Articles tagged as "South Africa"

The negative health impacts of HIV-associated stigma

Examining the associations between HIV-related stigma and health outcomes in people living with HIV/AIDS: a series of meta-analyses.

Rueda S, Mitra S, Chen S, Gogolishvili D, Globerman J, Chambers L, Wilson M, Logie CH, Shi Q, Morassaei S, Rourke SB. BMJ Open. 2016 Jul 13;6(7):e011453. doi: 10.1136/bmjopen-2016-011453.

Objective: To conduct a systematic review and series of meta-analyses on the association between HIV-related stigma and health among people living with HIV.

Data sources: A structured search was conducted on 6 electronic databases for journal articles reporting associations between HIV-related stigma and health-related outcomes published between 1996 and 2013.

Study eligibility criteria: Controlled studies, cohort studies, case-control studies and cross-sectional studies in people living with HIV were considered for inclusion.

Outcome measures: Mental health (depressive symptoms, emotional and mental distress, anxiety), quality of life, physical health, social support, adherence to antiretroviral therapy, access to and usage of health/social services and risk behaviours.

Results: 64 studies were included in our meta-analyses. We found significant associations between HIV-related stigma and higher rates of depression, lower social support and lower levels of adherence to antiretroviral medications and access to and usage of health and social services. Weaker relationships were observed between HIV-related stigma and anxiety, quality of life, physical health, emotional and mental distress and sexual risk practices. While risk of bias assessments revealed overall good quality related to how HIV stigma and health outcomes were measured on the included studies, high risk of bias among individual studies was observed in terms of appropriate control for potential confounders. Additional research should focus on elucidating the mechanisms behind the negative relationship between stigma and health to better inform interventions to reduce the impact of stigma on the health and well-being of people with HIV.

Conclusions: This systematic review and series of meta-analyses support the notion that HIV-related stigma has a detrimental impact on a variety of health-related outcomes in people with HIV. This review can inform the development of multifaceted, intersectoral interventions to reduce the impact of HIV-related stigma on the health and well-being of people living with HIV.

Abstract  Full-text [free] access 

Editor’s notes: There is a growing body of research documenting the negative impact of stigma and discrimination on the health of people living with HIV. Stigma is associated with poorer mental health, including emotional distress, depression and reduced psychological functioning. It has also been linked to intermediate health outcomes such as seeking healthcare and adherence to antiretroviral therapy. This paper reports a comprehensive systematic review and meta-analyses summarising the published evidence on the relationship between HIV-associated stigma and a wide range of health outcomes, including intermediate health outcomes. Results illustrate associations between HIV-associated stigma and depressive symptoms, lower levels of social support, ART adherence and use of health services. However, the majority of studies in the review were cross-sectional and longitudinal studies are necessary to explore the complex relationship between these factors, including the role of moderating factors, such as coping strategies. In addition, more research is necessary from low- and middle-income countries given that much of the published research is from North America. Further, there is also a need to better understand the intersection of HIV-associated stigma with other types of stigma experienced by people living with HIV, including homophobia, racism and gender discrimination. 

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

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

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

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

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

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

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

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

Abstract access

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

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

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

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

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

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

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

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

Abstract  Full-text [free] access 

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

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

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

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

Africa
South Africa
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Increased economic resources can reduce sexual vulnerability in young women

Economic resources and HIV preventive behaviors among school-enrolled young women in rural South Africa (HPTN 068).

Jennings L, Pettifor A, Hamilton E, Ritchwood TD, Xavier Gomez-Olive F, MacPhail C, Hughes J, Selin A, Kahn K. AIDS Behav. 2016 Jun 3. [Epub ahead of print]

Individual economic resources may have greater influence on school-enrolled young women's sexual decision-making than household wealth measures. However, few studies have investigated the effects of personal income, employment, and other financial assets on young women's sexual behaviors. Using baseline data from the HIV Prevention Trials Network (HPTN) 068 study, we examined the association of ever having sex and adopting sexually-protective practices with individual-level economic resources among school-enrolled women, aged 13-20 years (n = 2533). Age-adjusted results showed that among all women employment was associated with ever having sex (OR 1.56, 95 % CI 1.28-1.90). Among sexually-experienced women, paid work was associated with changes in partner selection practices (OR 2.38, 95 % CI 1.58-3.58) and periodic sexual abstinence to avoid HIV (OR 1.71, 95 % CI 1.07-2.75). Having money to spend on oneself was associated with reducing the number of sexual partners (OR 1.94, 95 % CI 1.08-3.46), discussing HIV testing (OR 2.15, 95 % CI 1.13-4.06), and discussing condom use (OR 1.99, 95 % CI 1.04-3.80). Having a bank account was associated with condom use (OR 1.49, 95 % CI 1.01-2.19). Economic hardship was positively associated with ever having sex, but not with sexually-protective behaviors. Maximizing women's individual economic resources may complement future prevention initiatives.

Abstract access

Editor’s notes: Young women bear a disproportionate amount of the burden of the HIV epidemic in Africa. There are strong socioeconomic drivers of the epidemic, and gender inequalities and poverty combine to make adolescent girls and young women particularly vulnerable to HIV infection.  Economic programmes have been used in many countries to influence specific behaviours and to improve health outcomes. However, the evidence of their effectiveness in the context of HIV prevention is mixed. This study examined the association of individual economic resources with sexual behaviour in adolescent girls and young women. Although people with greater economic resources were more likely to have had sex, thus increasing their exposure to HIV infection, they were also more likely to engage in behaviours that were protective against HIV.  Not all economic resources had a positive effect on behaviour, underscoring the fact that sexual decision-making is complex and multi-faceted. The study population was unmarried, in school, and living with at least one parent or guardian, so the findings may not be generalisable to young women who are out of school or in less stable living arrangements. Improving the individual economic status of adolescent girls and young women may have a positive impact on HIV prevention behaviour. However, women’s choices may be constrained by social norms and entrenched inequalities. This study raises further questions about how economic resources may influence HIV risk in young women, but also in young men. 

Africa
South Africa
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Changing norms: lessons from HIV advocacy for NCDs prevention

Ability of HIV advocacy to modify behavioral norms and treatment impact: a systematic review.

Sunguya BF, Munisamy M, Pongpanich S, Yasuoka J, Jimba M. Am J Public Health. 2016 Aug;106(8):e1-e8. Epub 2016 Jun 16.

Background: HIV advocacy programs are partly responsible for the global community's success in reducing the burden of HIV. The rising wave of the global burden of noncommunicable diseases (NCDs) has prompted the World Health Organization to espouse NCD advocacy efforts as a possible preventive strategy. HIV and NCDs share some similarities in their chronicity and risky behaviors, which are their associated etiology. Therefore, pooled evidence on the effectiveness of HIV advocacy programs and ideas shared could be replicated and applied during the conceptualization of NCD advocacy programs. Such evidence, however, has not been systematically reviewed to address the effectiveness of HIV advocacy programs, particularly programs that aimed at changing public behaviors deemed as risk factors.

Objectives: To determine the effectiveness of HIV advocacy programs and draw lessons from those that are effective to strengthen future noncommunicable disease advocacy programs.

Search methods: We searched for evidence regarding the effectiveness of HIV advocacy programs in medical databases: PubMed, The Cumulative Index to Nursing and Allied Health Literature Plus, Educational Resources and Information Center, and Web of Science, with articles dated from 1994 to 2014.

Search criteria. The review protocol was registered before this review. The inclusion criteria were studies on advocacy programs or interventions. We selected studies with the following designs: randomized controlled design studies, pre-post intervention studies, cohorts and other longitudinal studies, quasi-experimental design studies, and cross-sectional studies that reported changes in outcome variables of interest following advocacy programs. We constructed Boolean search terms and used them in PubMed as well as other databases, in line with a population, intervention, comparator, and outcome question. The flow of evidence search and reporting followed the standard Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

Data collection and analysis: We selected 2 outcome variables (i.e., changing social norms and a change in impact) out of 6 key outcomes of advocacy interventions. We assessed the risk of bias for all selected studies by using the Cochrane risk-of-bias tool for randomized studies and using the Risk of Bias for Nonrandomized Observational Studies for observational studies. We did not grade the collective quality of evidence because of differences between the studies, with regard to methods, study designs, and context. Moreover, we could not carry out meta-analyses because of heterogeneity and the diverse study designs; thus, we used a narrative synthesis to report the findings.

Main results: A total of 25 studies were eligible, of the 1463 studies retrieved from selected databases. Twenty-two of the studies indicated a shift in social norms as a result of HIV advocacy programs, and 3 indicated a change in impact. We drew 6 lessons from these programs that may be useful for noncommunicable disease advocacy: (1) involving at-risk populations in advocacy programs, (2) working with laypersons and community members, (3) working with peer advocates and activists, (4) targeting specific age groups and asking support from celebrities, (5) targeting several, but specific, risk factors, and (6) using an evidence-based approach through formative research.

Author conclusions: HIV advocacy programs have been effective in shifting social norms and facilitating a change in impact.

Public health implications: The lessons learned from these effective programs could be used to improve the design and implementation of future noncommunicable disease advocacy programs.

Abstract access

Editor’s notes: This article presents the results of a systematic review to answer a question about the effectiveness of HIV advocacy in changing social norms and changing impact among key populations. The review was conducted to learn from effective HIV advocacy and apply similar strategies for the prevention and reduction of the global burden of non-communicable diseases. The review included quantitative research only. After searching 3320 articles, 25 articles met the inclusion criteria. The HIV advocacy activities reviewed ranged from local and mass campaigns using a variety of media, to social marketing, celebrities, drama, promotional activities and counselling. Changes in social norms were assessed using six specific variables, for example testing behaviour change or HIV-associated stigma. Changes in impact were analysed in two aspects, changes in HIV transmission and in adherence to antiretroviral therapy. The review has found significant evidence of the effect of HIV advocacy on the outcomes of interest. The authors highlight lessons from HIV advocacy that might be useful for future non-communicable diseases advocacy. These included the vital role of peer-educator and of lay members of the community and the involvement of key populations in programmes that focus on them.  In addition, there is a need to tailor programmes to specific (rather than multiple) risks using local and salient evidence. 

Africa, Northern America, Oceania
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One-stop clinic-based ART initiation strengthens HIV treatment cascade

Initiating antiretroviral therapy for HIV at a patient's first clinic visit: the RapIT randomized controlled trial.

Rosen S, Maskew M, Fox MP, Nyoni C, Mongwenyana C, Malete G, Sanne I, Bokaba D, Sauls C, Rohr J, Long L. PLoS Med. 2016 May 10;13(5):e1002015. doi: 10.1371/journal.pmed.1002015. eCollection 2016.

Background: High rates of patient attrition from care between HIV testing and antiretroviral therapy (ART) initiation have been documented in sub-Saharan Africa, contributing to persistently low CD4 cell counts at treatment initiation. One reason for this is that starting ART in many countries is a lengthy and burdensome process, imposing long waits and multiple clinic visits on patients. We estimated the effect on uptake of ART and viral suppression of an accelerated initiation algorithm that allowed treatment-eligible patients to be dispensed their first supply of antiretroviral medications on the day of their first HIV-related clinic visit.

Methods and findings: RapIT (Rapid Initiation of Treatment) was an unblinded randomized controlled trial of single-visit ART initiation in two public sector clinics in South Africa, a primary health clinic (PHC) and a hospital-based HIV clinic. Adult (≥18 y old), non-pregnant patients receiving a positive HIV test or first treatment-eligible CD4 count were randomized to standard or rapid initiation. Patients in the rapid-initiation arm of the study ("rapid arm") received a point-of-care (POC) CD4 count if needed; those who were ART-eligible received a POC tuberculosis (TB) test if symptomatic, POC blood tests, physical exam, education, counseling, and antiretroviral (ARV) dispensing. Patients in the standard-initiation arm of the study ("standard arm") followed standard clinic procedures (three to five additional clinic visits over 2-4 wk prior to ARV dispensing). Follow up was by record review only. The primary outcome was viral suppression, defined as initiated, retained in care, and suppressed (≤400 copies/ml) within 10 mo of study enrollment. Secondary outcomes included initiation of ART ≤90 d of study enrollment, retention in care, time to ART initiation, patient-level predictors of primary outcomes, prevalence of TB symptoms, and the feasibility and acceptability of the intervention. A survival analysis was conducted comparing attrition from care after ART initiation between the groups among those who initiated within 90 d. Three hundred and seventy-seven patients were enrolled in the study between May 8, 2013 and August 29, 2014 (median CD4 count 210 cells/mm3). In the rapid arm, 119/187 patients (64%) initiated treatment and were virally suppressed at 10 mo, compared to 96/190 (51%) in the standard arm (relative risk [RR] 1.26 [1.05-1.50]). In the rapid arm 182/187 (97%) initiated ART ≤90 d, compared to 136/190 (72%) in the standard arm (RR 1.36, 95% confidence interval [CI], 1.24-1.49). Among 318 patients who did initiate ART within 90 d, the hazard of attrition within the first 10 mo did not differ between the treatment arms (hazard ratio [HR] 1.06; 95% CI 0.61-1.84). The study was limited by the small number of sites and small sample size, and the generalizability of the results to other settings and to non-research conditions is uncertain.

Conclusions: Offering single-visit ART initiation to adult patients in South Africa increased uptake of ART by 36% and viral suppression by 26%. This intervention should be considered for adoption in the public sector in Africa.

Abstract  Full-text [free] access 

Editor’s notes: This randomised controlled trial provides evidence that initiating ART at a single clinic visit limits pre-ART losses and increases the proportion in care with viral suppression within the first year of ART. Almost all people in the rapid arm initiated ART within 90 days. Attrition post-ART initiation remained quite high. One in three participants initiating ART in the rapid arm did not achieve the primary outcome of retention in care with viral suppression. However, this was not enough to offset the clear benefit of reduced pre-ART loss to follow-up.

There are a few things to note about the study. Firstly, the study design allowed for people who were enrolled at various stages in the pre-ART period, from HIV testing to receipt of CD4+ cell count. Fewer than half were enrolled on the day of HIV diagnosis. Secondly, the trial procedures relating to ART initiation were performed by research staff embedded in the health facilities. The one-stop ART initiation strategy was quite intensive, involving point-of-care testing for CD4+ cell count, TB, and routine pre-ART blood tests. This took over two hours for a single person, and more than four hours if TB testing was required. Lastly, the virologic suppression outcome was based on viral load measurement at any point between three and 12 months. It will therefore be particularly interesting to see longer-term data on virologic suppression and retention to see whether the effects were sustained.

The effectiveness and cost-effectiveness of this strategy should now be evaluated. The removal of CD4+ cell count eligibility criteria for ART might help to streamline the pre-initiation procedures, but additional effort might be required to make this process more efficient and suitable for implementation in routine care settings.  

Africa
South Africa
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ART reduces, but does not eliminate, HIV transmission in serodiscordant couples in a real-world setting

Antiretroviral therapy to prevent HIV acquisition in serodiscordant couples in a hyperendemic community in rural South Africa.  

Oldenburg CE, Barnighausen T, Tanser F, Iwuji CC, De Gruttola V, Seage GR, 3rd, Mimiaga MJ, Mayer KH, Pillay D, Harling G. Clin Infect Dis. 2016 May 20. pii: ciw335. [Epub ahead of print]

Background: Antiretroviral therapy (ART) was highly efficacious in preventing HIV transmission in stable serodiscordant couples in the HPTN-052 study, a resource-rich randomized controlled trial. However, minimal evidence exists of the effectiveness of ART in preventing HIV acquisition in stable serodiscordant couples in real-life population-based settings in hyperendemic communities of sub-Saharan Africa, where health systems are typically resource-poor and overburdened, adherence to ART is suboptimal, and HIV status disclosure to sexual partners is inconsistent.

Methods: Data arose from a population-based open cohort in KwaZulu-Natal, South Africa. HIV-uninfected individuals present between January 2005 and December 2013 (n=17 016) were included. Interval-censored time-updated proportional hazards regression was used to assess how the ART status affected HIV transmission risk in stable serodiscordant relationships.

Results: Of 17 016 individuals, 1846 had an HIV-uninfected and 196 had an HIV-infected stable partner over the follow-up period. HIV incidence was 3.8 per 100 person-years (100PY) among individuals with an HIV-infected partner (95% confidence interval [CI] 2.3-5.6), corresponding to 1.4 per 100PY (95% CI 0.4-3.5) among those with HIV-infected partners on ART and 5.6 per 100PY (95% CI 3.5-8.4) among those with partners not on ART. Use of ART was associated with a 77% decrease in HIV acquisition risk amongst serodiscordant couples (aHR=0.23, 95% CI 0.07-0.80).

Conclusions: ART initiation was associated with a very large reduction in HIV acquisition in serodiscordant couples in rural KwaZulu-Natal. However, real-life effectiveness was substantially lower than in the HPTN-052 trial. To eliminate HIV transmission in serodiscordant couples, additional prevention interventions are likely needed.

Abstract access

Editor’s notes: The landmark HPTN-052 multi-country trial among stable serodiscordant couples demonstrated that antiretroviral therapy (ART) substantially lowers the probability of transmission from HIV-positive people to their HIV-negative partners. However, the magnitude of effect of ART on transmission may not be generalisable to population level because in real-life settings, partnerships may not be stable, and there are operational challenges to programmatic delivery of ART at scale.

This study estimated the transmission risk in stable, serodiscordant couples, in a real-life setting in rural KwaZulu-Natal. The study included all stable serodiscordant couples in the community, whereas HPTN-052 enrolled individuals who presented to health services, and restricted recruitment to HIV-positive participants who disclosed their positive status to their partner.

The authors found that ART was associated with a decrease of 77% in transmission risk in this real-world setting, compared to a decrease of about 89% among people who immediately initiated ART in the HPTN-052 study.

The authors attributed this reduced effect size to a higher number of missed visits and lower adherence to ART in a real-life setting compared to the controlled trial. They also found fewer HIV-positive people with virologic suppression (77%, versus about 90% in the HPTN-052 trial) and lower disclosure rates (disclosure of HIV status to their partner was a requirement for inclusion in the trial).

The authors conclude that ART is highly effective in preventing HIV transmission in stable serodiscordant couples, but that to eliminate HIV transmission, additional preventive measures are necessary. 

Epidemiology, treatment
Africa
South Africa
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Using mathematical models to understand the impact of universal therapy for HIV serodiscordant couples

Estimating the impact of universal antiretroviral therapy for HIV serodiscordant couples through home HIV testing: insights from mathematical models.

Roberts ST, Khanna AS, Barnabas RV, Goodreau SM, Baeten JM, Celum C, Cassels S. J Int AIDS Soc. 2016 May 11;19(1):20864. doi: 10.7448/IAS.19.1.20864. eCollection 2016.

Introduction: Antiretroviral therapy (ART) prevents HIV transmission within HIV serodiscordant couples (SDCs), but slow implementation and low uptake has limited its impact on population-level HIV incidence. Home HIV testing and counselling (HTC) campaigns could increase ART uptake among SDCs by incorporating couples' testing and ART referral. We estimated the reduction in adult HIV incidence achieved by incorporating universal ART for SDCs into home HTC campaigns in KwaZulu-Natal (KZN), South Africa, and southwestern (SW) Uganda.

Methods: We constructed dynamic, stochastic, agent-based network models for each region. We compared adult HIV incidence after 10 years under three scenarios: (1) "Current Practice," (2) "Home HTC" with linkage to ART for eligible persons (CD4 <350) and (3) "ART for SDCs" regardless of CD4, delivered alongside home HTC.

Results: ART for SDCs reduced HIV incidence by 38% versus Home HTC: from 1.12 (95% CI: 0.98-1.26) to 0.68 (0.54-0.82) cases per 100 person-years (py) in KZN, and from 0.56 (0.50-0.62) to 0.35 (0.30-0.39) cases per 100 py in SW Uganda. A quarter of incident HIV infections were averted over 10 years, and the proportion of virally suppressed HIV-positive persons increased approximately 15%.

Conclusions: Using home HTC to identify SDCs and deliver universal ART could avert substantially more new HIV infections than home HTC alone, with a smaller number needed to treat to prevent new HIV infections. Scale-up of home HTC will not diminish the effectiveness of targeting SDCs for treatment. Increasing rates of couples' testing, disclosure, and linkage to care is an efficient way to increase the impact of home HTC interventions on HIV incidence.

Abstract  Full-text [free] access 

Editor’s notes: Delivering effective and efficient HIV prevention programmes to serodiscordant couples continues to be a challenge. The study used a dynamic stochastic agent–based network model to estimate the impact of universal antiretroviral therapy for serodiscordant couples. The authors examined the scaling up of antiretroviral therapy through home HIV testing and counselling in KwaZulu-Natal in South Africa and South-western Uganda. Data from South Africa and Uganda were used to compare three HIV programme scenarios. These included routine antiretroviral therapy delivery in the general population, routine antiretroviral therapy  delivery in the general population and home HIV testing and counselling campaigns, and home HIV testing and counselling and delivery of antiretroviral therapy to serodiscordant couples during home HIV testing and counselling campaigns.  The authors found that a combination of HIV prevention programmes that provide universal antiretroviral therapy for serodiscordant couples in the context of home HIV testing and counselling had more impact in reducing HIV incidence. The study demonstrated that home HIV testing and counselling and linkage to care HIV programmes can substantially reduce HIV incidence in South Africa and Uganda. This is a very interesting and well-designed modelling study which incorporates the effects of partnership dynamics in estimating the population level impact of HIV programmes.

HIV modelling
Africa
South Africa, Uganda
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Oral PrEP reduces risk of HIV and does not result in riskier sex

Effectiveness and safety of oral HIV pre-exposure prophylaxis (PrEP) for all populations: A systematic review and meta-analysis.

Fonner VA, Dalglish SL, Kennedy CE, Baggaley R, O'Reilly K R, Koechlin FM, Rodolph M, Hodges-Mameletzis I, Grant RM. AIDS. 2016 May 5. [Epub ahead of print]

Objective: Pre-exposure prophylaxis (PrEP) offers a promising new approach to HIV prevention. This systematic review and meta-analysis evaluated the evidence for use of oral PrEP containing tenofovir disoproxil fumarate (TDF) as an additional HIV prevention strategy in populations at substantial risk for HIV based on HIV acquisition, adverse events, drug resistance, sexual behavior, and reproductive health outcomes.

Design: Rigorous systematic review and meta-analysis.

Methods: A comprehensive search strategy reviewed three electronic databases and conference abstracts through April 2015. Pooled effect estimates were calculated using random-effects meta-analysis.

Results: Eighteen studies were included, comprising data from 39 articles and six conference abstracts. Across populations and PrEP regimens, PrEP significantly reduced the risk of HIV acquisition compared to placebo. Trials with PrEP use >70% demonstrated the highest PrEP effectiveness (RR = 0.30, 95% CI: 0.21-0.45, p < 0.001) compared to placebo. Trials with low PrEP use did not show a significantly protective effect. Adverse events were similar between PrEP and placebo groups. More cases of drug-resistant HIV infection were found among PrEP users who initiated PrEP while acutely HIV-infected, but incidence of acquiring drug-resistant HIV during PrEP use was low. Studies consistently found no association between PrEP use and changes in sexual risk behavior. PrEP was not associated with increased pregnancy-related adverse events or hormonal contraception effectiveness.

Conclusion: PrEP is protective against HIV infection across populations, presents few significant safety risks, and no evidence of behavioral risk compensation. The effective and cost-effective use of PrEP will require development of best practices for fostering uptake and adherence among people at substantial HIV-risk.

Abstract access

Editor’s notes: This systematic review is the first to aggregate data from across oral pre-exposure prophylaxis (PrEP) studies, including randomized control trials and observational studies, to present clear evidence on the effectiveness of oral PrEP use. The findings confirm that oral PrEP significantly reduces the risk of acquiring HIV if taken consistently and correctly across populations, countries, and most age groups. Differences in efficacy directly correlate with adherence, which accounts for the lower efficacy seen in some subgroups. Perhaps two of the most compelling analyses presented in this paper relate to resistance and behavioural disinhibition. The risk of resistance was shown to be quite low, and study participants exhibiting resistant HIV either enrolled in the studies during an acute infection stage or acquired resistant strains during the course of the research. Regarding behavioural disinhibition, indicators measured such as rates of sexually transmitted infections revealed that PrEP use in the efficacy trials was not associated with behavioural disinhibition and in some studies, resulted in even safer sexual behaviour than what was reported at baseline. Recently completed demonstration projects have reported increased rates of STIs among gay men and other men who have sex with men. However, in the open-label extensions included in this review, where counselling was more intensive, safer sex practices were maintained, thus suggesting that counselling can be effective in preventing behavioural disinhibition. 

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Preventing risky sexual behaviour and intimate partner violence in adolescents

Effects of PREPARE, a multi-component, school-based HIV and intimate partner violence (IPV) prevention programme on adolescent sexual risk behaviour and IPV: cluster randomised controlled trial.

Mathews C, Eggers SM, Townsend L, Aaro LE, de Vries PJ, Mason-Jones AJ, De Koker P, McClinton Appollis T, Mtshizana Y, Koech J, Wubs A, De Vries H. AIDS Behav. 2016 May 3. [Epub ahead of print]

Young South Africans, especially women, are at high risk of HIV. We evaluated the effects of PREPARE, a multi-component, school-based HIV prevention intervention to delay sexual debut, increase condom use and decrease intimate partner violence (IPV) among young adolescents. We conducted a cluster RCT among Grade eights in 42 high schools. The intervention comprised education sessions, a school health service and a school sexual violence prevention programme. Participants completed questionnaires at baseline, 6 and 12 months. Regression was undertaken to provide ORs or coefficients adjusted for clustering. Of 6244 sampled adolescents, 55.3 % participated. At 12 months there were no differences between intervention and control arms in sexual risk behaviours. Participants in the intervention arm were less likely to report IPV victimisation (35.1 vs. 40.9 %; OR 0.77, 95 % CI 0.61-0.99; t(40) = 2.14) suggesting the intervention shaped intimate partnerships into safer ones, potentially lowering the risk for HIV.

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Editor’s notes: Worldwide, HIV is one of the leading causes of death among adolescents. A key objective of the Global Strategy for Women’s, Children’s and Adolescents’ Health, launched in 2015, is to end the HIV epidemic by 2030. In South Africa, the prevalence and incidence of HIV remains high among young South Africans, especially among women. Early sexual debut and condomless sex are risk factors for HIV and other sexually transmitted infections. Another important risk factor in South Africa is the high level of intimate partner violence, which can also increase the risk of HIV infection among women. This cluster randomised trial sought to address these risk factors among young adolescents (average age 13 years) in public high schools in the Western Cape. The education component of the programme comprised 21 sessions delivered weekly immediately after school. One explanation for the lack of an effect on sexual behaviour was sub-optimal exposure to the activity as a result of poor attendance at sessions. Overall, the mean attendance was 8.02 sessions with higher attendance among girls than among boys. Even so, self-reported intimate partner violence – a factor that predisposes HIV infection – was reduced. The investigators suggest that this may be because attendance was higher at earlier sessions, which addressed gender issues, so more participants received exposure to content associated with intimate partner violence than sexual behaviour.

Achieving high, sustained attendance rates at after-school programmes is challenging and as the investigators note, perhaps the most efficient way to ensure that adolescents receive adequate exposure to HIV risk reduction programmes is to embed them in the school curriculum. However, programmes also need to address other structural, social and environmental factors affecting HIV infection.

Africa
South Africa
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