Articles tagged as "South Africa"

Circumcising young adults: a higher return on investment

Effectiveness of and financial returns to voluntary medical male circumcision for HIV prevention in South Africa: an incremental cost-effectiveness analysis.

Haacker M, Fraser-Hurt N, Gorgens M. PLoS Med. 2016 May 3;13(5):e1002012. doi: 10.1371/journal.pmed.1002012. eCollection 2016.

Background: Empirical studies and population-level policy simulations show the importance of voluntary medical male circumcision (VMMC) in generalized epidemics. This paper complements available scenario-based studies (projecting costs and outcomes over some policy period, typically spanning decades) by adopting an incremental approach-analyzing the expected consequences of circumcising one male individual with specific characteristics in a specific year. This approach yields more precise estimates of VMMC's cost-effectiveness and identifies the outcomes of current investments in VMMC (e.g., within a fiscal budget period) rather than of investments spread over the entire policy period.

Methods/findings: The model has three components. We adapted the ASSA2008 model, a demographic and epidemiological model of the HIV epidemic in South Africa, to analyze the impact of one VMMC on HIV incidence over time and across the population. A costing module tracked the costs of VMMC and the resulting financial savings owing to reduced HIV incidence over time. Then, we used several financial indicators to assess the cost-effectiveness of and financial return on investments in VMMC. One circumcision of a young man up to age 20 prevents on average over 0.2 HIV infections, but this effect declines steeply with age, e.g., to 0.08 by age 30. Net financial savings from one VMMC at age 20 are estimated at US$617 at a discount rate of 5% and are lower for circumcisions both at younger ages (because the savings occur later and are discounted more) and at older ages (because male circumcision becomes less effective). Investments in male circumcision carry a financial rate of return of up to 14.5% (for circumcisions at age 20). The cost of a male circumcision is refinanced fastest, after 13 y, for circumcisions at ages 20 to 25. Principal limitations of the analysis arise from the long time (decades) over which the effects of VMMC unfold-the results are therefore sensitive to the discount rate applied, and more generally to the future course of the epidemic and of HIV/AIDS-related policies pursued by the government.

Conclusions: VMMC in South Africa is highly effective in reducing both HIV incidence and the financial costs of the HIV response. The return on investment is highest if males are circumcised between ages 20 and 25, but this return on investment declines steeply with age.

Abstract  Full-text [free] access 

Editor’s notes: Voluntary medical male circumcision is known to be an effective HIV-infection prevention method. While many models and papers have explored the cost and cost-effectiveness of voluntary medical male circumcision at a population level, the authors carry out their analysis using an incremental approach, looking at the expected consequences of circumcising one male individual within a specific year. Their findings are consistent with previous work on the topic, namely that voluntary medical male circumcision is highly effective in countries with high HIV prevalence and is, under many circumstances, cost-saving. They also find that voluntary medical male circumcision is most effective when performed at age 20, and effectiveness declines at higher ages due to diminished direct and indirect effects on HIV incidence.

While it would indeed be wise for countries to consider long-term impacts of programmes, governments often make decisions in the short-term. It is therefore important for governments to understand the benefits of a programme or policy that are accrued during the timeframe of presidential or congressional terms. The findings and the approach used in this study are very important because they present evidence of impact of investment within a government’s current budget process. By providing a way to measure the immediate return on investment, the authors of this paper help inform policymakers in a way that is tangible, pragmatic, and, unfortunately, not often used.  

Africa
South Africa
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Inequalities in access to health care for older people living with HIV in South Africa

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

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

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

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

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

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

Abstract access

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

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

Africa
South Africa
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Injectable PrEP, if targeted well, could be good value for money

Cost-effectiveness of injectable preexposure prophylaxis for HIV prevention in South Africa.

Glaubius RL, Hood G, Penrose KJ, Parikh UM, Mellors JW, Bendavid E, Abbas UL. Clin Infect Dis. 2016 May 18. pii: ciw321. [Epub ahead of print]

Background: Long-acting injectable antiretrovirals such as rilpivirine (RPV) could promote adherence to preexposure prophylaxis (PrEP) for HIV prevention. However, the cost-effectiveness of injectable PrEP is unclear.

Methods: We constructed a dynamic model of the heterosexual HIV epidemic in KwaZulu-Natal, South Africa, and analyzed scenarios of RPV PrEP scale-up for combination HIV prevention in comparison with a reference scenario without PrEP. We estimated new HIV infections, life-years and costs, and incremental cost-effectiveness ratios, over ten-year and lifetime horizons, assuming a societal perspective.

Results: Compared with no PrEP, unprioritized scale-up of RVP PrEP covering 2.5%-15% of adults prevented up to 9% of new infections over ten years. HIV prevention doubled (17%) when the same coverage was prioritized to 20-29 year-old women, costing $10 880-$19 213 per infection prevented. Prioritization of PrEP to 80% of individuals at highest behavioral risk achieved comparable prevention (4%-8%) at <1% overall coverage, costing $298-$1242 per infection prevented. Over lifetime, PrEP scale-up among 20-29 year-old women was very cost-effective (<$1600 per life-year gained), dominating unprioritized PrEP, while risk-prioritization was cost-saving. PrEP's ten-year impact decreased by almost 50% with increases in incremental cost-effectiveness ratios (up to 4.2-fold) in conservative base-case analysis. Sensitivity analysis identified PrEP's costs, efficacy and reliability of delivery, as the principal drivers of uncertainty in PrEP's cost-effectiveness, and PrEP remained cost-effective under the assumption of universal access to second-line antiretroviral therapy.

Conclusions: Compared with no PrEP, prioritized scale-up of RPV PrEP in KwaZulu-Natal could be very cost-effective or cost-saving, but suboptimal PrEP would erode benefits and increase costs.

Abstract access

Editor’s notes: Pre-exposure prophylaxis (PrEP) has been shown to work when people are able to use it well.  But recent trials have illustrated that people are not always able to take tablets or use vaginal gels frequently enough to maximise protection. A promising area in HIV prevention research is long-lasting injectable PrEP, which would only require application once every month or so. This paper estimates whether injectable PrEP might be cost effective in South Africa.  The authors explore how this form of PrEP should be targeted to different groups. Injectable PrEP is estimated to be very cost-effective in general, and would save money if people at highest risk were able to gain access. However, because an injectable product has not been fully developed yet, this analysis requires many assumptions. The authors test how changes in these assumptions might give a different conclusion. They find that the most important factors are the cost of injectable PrEP products themselves, how well they work, and whether they can be made available to people who need them.

Africa
South Africa
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Role for LAM test in TB diagnosis among the sickest people living with HIV

Lateral flow urine lipoarabinomannan assay for detecting active tuberculosis in HIV-positive adults.

Shah M, Hanrahan C, Wang ZY, Dendukuri N, Lawn SD, Denkinger CM, Steingart KR. Cochrane Database Syst Rev. 2016 May 10;5:CD011420. doi: 10.1002/14651858.CD011420.pub2.

Background: Rapid detection of tuberculosis (TB) among people living with human immunodeficiency virus (HIV) is a global health priority. HIV-associated TB may have different clinical presentations and is challenging to diagnose. Conventional sputum tests have reduced sensitivity in HIV-positive individuals, who have higher rates of extrapulmonary TB compared with HIV-negative individuals. The lateral flow urine lipoarabinomannan assay (LF-LAM) is a new, commercially available point-of-care test that detects lipoarabinomannan (LAM), a lipopolysaccharide present in mycobacterial cell walls, in people with active TB disease.

Objectives: To assess the accuracy of LF-LAM for the diagnosis of active TB disease in HIV-positive adults who have signs and symptoms suggestive of TB (TB diagnosis). To assess the accuracy of LF-LAM as a screening test for active TB disease in HIV-positive adults irrespective of signs and symptoms suggestive of TB (TB screening).

Search methods: We searched the following databases without language restriction on 5 February 2015: the Cochrane Infectious Diseases Group Specialized Register; MEDLINE (PubMed,1966); EMBASE (OVID, from 1980); Science Citation Index Expanded (SCI-EXPANDED, from 1900), Conference Proceedings Citation Index-Science (CPCI-S, from 1900), and BIOSIS Previews (from 1926) (all three using the Web of Science platform; MEDION; LILACS (BIREME, from 1982); SCOPUS (from 1995); the metaRegister of Controlled Trials (mRCT); the search portal of the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP); and ProQuest Dissertations & Theses A&l (from 1861).

Selection criteria: Eligible study types included randomized controlled trials, cross-sectional studies, and cohort studies that determined LF-LAM accuracy for TB against a microbiological reference standard (culture or nucleic acid amplification test from any body site). A higher quality reference standard was one in which two or more specimen types were evaluated for TB, and a lower quality reference standard was one in which only one specimen type was evaluated for TB. Participants were HIV-positive people aged 15 years and older.

Data collection and analysis: Two review authors independently extracted data from each included study using a standardized form. We appraised the quality of studies using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. We evaluated the test at two different cut-offs: (grade 1 or 2, based on the reference card scale of five intensity bands). Most analyses used grade 2, the manufacturer's currently recommended cut-off for positivity. We carried out meta-analyses to estimate pooled sensitivity and specificity using a bivariate random-effects model and estimated the models using a Bayesian approach. We determined accuracy of LF-LAM combined with sputum microscopy or Xpert(R) MTB/RIF. In addition, we explored the influence of CD4 count on the accuracy estimates. We assessed the quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Main results: We included 12 studies: six studies evaluated LF-LAM for TB diagnosis and six studies evaluated the test for TB screening. All studies were cross-sectional or cohort studies. Studies for TB diagnosis were largely conducted among inpatients (median CD4 range 71 to 210 cells per µL) and studies for TB screening were largely conducted among outpatients (median CD4 range 127 to 437 cells per µL). All studies were conducted in low- or middle-income countries. Only two studies for TB diagnosis (33%) and one study for TB screening (17%) used a higher quality reference standard LF-LAM for TB diagnosis (grade 2 cut-off): meta-analyses showed median pooled sensitivity and specificity (95% credible interval (CrI)) of 45% (29% to 63%) and 92% (80% to 97%), (five studies, 2313 participants, 35% with TB, low quality evidence). The pooled sensitivity of a combination of LF-LAM and sputum microscopy (either test positive) was 59% (47% to 70%), which represented a 19% (4% to 36%) increase over sputum microscopy alone, while the pooled specificity was 92% (73% to 97%), which represented a 6% (1% to 24%) decrease from sputum microscopy alone (four studies, 1876 participants, 38% with TB). The pooled sensitivity of a combination of LF-LAM and sputum Xpert(R) MTB/RIF (either test positive) was 75% (61% to 87%) and represented a 13% (1% to 37%) increase over Xpert(R) MTB/RIF alone. The pooled specificity was 93% (81% to 97%) and represented a 4% (1% to 16%) decrease from Xpert(R) MTB/RIF alone (three studies, 909 participants, 36% with TB). Pooled sensitivity and specificity of LF-LAM were 56% (41% to 70%) and 90% (81% to 95%) in participants with a CD4 count of less than or equal to 100 cells per µL (five studies, 859 participants, 47% with TB) versus 26% (16% to 46%) and 92% (78% to 97%) in participants with a CD4 count greater than 100 cells per µL (five studies, 1410 participants, 30% with TB). LF-LAM for TB screening (grade 2 cut-off): for individual studies, sensitivity estimates (95% CrI) were 44% (30% to 58%), 28% (16% to 42%), and 0% (0% to 71%) and corresponding specificity estimates were 95% (92% to 97%), 94% (90% to 97%), and 95% (92% to 97%) (three studies, 1055 participants, 11% with TB, very low quality evidence). There were limited data for additional analyses. The main limitations of the review were the use of a lower quality reference standard in most included studies, and the small number of studies and participants included in the analyses. The results should, therefore, be interpreted with caution.

Authors' conclusions: We found that LF-LAM has low sensitivity to detect TB in adults living with HIV whether the test is used for diagnosis or screening. For TB diagnosis, the combination of LF-LAM with sputum microscopy suggests an increase in sensitivity for TB compared to either test alone, but with a decrease in specificity. In HIV-positive individuals with low CD4 counts who are seriously ill, LF-LAM may help with the diagnosis of TB.

Abstract  Full-text [free] access

Editor’s notes: Tuberculosis (TB) remains a leading cause of death among people living with HIV. Diagnostic tests for TB are suboptimal, and a test for TB with adequate performance which could be used by nurses in primary care clinics would be a great advance. Lipoarabinomannam (LAM) is a component of mycobacterial cell wall which can be found in urine. A lateral flow assay to detect LAM in urine is commercially available at low cost, and can be used in primary care settings without the need for laboratory equipment. However the test is insensitive, such that it has no useful role among HIV-negative people, but has better sensitivity among people living with HIV, leading to questions concerning its role in TB diagnostic pathways.

This systematic review puts together data concerning the performance of the LAM lateral flow assay when used either as a screening test or for diagnosis of TB among people living with HIV. Assessment is made more complicated because the recommended reference cut-off for the test has been changed, with relatively few studies performed after the recommended cut off became what is referred to here as the “higher quality” reference standard (grade two test band intensity, rather than grade one as was previously recommended). Based on the grade two cut–off, the pooled estimate of sensitivity of the test was 45%. As expected, sensitivity was better for individuals with low CD4 counts.

This review informed WHO recommendations on the use of the LAM assay, suggesting that its use should be restricted to assisting with TB diagnosis in people living with HIV with low CD4 counts who are seriously ill. This is consistent with the results of the recent trial (PMID: 26970721) comparing management of hospitalised HIV-positive people reporting one or more TB symptoms with routine testing of urine for LAM compared to standard diagnostic tests, which found that the addition of LAM testing resulted in a small reduction in eight-week mortality.

Overall, LAM is inadequate as a single test for TB, and an accurate diagnostic test that could be used in-session for TB diagnosis in primary care clinics remains a pressing priority.

Comorbidity, HIV testing
Africa
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Trial shows improvements to uptake of VMMC and linkage into HIV care but little effect on ART initiation

Uptake of antiretroviral therapy and male circumcision after community-based HIV testing and strategies for linkage to care versus standard clinic referral: a multisite, open-label, randomised controlled trial in South Africa and Uganda.

Barnabas RV, van Rooyen H, Tumwesigye E, Brantley J, Baeten JM, van Heerden A, Turyamureeba B, Joseph P, Krows M, Thomas KK, Schaafsma TT, Hughes JP, Celum C. Lancet HIV. 2016 May;3(5):e212-20. doi: 10.1016/S2352-3018(16)00020-5. Epub 2016 Mar 10.

Background: Male circumcision decreases HIV acquisition by 60%, and antiretroviral therapy (ART) almost eliminates HIV transmission from HIV-positive people who are virally suppressed; however, coverage of these interventions has lagged behind targets. We aimed to assess whether community-based HIV testing with counsellor support and point-of-care CD4 cell count testing would increase uptake of ART and male circumcision.

Methods: We did this multisite, open-label, randomised controlled trial in six research-naive communities in rural South Africa and Uganda. Eligible HIV-positive participants (aged ≥16 years) were randomly assigned (1:1:1) in a factorial design to receive lay counsellor clinic linkage facilitation, lay counsellor follow-up home visits, or standard-of-care clinic referral, and then (1:1) either point-of-care CD4 cell count testing or referral for CD4 testing. HIV-negative uncircumcised men (aged 16-49 years) who could receive secure mobile phone text messages were randomly assigned (1:1:1) to receive text message reminders, lay counsellor visits, or standard clinic referral. The study biostatistician generated the randomisation schedule via a computer-generated random number program with varying block sizes (multiples of six or three) stratified by country. Primary outcomes for HIV-positive people were obtaining a CD4 cell count, linkage to an HIV clinic, ART initiation, and viral suppression at 9 months, and for HIV-negative uncircumcised men were visiting a circumcision facility and uptake of male circumcision at 3 months. We assessed social harms as a safety outcome throughout the study. We did the primary analyses by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT02038582.

Findings: Between June 6, 2013, and March 11, 2015, 15 332 participants were tested. 2339 (15%) participants tested HIV positive, of whom 1325 (57%) were randomly assigned to receive lay counsellor clinic linkage facilitation (n=437), lay counsellor follow-up home visits (n=449), or standard clinic referral (n=439), and then point-of-care CD4 cell testing (n=206, n=220, and n=213, respectively) or referral for CD4 testing (n=231, n=229, and n=226, respectively). 12 993 (85%) participants tested HIV negative, of whom 750 (6%) uncircumcised men were randomly assigned to receive clinic referral (n=230), text message reminders (n=288), or lay counsellor follow-up visits (n=232). 1218 (93%) of 1303 HIV-positive participants were linked to care, but only 488 (37%) participants initiated ART. Overall, 635 (50%) of 1272 HIV-positive individuals achieved viral suppression at 9 months: 219 (52%) of 419 participants in the clinic facilitation group, 202 (47%) of 431 participants in the lay counsellor follow-up group, and 214 (51%) of 422 participants in the clinic referral group, with no significant differences between groups (p=0.668 for clinic facilitation and p=0.273 for lay counsellor follow-up vs clinic referral). 523 (72%) of 734 HIV-negative men visited a circumcision facility, with no difference between groups. 62 (28%) of 224 men were circumcised in the male circumcision clinic referral group compared with 137 (48%) of 284 men in the text message reminder group (relative risk 1.72, 95% CI 1.36-2.17; p<0.0001) and 106 (47%) of 226 men in the lay counsellor follow-up group (1.67, 1.29-2.14; p=0.0001). No cases of study-related social harm were reported, including probing about partnership separation, unintended disclosure, gender-based violence, and stigma.

Interpretation: All the community-based strategies achieved high rates of linkage of HIV-positive people to HIV clinics, roughly a third of whom initiated ART, and of those more than 80% were virally suppressed at 9 months. Uptake of male circumcision was almost two-times higher in men who received text message reminders or lay counsellor visits than in those who received standard-of-care clinic referral. Clinic barriers to ART initiation should be addressed in future strategies to increase the proportion of HIV-positive people accessing treatment and achieving viral suppression.

Abstract access

Editor’s notes: This study described a robust evaluation of approaches to enhance uptake of antiretroviral therapy (ART) and voluntary medical male circumcision (VMMC) following community-based approaches of HIV testing (home-based and mobile HIV testing). For HIV negative men, the close to 50% uptake of VMMC from the text message reminder approach is especially encouraging as it seems a low cost method for wider scale-up. The limitation however is that reliable and private access to a phone would be necessary. Nonetheless, with the increasing availability of mobile phones in Africa, this is a promising approach.

The findings for people living with HIV are more complex. There was remarkably high (93%) linkage into care in the study settings at nine months – even in the referral only arm. Unfortunately, this did not translate into high proportions initiating ART overall, 37%. The benefits from the approaches to enhance uptake of ART were also mixed. ART initiation was increased with lay-counsellor follow-up but not with clinic facilitation, even though the latter did illustrate benefits for linkage to care. Further, viral suppression at nine months was similar across the study arms. Point-of-care CD4-counts did not affect rates of linkage, ART initiation or viral suppression.

The findings from this comprehensive evaluation of approaches to enhance uptake of services remind us of the opportunity not only to actively promote VMMC for HIV-negative men as part of HIV-testing services, but also that both text messages and lay counsellor follow-up can increase uptake. The study also highlights that increasing linkage to care for people living with HIV does not necessarily translate into increasing uptake of treatment. The authors describe possible reasons for this and it seems that addressing health systems challenges within facilities and innovations around treatment delivery should be priorities.

Health care delivery
Africa
South Africa, Uganda
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HIV testing in South Africa: on track to reach the first “90”?

Changes in self-reported HIV testing during South Africa's 2010/2011 national testing campaign: gains and shortfalls.

Maughan-Brown B, Lloyd N, Bor J, Venkataramani AS. J Int AIDS Soc. 2016; 19(1): 20658.

Objectives: HIV counselling and testing is critical to HIV prevention and treatment efforts. Mass campaigns may be an effective strategy to increase HIV testing in countries with generalized HIV epidemics. We assessed the self-reported uptake of HIV testing among individuals who had never previously tested for HIV, particularly those in high-risk populations, during the period of a national, multisector testing campaign in South Africa (April 2010 and June 2011).

Design: This study was a prospective cohort study.

Methods: We analyzed data from two waves (2010/2011, n=16 893; 2012, n=18 707) of the National Income Dynamics Study, a nationally representative cohort that enabled prospective identification of first-time testers. We quantified the number of adults (15 years and older) testing for the first time nationally. To assess whether the campaign reached previously underserved populations, we examined changes in HIV testing coverage by age, gender, race and province sub-groups. We also estimated multivariable logistic regression models to identify socio-economic and demographic predictors of first-time testing.

Results: Overall, the proportion of adults ever tested for HIV increased from 43.7% (95% confidence interval (CI): 41.48, 45.96) to 65.2% (95% CI: 63.28, 67.10) over the study period, with approximately 7.6 million (95% CI: 6,387,910; 8,782,986) first-time testers. Among black South Africans, the country's highest HIV prevalence sub-group, HIV testing coverage improved among poorer and healthier individuals, thus reducing gradients in testing by wealth and health. In contrast, HIV testing coverage remained lower for men, younger individuals and the less educated, indicating persistent if not widening disparities by gender, age and education. Large geographic disparities in coverage also remained as of 2012.

Conclusions: Mass provision of HIV testing services can be effective in increasing population coverage of HIV testing. The geographic and socio-economic disparities in programme impacts can help guide best practices for future efforts. These efforts should focus on hard-to-reach populations, including men and less-educated individuals.

Abstract Full-text [free] access

Editor’s notes: In South Africa, around one in eight people are living with HIV yet around half of these people do not know that they are HIV positive. To meet the 90-90-90 treatment target by 2020, there needs to be considerable expansion of HIV testing coverage. This analysis used independent nationally representative data on self-reported HIV testing to demonstrate that coverage of HIV testing increased substantially following the national multi-sector HIV testing campaign in 2010/11. Despite the expansion in coverage, in the 2012 survey one in three people aged >15 years reported never having received an HIV test. There was marked gender disparity, some 72% of women versus 57% men reported ever having tested in the 2012 survey. There were also prominent gaps among certain socio-economic groups, suggesting persistent inequities in access to HIV testing. 

Although South Africa performs around 10 million HIV tests per year, the number of people tested falls substantially below the target of 30 million tests set for 2016 in the National Strategic Plan. In September, South Africa will implement the “test and treat” approach where all people living with HIV will be offered antiretroviral therapy. In addition, demonstration projects are underway of pre-exposure prophylaxis (PrEP) for HIV prevention. HIV testing services  is the gateway to all treatment and prevention services. The national campaign for HIV testing will clearly need to be revitalised in order to maximise the impact of these public health activities. At the same time, the data reported here would suggest that more innovative and focused approaches may be necessary for difficult to reach population groups.

Africa
South Africa
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Finding out at home: community members’ and healthcare workers’ views on the use of oral HIV self-testing in Kayelitsha, South Africa

'I know that I do have HIV but nobody saw me': oral HIV self-testing in an informal settlement in South Africa.

Martinez Perez G, Cox V, Ellman T, Moore A, Patten G, Shroufi A, Stinson K, Van Cutsem G, Ibeto M. PLoS One. 2016 Apr 4;11(4):e0152653. doi: 10.1371/journal.pone.0152653. eCollection 2016.

Reaching universal HIV-status awareness is crucial to ensure all HIV-infected patients access antiretroviral treatment (ART) and achieve virological suppression. Opportunities for HIV testing could be enhanced by offering self-testing in populations that fear stigma and discrimination when accessing conventional HIV Counselling and Testing (HCT) in health care facilities. This qualitative research aims to examine the feasibility and acceptability of unsupervised oral self-testing for home use in an informal settlement of South Africa. Eleven in-depth interviews, two couple interviews, and two focus group discussions were conducted with seven healthcare workers and thirteen community members. Thematic analysis was done concurrently with data collection. Acceptability to offer home self-testing was demonstrated in this research. Home self-testing might help this population overcome barriers to accepting HCT; this was particularly expressed in the male and youth groups. Nevertheless, pilot interventions must provide evidence of potential harm related to home self-testing, intensify efforts to offer quality counselling, and ensure linkage to HIV/ART-care following a positive self-test result.

 Abstract Full-text [free] access

Editor’s notes: This is a qualitative study with services users and healthcare workers from an HIV testing service ran by Médecins Sans Frontières (MSF) in Kayelitsha, South Africa. Couple and individual interviews and focus group discussions were conducted with 20 people. The participants discussed preferences of types of HIV testing and acceptability of HIV home-testing. The aim was to inform the pilot of an activity for the use of an oral HIV self-testing device (OraQuick). OraQuick is self-administered as an oral swab and gives results straightaway. The study sample included people who had previously refused an HIV test in the clinic, people who had received an HIV test in the clinic and agreed to a couple interview with their partners. Key reasons for refusing an HIV test in the clinic included: fear of finding out one’s status, fear of HIV-treated discrimination and concerns about confidentiality in testing services. Clinics were seen by male participants as ‘women’s places’.  Men thought visiting a service for an HIV test could harm one’s reputation. Home-testing was seen as preferable because it afforded more privacy. However, not wanting to know one’s status remains a barrier even with home-testing. There were concerns that partners (of both sexes) could pressure one another to test with OraQuick and tensions could arise in case of serodiscordant results. There were concerns that some users could get confused by a test that detects the presence of HIV in the mouth. This would contradict current awareness that HIV cannot be passed through kissing. False-negative tests could encourage unsafe sex. Participants worried that some people may not link into care and treatment after finding out they are HIV positive with a home-test. The study concludes that home-testing could reach populations (especially male partners of women living with HIV and young people) that do not come forward for testing through other services, including clinic-based and voluntary community testing. Many of the disadvantages of home-testing could be mitigated with appropriate education and pre-test counselling. The pilot study continues.  It is expected that the study will be able to address questions of linkage to care for people who test HIV-positive. 

Africa
South 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.

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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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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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