a parent.

Conclusion: Until new infections contract significantly, improvements in HIV/AIDS treatment suggest that the population of children living with HIV-infected adults will remain substantial. It is vital to on-going efforts to reduce childhood morbidity and mortality to consider whether current care and outreach sufficiently address the distinct vulnerabilities of these children.

Abstract Full-text [free] access

Editor’s notes: This paper is an important contribution to the literature on the impact of the HIV epidemic. Using Demographic and Health Survey (DHS) data from 23 countries it highlights the considerable number of children living with HIV-positive adults in sub-Saharan Africa. However, notable exceptions from the analysis (no DHS data available) included South Africa. This, coupled with specific issues related to DHS data collection methods and response rates, means that the number of children living with HIV-positive adults is much higher. Reductions in mortality from HIV due to increased treatment availability and the addition of adults newly acquiring HIV means that population of children living with an HIV-positive adult will continue to increase in the near future.

Children living with HIV-positive adults are clearly vulnerable and like all vulnerable children should be focussed on in efforts to promote child wellbeing. The authors suggest, however, that children living with HIV-positive adults may have distinct vulnerabilities that need to be considered. These include direct exposure to opportunistic infections, social stigma and disrupted networks, as well as increases in poverty. The challenge for many countries is how to identify these children and ensure that focussed programmes are delivered effectively.

Africa
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Testing for acute HIV infection feasible but impact remains uncertain

Incorporating acute HIV screening into routine HIV testing at sexually transmitted infection clinics and HIV testing and counseling centers in Lilongwe, Malawi.

Rutstein SE, Pettifor AE, Phiri S, Kamanga G, Hoffman IF, Hosseinipour MC, Rosenberg NE, Nsona D, Pasquale D, Tegha G, Powers K, Phiri M, Tembo B, Chege W, Miller WC. J Acquir Immune Defic Syndr. 2015 Sep 29. [Epub ahead of print]

Background and objectives: Integrating acute HIV infection (AHI) testing into clinical settings is critical to prevent transmission and realize potential treatment-as-prevention benefits. We evaluated acceptability of AHI testing and compared AHI prevalence at sexually transmitted infection (STI) and HIV testing and counseling (HTC) clinics in Lilongwe, Malawi.

Methods: We conducted HIV RNA testing for HIV-seronegative patients visiting STI and HTC clinics. AHI was defined as positive RNA and negative/discordant rapid antibody tests. We evaluated demographic, behavioral, and transmission-risk differences between STI and HTC patients and assessed performance of a risk-score for targeted screening.

Results: Nearly two-thirds (62.8%, 9280/14 755) of eligible patients consented to AHI testing. We identified 59 persons with AHI (prevalence=0.64%) - a 0.9% case-identification increase. Prevalence was higher at STI (1.03% (44/4255)) than HTC clinics (0.3% (15/5025), p<0.01), accounting for 2.3% of new diagnoses, vs 0.3% at HTC. Median viral load (VL) was 758 050 copies/ml; 25% (15/59) had VL ≥10 000 000 copies/ml. Median VL was higher at STI (1 000 000 copies/ml) compared to HTC (153 125 copies/ml, p=0.2). Among persons with AHI, those tested at STI clinics were more likely to report genital sores compared to those tested at HTC (54.6% versus 6.7%, p<0.01). The risk score algorithm performed well in identifying persons with AHI at HTC (sensitivity=73%, specificity=89%).

Conclusions: The majority of patients consented to AHI testing. AHI prevalence was substantially higher in STI clinics than HTC. Remarkably high VLs and concomitant genital sores demonstrates the potential for transmission. Universal AHI screening at STI clinics, and targeted screening at HTC centers, should be considered.

Abstract access 

Editor’s notes: Acute HIV infection (AHI) is defined as the time from HIV acquisition to the appearance of detectable antibodies. Individuals with AHI are highly infectious, at least partly due to high viral load. Effective strategies to identify and treat people with AHI could increase the impact of treatment as prevention strategies, although there continues to be debate around the contribution of AHI to HIV transmission at population level.

This study in Malawi was part of a clinical trial evaluating the impact of behavioural and antiretroviral programmes during AHI. The study was done in four high-volume urban facilities. Pooled HIV RNA testing was performed on blood from participants with negative or discordant rapid HIV tests, according to the routine testing algorithm (discordant defined as one positive and two negative tests). Overall participation rates were relatively low, with only one in three individuals with negative or discordant rapid HIV tests included. Most of the loss was due to potentially eligible persons not being screened. The reasons for this are not mentioned, although more than a third that were screened did not consent. Overall, one in 150 participants had AHI. This was higher, at one in 100, at the STI clinics. The proportion with AHI was lower than previous research in Malawi, which could reflect a decline in HIV incidence at population level.

The potential risk of HIV transmission during AHI is highlighted by the characteristics of the people with AHI. Almost half had HIV RNA >6 log10 copies/ml, a similar proportion had genital ulcers, and only one in five reported condom use at last sex. The algorithm for focussing AHI testing, previously developed in the same setting, had suboptimal performance across all sites. 

This study adds to a body of evidence that suggests testing for AHI is feasible and will increase the overall yield of HIV testing by a small amount. We now need more evidence around whether programmatic implementation of AHI testing would have an impact on HIV transmission, and on the cost-effectiveness of different testing strategies. Data from treatment as prevention trials, none of which have included specific strategies to diagnose AHI, will also indirectly inform whether this should become a higher priority for public health programmes. 

Africa
Malawi
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More rigorous evidence necessary on role of peers in adolescent sexual behaviour

Is the sexual behaviour of young people in sub-Saharan Africa influenced by their peers? A systematic review.

Fearon E, Wiggins RD, Pettifor AE, Hargreaves JR. Soc Sci Med. 2015 Oct 9;146:62-74. doi: 10.1016/j.socscimed.2015.09.039. [Epub ahead of print]

Adolescents in sub-Saharan Africa are highly vulnerable to HIV, other sexually transmitted infections (STIs) and unintended pregnancies. Evidence for the effectiveness of individual behaviour change interventions in reducing incidence of HIV and other biological outcomes is limited, and the need to address the social conditions in which young people become sexually active is clear. Adolescents' peers are a key aspect of this social environment and could have important influences on sexual behaviour. There has not yet been a systematic review on the topic in sub-Saharan Africa. We searched 4 databases to find studies set in sub-Saharan Africa that included an adjusted analysis of the association between at least one peer exposure and a sexual behaviour outcome among a sample where at least 50% of the study participants were aged between 13 and 20 years. We classified peer exposures using a framework to distinguish different mechanisms by which influence might occur. We found 30 studies and retained 11 that met quality criteria. There were 3 cohort studies, 1 time to event and 7 cross-sectional. The 11 studies investigated 37 different peer exposure-outcome associations. No studies used a biological outcome and all asked about peers in general rather than about specific relationships. Studies were heterogeneous in their use of theoretical frameworks and means of operationalizing peer influence concepts. All studies found evidence for an association between peers and sexual behaviour for at least one peer exposure/outcome/sub-group association. Of all 37 outcome/exposure/sub-group associations tested, there was evidence for 19 (51%). There were no clear patterns by type of peer exposure, outcome or adolescent sub-group. There is a lack of conclusive evidence about the role of peers in adolescent sexual behaviour in sub-Saharan Africa. We argue that longitudinal designs, use of biological outcomes and approaches from social network analysis are priorities for future studies.

Abstract  Full-text [free] access

Editor’s notes: This is the first quantitative systematic review of the role of peers in shaping young people’s sexual behaviour in sub-Saharan Africa. Each of the 11 higher-quality studies included found evidence for at least one association between a peer exposure and a sexual behaviour outcome. But overall, no clear patterns were found for the conditions in which peer exposures might, or might not, impact sexual behaviour. The mixed findings may highlight inherent difficulties with assessing such associations, such as reverse causation in cross-sectional studies (e.g. selection of peers based on established sexual behaviour), and reliance on self-reported sexual behaviour (likely to be a particular problem among adolescents). One interesting aspect of the paper was the classification of peer exposures into one of six types (including peer approval, peer connectedness, and status within peer networks). Given the likely importance of peers in adolescent behaviour, methods that collect information about specific peers and relationships such as social network analysis, rather than asking about peers in general, could help to identify peer effects.

Africa
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Invitation plus tracing increases male partner testing during pregnancy

Recruiting male partners for couple HIV testing and counselling in Malawi's option B+ programme: an unblinded randomised controlled trial.

Rosenberg NE, Mtande TK, Saidi F, Stanley C, Jere E, Paile L, Kumwenda K, Mofolo I, Ng'ambi W, Miller WC, Hoffman I, Hosseinipour M. Lancet HIV. 2015 Nov;2(11):e483-91. doi: 10.1016/S2352-3018(15)00182-4. Epub 2015 Oct 22.

Background: Couples HIV testing and counselling (CHTC) is encouraged but is not widely done in sub-Saharan Africa. We aimed to compare two strategies for recruiting male partners for CHTC in Malawi's option B+ prevention of mother-to-child transmission programme: invitation only versus invitation plus tracing and postulated that invitation plus tracing would be more effective.

Methods: We did an unblinded, randomised, controlled trial assessing uptake of CHTC in the antenatal unit at Bwaila District Hospital, a maternity hospital in Lilongwe, Malawi. Women were eligible if they were pregnant, had just tested HIV-positive and therefore could initiate antiretroviral therapy, had not yet had CHTC, were older than 18 years or 16-17 years and married, reported a male sex partner in Lilongwe, and intended to remain in Lilongwe for at least 1 month. Women were randomly assigned (1:1) to either the invitation only group or the invitation plus tracing group with block randomisation (block size=4). In the invitation only group, women were provided with an invitation for male partners to present to the antenatal clinic. In the invitation plus tracing group, women were provided with the same invitation, and partners were traced if they did not present. When couples presented they were offered pregnancy information and CHTC. Women were asked to attend a follow-up visit 1 month after enrolment to assess social harms and sexual behaviour. The primary outcome was the proportion of couples who presented to the clinic together and received CHTC during the study period and was assessed in all randomly assigned participants. This study is registered with ClinicalTrials.gov, number NCT02139176.

Findings: Between March 4, 2014, and Oct 3, 2014, 200 HIV-positive pregnant women were enrolled and randomly assigned to either the invitation only group (n=100) or the invitation plus tracing group (n=100). 74 couples in the invitation plus tracing group and 52 in the invitation only group presented to the clinic and had CHTC (risk difference 22%, 95% CI 9-35; p=0.001) during the 10 month study period. Of 181 women with follow-up data, two reported union dissolution, one reported emotional distress, and none reported intimate partner violence. One male partner, when traced, was confused about which of his sex partners was enrolled in the study. No other adverse events were reported.

Interpretation: An invitation plus tracing strategy was highly effective at increasing CHTC uptake. Invitation plus tracing with CHTC could have many substantial benefits if brought to scale.

Abstract access

Editor’s notes: A major challenge to the Option B+ prevention of mother-to-child-transmission programme is retaining women in HIV care. Lack of male partner support may be an important barrier to retention. Couples HIV testing and counselling (CHTC) can increase mutual disclosure, enhance behavioural HIV prevention, and ultimately improve maternal, child and male partner health outcomes.  However, uptake of CHTC in antenatal settings remains low throughout most of sub-Saharan Africa. This randomised controlled trial illustrates that combining an invitation for the male partner to present to the antenatal clinic with active tracing of the partner by the study team greatly increased uptake of CHTC. A unique feature of the programme was that the invitation and tracing messages focused on general health during pregnancy, rather than on HIV, which may have improved acceptability. Even in the invitation alone arm, over half of the male partners presented for CHTC. Both strategies found that over half the men who tested were HIV positive, and the majority were unaware of their status. Women in the invitation plus tracing arm had higher retention in the Option B+ programme at one month than individuals in the invitation alone arm, and were more likely to report safer sex behaviour. 

Although provider-based strategies for increasing couples testing are more expensive than patient-based strategies, they may be very cost-effective in settings of high HIV prevalence where few men are aware of their HIV status. Interestingly, most gains in partner uptake from tracing were a result of telephone contact, which is relatively low cost. Longer term follow-up is necessary to assess whether increases in retention are maintained over time but the results demonstrate the potential for provider-based strategies for increasing CHTC to help achieve UNAIDS 90-90-90 targets.

Africa
Malawi
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AIDS and bacterial disease remain leading causes of hospital admission

Causes of hospital admission among people living with HIV worldwide: a systematic review and meta-analysis.

Ford N, Shubber Z, Meintjes G, Grinsztejn B, Eholie S, Mills EJ, Davies MA, Vitoria M, Penazzato M, Nsanzimana S, Frigati L, O'Brien D, Ellman T, Ajose O, Calmy A, Doherty M. Lancet HIV. 2015 Oct;2(10):e438-44. doi: 10.1016/S2352-3018(15)00137-X. Epub 2015 Aug 11.

Background: Morbidity associated with HIV infection is poorly characterised, so we aimed to investigate the contribution of different comorbidities to hospital admission and in-hospital mortality in adults and children living with HIV worldwide.

Methods: Using a broad search strategy combining terms for hospital admission and HIV infection, we searched MEDLINE via PubMed, Embase, Web of Science, LILACS, AIM, IMEMR and WPIMR from inception to Jan 31, 2015, to identify studies reporting cause of hospital admission in people living with HIV. We focused on data reported after 2007, the period in which access to antiretroviral therapy started to become widespread. We estimated pooled proportions of hospital admissions and deaths per disease category by use of random-effects models. We stratified data by geographical region and age.

Findings: We obtained data from 106 cohorts, with reported causes of hospital admission for  313 006 adults and 6182 children living with HIV. For adults, AIDS-related illnesses (25 119 patients, 46%, 95% CI 40-53) and bacterial infections (14 034 patients, 31%, 20-42) were the leading causes of hospital admission. These two categories were the most common causes of hospital admission for adults in all geographical regions and the most common causes of mortality. Common region-specific causes of hospital admission included malnutrition and wasting, parasitic infections, and haematological disorders in the Africa region; respiratory disease, psychiatric disorders, renal disorders, cardiovascular disorders, and liver disease in Europe; haematological disorders in North America; and respiratory, neurological, digestive and liver-related conditions, viral infections, and drug toxicity in South and Central America. For children, AIDS-related illnesses (783 patients, 27%, 95% CI 19-34) and bacterial infections (1190 patients, 41%, 26-56) were the leading causes of hospital admission, followed by malnutrition and wasting, haematological disorders, and, in the African region, malaria. Mortality in individuals admitted to hospital was 20% (95% CI 18-23, 12 902 deaths) for adults and 14% (10-19, 643 deaths) for children.

Interpretation: This review shows the importance of prompt HIV diagnosis and treatment, and the need to reinforce existing recommendations to provide chemoprophylaxis and vaccination against major preventable infectious diseases to people living with HIV to reduce serious AIDS and non-AIDS morbidity.

Abstract access 

Editor’s notes: Despite the widening availability of antiretroviral therapy (ART), HIV-associated disease remains an important cause of illness and death. In this systematic review the authors summarise published data concerning causes of hospital admission among HIV-positive people since 2007. This date was selected on the basis that access to ART was limited prior to 2007.

Overall the most common causes of admission among adults, across all geographical regions, were AIDS-associated illness and bacterial infections. Tuberculosis was the most common cause among adults, accounting for 18% of all admissions, followed by bacterial pneumonia (15%). Among children, similarly AIDS-associated illnesses (particularly tuberculosis and Pneumocystis pneumonia) and bacterial infections were the most common causes of admission. Among the 20% of adults who died during their admission, the most common causes of death were tuberculosis, bacterial infections, cerebral toxoplasmosis and cryptococcal meningitis. Among children the most common causes of death were tuberculosis, bacterial infections and Pneumocystis pneumonia. Tuberculosis is likely to have been underestimated in these studies. Autopsy studies consistently illustrate that around half of HIV-positive people who have tuberculosis identified at autopsy had not been diagnosed prior to death.

The review highlights that the majority of severe HIV-associated disease remains attributable to advanced immunosuppression. This is reflected by a median CD4 count at admission among adults of 168 cells per µl. Some 30% of people first tested HIV positive at the time of the admission. The review underlines the need to promote HIV testing so that HIV-positive people can access ART, and prevent the complications of advanced HIV disease. It also underscores the need for better coverage of screening for tuberculosis and preventive therapy for people without active disease.  

Avoid TB deaths
Comorbidity, Epidemiology
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Peer support benefits MSM in Malawi

Feasibility of a combination HIV prevention program for men who have sex with men in Blantyre, Malawi.

Wirtz AL, Trapence G, Jumbe V, Umar E, Ketende S, Kamba D, Berry M, Stromdahl S, Beyrer C, Muula AS, Baral S. J Acquir Immune Defic Syndr. 2015 Oct 1;70(2):155-62. doi: 10.1097/QAI.0000000000000693.

Introduction: The use of combination HIV prevention interventions (CHPI) now represent the standard of care to minimize HIV acquisition risks among men who have sex with men (MSM). There has been limited evaluation of these approaches in generalized HIV epidemics and/or where MSM are stigmatized. A peer-based CHPI program to target individual, social, and structural risks for HIV was developed for MSM in Blantyre, Malawi.

Methods: To test the feasibility of CHPI, adult MSM were followed prospectively from January 2012 to May 2013. Participants (N = 103) completed sociobehavioral surveys and HIV testing at each of the 3 follow-up study visits.

Results: Approximately 90% of participants attended each study visit and 93.2% (n = 96) completed the final visit. Participants met with peer educators a median of 3 times (range: 1-10) in the follow-up visits 2 and 3. Condom use at last sex improved from baseline through follow-up visit 3 with main (baseline: 62.5%, follow-up 3: 77.0%; P = 0.02) and casual male partners (baseline: 70.7%, follow-up 3: 86.3%; P = 0.01). Disclosure of sexual behaviors/orientation to family increased from 25% in follow-up 1 to 55% in follow-up 3 (P < 0.01).

Discussion: Participants maintained a high level of retention in the study highlighting the feasibility of leveraging community-based organizations to recruit and retain MSM in HIV prevention and treatment interventions in stigmatizing settings. Group-level changes in sexual behavior and disclosure in safe settings for MSM were noted. CHPI may represent a useful model to providing access to other HIV prevention for MSM and aiding retention in care and treatment services for MSM living with HIV in challenging environments.

Abstract access

Editor’s notes: Gay men and other men who have sex with men are a key, difficult-to-reach population in many parts of sub-Saharan Africa. Stigma and criminalization of same-sex practices cause many challenges in improving access to HIV prevention and treatment services. This study tested the feasibility of a combination HIV prevention programme for gay men and other men who have sex with men in Malawi. The programme worked at three levels. At the individual level peer educators provided outreach to increase use of condoms, lubricants and other prevention methods. The health sector level provided training for doctors and nurses, to improve access to services. The community level built capacity to advocate in national HIV strategies and support decriminalisation of homosexuality. Study participants were identified by respondent-driven sampling. Retention was very high in the cohort, and over 16 months, participants reported improved behaviour-associated outcomes. This study was implemented by a community-based organisation and peer educators, and used several methods to protect participant confidentiality and privacy which can be adopted by others working in stigmatising settings. Overall, the study demonstrates that HIV prevention programmes for gay men and other men who have sex with men can be implemented if security measures and awareness of the social and political situation are well maintained.  

Africa
Malawi
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Comparing strategies for HIV testing and counselling for children and adolescents

Uptake and yield of HIV testing and counselling among children and adolescents in sub-Saharan Africa: a systematic review.

Govindasamy D, Ferrand RA, Wilmore SM, Ford N, Ahmed S, Afnan-Holmes H, Kranzer K. J Int AIDS Soc. 2015 Oct 14;18(1):20182. doi: 10.7448/IAS.18.1.20182. eCollection 2015.

Introduction: In recent years children and adolescents have emerged as a priority for HIV prevention and care services. We conducted a systematic review to investigate the acceptability, yield and prevalence of HIV testing and counselling (HTC) strategies in children and adolescents (5 to 19 years) in sub-Saharan Africa.

Methods: An electronic search was conducted in MEDLINE, EMBASE, Global Health and conference abstract databases. Studies reporting on HTC acceptability, yield and prevalence and published between January 2004 and September 2014 were included. Pooled proportions for these three outcomes were estimated using a random effects model. A quality assessment was conducted on included studies.

Results and discussion: A total of 16 380 potential citations were identified, of which 21 studies (23 entries) were included. Most studies were conducted in Kenya (n=5) and Uganda (n=5) and judged to provide moderate (n=15) to low quality (n=7) evidence, with data not disaggregated by age. Seven studies reported on provider-initiated testing and counselling (PITC), with the remainder reporting on family-centred (n=5), home-based (n=5), outreach (n=5) and school-linked HTC among primary schoolchildren (n=1). PITC among inpatients had the highest acceptability (86.3%; 95% confidence interval [CI]: 65.5 to 100%), yield (12.2%; 95% CI: 6.1 to 18.3%) and prevalence (15.4%; 95% CI: 5.0 to 25.7%). Family-centred HTC had lower acceptance compared to home-based HTC (51.7%; 95% CI: 10.4 to 92.9% vs. 84.9%; 95% CI: 74.4 to 95.4%) yet higher prevalence (8.4%; 95% CI: 3.4 to 13.5% vs. 3.0%; 95% CI: 1.0 to 4.9%). School-linked HTC showed poor acceptance and low prevalence.

Conclusions: While PITC may have high test acceptability priority should be given to evaluating strategies beyond healthcare settings (e.g. home-based HTC among families) to identify individuals earlier in their disease progression. Data on linkage to care and cost-effectiveness of HTC strategies are needed to strengthen policies.

Abstract  Full-text [free] access

Editor’s notes: In sub-Saharan Africa children and adolescents are a priority group for HIV prevention and care services. Children and adolescents living with HIV are less likely than adults to know their HIV status, to access treatment and to achieve virologic suppression. As with adults, the first essential step to managing HIV in children and adolescents is to provide appropriate HIV testing and counselling services. This is the first systematic review to assess HIV testing and counselling strategies in this age group, 5-19 years. One key finding is the lack of data on testing and counselling services for this age group. Most services replicate strategies developed for adults with little consideration for the specific needs of children and adolescents. The studies illustrated that health care facility-based provider-initiated testing and counselling had relatively high acceptance, yield and linkage-to-care, but tended to identify individuals at a late stage of disease. In contrast, community-based approaches had the potential to diagnose asymptomatic children. Further work on innovative approaches, family-centred and mobile-based, should be assessed.  

HIV testing
Africa
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High uptake of HIV self-testing among adolescents

Uptake, accuracy, safety, and linkage into care over two years of promoting annual self-testing for HIV in Blantyre, Malawi: a community-based prospective study.

Choko AT, MacPherson P, Webb EL, Willey BA, Feasy H, Sambakunsi R, Mdolo A, Makombe SD, Desmond N, Hayes R, Maheswaran H, Corbett EL.  PLoS Med. 2015 Sep 8;12(9):e1001873. doi: 10.1371/journal.pmed.1001873. eCollection 2015.

Background: Home-based HIV testing and counselling (HTC) achieves high uptake, but is difficult and expensive to implement and sustain. We investigated a novel alternative based on HIV self-testing (HIVST). The aim was to evaluate the uptake of testing, accuracy, linkage into care, and health outcomes when highly convenient and flexible but supported access to HIVST kits was provided to a well-defined and closely monitored population.

Methods and findings: Following enumeration of 14 neighbourhoods in urban Blantyre, Malawi, trained resident volunteer-counsellors offered oral HIVST kits (OraQuick ADVANCE Rapid HIV-1/2 Antibody Test) to adult (≥16 y old) residents (n = 16 660) and reported community events, with all deaths investigated by verbal autopsy. Written and demonstrated instructions, pre- and post-test counselling, and facilitated HIV care assessment were provided, with a request to return kits and a self-completed questionnaire. Accuracy, residency, and a study-imposed requirement to limit HIVST to one test per year were monitored by home visits in a systematic quality assurance (QA) sample. Overall, 14 004 (crude uptake 83.8%, revised to 76.5% to account for population turnover) residents self-tested during months 1-12, with adolescents (16-19 y) most likely to test. 10 614/14 004 (75.8%) participants shared results with volunteer-counsellors. Of 1257 (11.8%) HIV-positive participants, 26.0% were already on antiretroviral therapy, and 524 (linkage 56.3%) newly accessed care with a median CD4 count of 250 cells/µl (interquartile range 159-426). HIVST uptake in months 13-24 was more rapid (70.9% uptake by 6 mo), with fewer (7.3%, 95% CI 6.8%-7.8%) positive participants. Being "forced to test", usually by a main partner, was reported by 2.9% (95% CI 2.6%-3.2%) of 10 017 questionnaire respondents in months 1-12, but satisfaction with HIVST (94.4%) remained high. No HIVST-related partner violence or suicides were reported. HIVST and repeat HTC results agreed in 1639/1649 systematically selected (1 in 20) QA participants (99.4%), giving a sensitivity of 93.6% (95% CI 88.2%-97.0%) and a specificity of 99.9% (95% CI 99.6%-100%). Key limitations included use of aggregate data to report uptake of HIVST and being unable to adjust for population turnover.

Conclusions: Community-based HIVST achieved high coverage in two successive years and was safe, accurate, and acceptable. Proactive HIVST strategies, supported and monitored by communities, could substantially complement existing approaches to providing early HIV diagnosis and periodic repeat testing to adolescents and adults in high-HIV settings.

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Editor’s notes: The new global 90–90–90 targets call for 90% of all people with HIV to be diagnosed, 90% of people with HIV diagnosed to receive ART and 90% of people on ART to have a suppressed viral load by 2020. The first 90 (diagnosis of HIV) is essential to the second 90 (initiation of ART among people with HIV) and the ultimate outcome of the third 90 (viral load suppression among people on ART), which improves client outcomes and prevents HIV transmission.

The first 90 is also the most problematic, especially for adolescents, men and key populations, as HIV testing primarily takes place at the health care facility, which is typically underutilised by these groups.

This article reports on a prospective study on community-based oral HIV self-testing (HIVST) among adults (16 years or older) in Blantyre, Malawi. HIVST involves individuals performing and interpreting their own HIV test, in this study by using an oral HIV test kit. The high acceptability and ease of distribution of oral test kits makes HIVST of special interest in settings with high HIV prevalence, where the aim is to achieve affordable universal coverage and regular repeat testing.

The authors found high uptake among men and adolescents (two hard-to-reach groups), and a high accuracy of HIVST, but suboptimal linkage post-testing to ART services: less than 60% of HIV-positive clients not yet on ART were linked to HIV care. However, they attribute these good outcomes partially to the involvement of trained volunteers in their community-based HIV care service delivery model. They suggest re-evaluating accuracy and uptake of post-testing services when using different tests or less supportive models, for example over-the-counter or vending machine sales of oral HIV test kits.

The authors found that 35% of participants had never previously tested. Interestingly they also found that among self-testing participants, HIV prevalence was highest in the age group 40-49 years (with a pooled estimate among men and women of 23%). The authors emphasize that the high acceptability of HIVST services among adolescents and men could facilitate linkage into HIV prevention programmes, such as pre-exposure prophylaxis and voluntary medical male circumcision, as well as ensuring prompt linkage into HIV care. They conclude that HIV self-testing is complementary to existing strategies in providing early HIV diagnosis and periodic repeat testing, and that HIVST has potential to be scaled up in other low-income settings where annual repeat HIV testing is recommended. 

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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.  

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Malawi
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