Articles tagged as "United Republic of Tanzania"

Childhood sexual violence and HIV risk in Tanzania

HIV and childhood sexual violence: implications for sexual risk behaviors and HIV testing in Tanzania.

Chiang LF, Chen J, Gladden MR, Mercy JA, Kwesigabo G, Mrisho F, Dahlberg LL, Nyunt MZ, Brookmeyer KA, Vagi K. AIDS Educ Prev. 2015 Oct;27(5):474-87. doi: 10.1521/aeap.2015.27.5.474

Prior research has established an association between sexual violence and HIV. Exposure to sexual violence during childhood can profoundly impact brain architecture and stress regulatory response. As a result, individuals who have experienced such trauma may engage in sexual risk-taking behavior and could benefit from targeted interventions. In 2009, nationally representative data were collected on violence against children in Tanzania from 13-24 year old respondents (n = 3739). Analyses show that females aged 19-24 (n = 579) who experienced childhood sexual violence, were more likely to report no/infrequent condom use in the past 12 months (AOR = 3.0, CI [1.5, 6.1], p = 0.0017) and multiple sex partners in the past 12 months (AOR = 2.3, CI [1.0, 5.1], p = 0.0491), but no more likely to know where to get HIV testing or to have ever been tested. Victims of childhood sexual violence could benefit from targeted interventions to mitigate impacts of violence and prevent HIV.

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Editor’s notes: A growing body of evidence has established an association between sexual violence and increased vulnerability to HIV infection. Childhood sexual violence may increase HIV risk both directly (e.g. forced sex) and indirectly (e.g. through high-risk sex behaviours later in life). This paper examined two questions: is childhood violence exposure associated with (i) high-risk sexual behaviour in early adulthood and (ii) increased/decreased knowledge and uptake of HIV testing services.

A nationally representative sample of females aged 19-24 years were surveyed. Women were excluded from the analyses if they were not sexually active. Some 26.1% of 579 women reported childhood sexual violence (answering yes to one of four questions around unwanted touch / attempted rape / unwanted / coercive sexual intercourse before age 18 years). Childhood sexual violence was associated with (i) low / no condom use with someone other than husband / live in partner and (ii) >1 sexual partner, past 12 months. There was no association with knowledge or uptake of HIV testing services. These findings are consistent with research done elsewhere and suggest childhood sexual violence is associated with increased sexual risk taking behaviours in early adulthood. These findings present evidence for the importance of programmes to reduce childhood exposure to violence and focussed, adolescent-friendly sexual health services.

Africa
United Republic of Tanzania
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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.

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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.

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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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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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Optimal methods to deliver HTC in health facility out-patient settings

Strengthening HIV test access and treatment uptake study (Project STATUS): a randomized trial of HIV testing and counseling interventions.

McNaghten AD, Schilsky Mneimneh A, Farirai T, Wamai N, Ntiro M, Sabatier J, Makhunga-Ramfolo N, Mwanasalli S, Awor A, Moore J, Project SST. J Acquir Immune Defic Syndr. 2015 Aug 6. [Epub ahead of print]

Objective: To determine which of 3 HIV testing and counseling (HTC) models in outpatient departments (OPDs) increases HIV testing and entry of newly identified HIV-infected patients into care.

Design: Randomized trial of HIV testing and counseling interventions.

Methods: Thirty-six OPDs in South Africa, Tanzania and Uganda were randomly assigned to 3 different HTC models: A) health care providers referred eligible patients (aged 18-49, not tested in the past year, not known HIV positive) to on-site voluntary counseling and testing (VCT) for HTC offered and provided by VCT counselors after clinical consultation; B) health care providers offered and provided HTC to eligible patients during clinical consultation; and C) nurse or lay counselors offered and provided HTC to eligible patients before clinical consultation. Data were collected October 2011-September 2012. We describe testing eligibility and acceptance, HIV prevalence, and referral and entry into care. Chi-square analyses were conducted to examine differences by model.

Results: Of 79 910 patients, 45% were age-eligible and 16 099 (45%) age-eligibles were tested. Ten percent tested HIV positive. Significant differences were found in percent tested by model. The proportion of age eligible patients tested by Project STATUS was highest for Model C (54.1%, 95% confidence interval [CI]=42.4-65.9), followed by Model A (41.7%, 95% CI=30.7-52.8) and Model B (33.9%, 95% CI=25.7-42.1). Of the 1,596 newly identified HIV-positives, 94% were referred to care (96.1% in Model A, 94.7% in Model B, and 94.9% in Model C), and 58% entered on-site care (74.4% in Model A, 54.8% in Model B, and 55.6% in Model C) with no significant differences in referrals or care entry by model.

Conclusions: Model C resulted in the highest proportion of all age eligible patients receiving a test. Although 94% of STATUS patients with a positive test result were referred to care, only 58% entered care. We found no differences in patients entering care by HTC model. Routine HTC in OPDs is acceptable to patients and effective for identifying HIV-infected persons, but additional efforts are needed to increase entry to care.

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Editor’s notes: While there has been much attention given in recent years to community models of HIV testing, WHO and UNAIDS guidelines continue to recommend the importance of efforts to improve access to HIV testing in health facilities. This interesting study conducted under “real world” conditions, examined different models of out-patient department based testing. It found that the model which focussed on people while they waited for their clinical consultation, achieved the highest proportion taking up testing among people who were eligible. Beyond this step, the authors report that proportions referred and entered into care did not differ significantly and the proportion who did so was low (<60%). This was despite the fact the fact that the study population consisted entirely of people already utilising services at the health care facility. The majority of participants were women. No further information on the clinical status or CD4 counts of people identified as HIV positive is provided, although that would be interesting follow-up information in future. This study highlights not only that facility based HIV testing and counselling should not be forgotten as an important means to increase access to testing, but also that linkage to care is a problem even among individuals already utilising general health services.  

HIV testing
Africa
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HIV-associated stigma may impede HIV medication adherence among people living with HIV

The association of HIV-related stigma to HIV medication adherence: a systematic review and synthesis of the literature.

Sweeney SM, Vanable PA. AIDS Behav. 2015 Aug 25. [Epub ahead of print]

This paper provides a review of the quantitative literature on HIV-related stigma and medication adherence, including: (1) synthesis of the empirical evidence linking stigma to adherence, (2) examination of proposed causal mechanisms of the stigma and adherence relationship, and (3) methodological critique and guidance for future research. We reviewed 38 studies reporting either cross-sectional or prospective analyses of the association of HIV-related stigma to medication adherence since the introduction of antiretroviral therapies (ART). Although there is substantial empirical evidence linking stigma to adherence difficulties, few studies provided data on psychosocial mechanisms that may account for this relationship. Proposed mechanisms include: (a) enhanced vulnerability to mental health difficulties, (b) reduction in self-efficacy, and (c) concerns about inadvertent disclosure of HIV status. Future research should strive to assess the multiple domains of stigma, use standardized measures of adherence, and include prospective analyses to test mediating variables.

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Editor’s notes: People living with HIV often experience stigma and discrimination including social isolation and negative stereotyping. Recent evidence suggests that stigma may influence adherence to HIV medication among people living with HIV. This paper presents findings from a systematic review of the evidence on the impact of HIV-associated stigma on HIV medication adherence. The authors identified 38 studies which quantitatively assessed the association between stigma and medication adherence. All studies found evidence indicating that stigma contributed to adherence difficulties among people living with HIV. Included studies looked at diverse patient populations sampled from different countries and contexts. While stigma is heavily influenced by the socio-cultural context, the association between stigma and adherence across diverse contexts indicates that there may be commonalities in what causes stigma and how this relates to adherence.

The authors of this review suggest three possible causal mechanisms of HIV-associated stigma and medication adherence: (1) There may be links between stigma and depressive symptoms, and between depressive symptoms and adherence. Internalized stigma may enhance vulnerability to depressive symptoms, and this may influence adherence to HIV medication. (2) Stigma may cause reductions in self-efficacy – a person’s judgment of his or her ability to organize and execute behaviours - which may influence medication adherence. (3) People may fear HIV status disclosure by being seen taking HIV medication. Fear of status disclosure, and associated stigma, may cause people to avoid taking HIV medication.

The studies included in this review indicate a clear link between HIV-associated stigma and HIV medication adherence. There may be commonalities in what causes stigma across multiple populations. Future research should assess the influence of multiple forms of stigma on adherence, and on testing causal mechanisms between stigma and adherence. 

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Wide variation in national HIV policies associated with HIV testing and treatment across six African countries

A comparative analysis of national HIV policies in six African countries with generalized epidemics.

Church K, Kiweewa F, Dasgupta A, Mwangome M, Mpandaguta E, Gomez-Olive FX, Oti S, Todd J, Wringe A, Geubbels E, Crampin A, Nakiyingi-Miiro J, Hayashi C, Njage M, Wagner RG, Ario AR, Makombe SD, Mugurungi O, Zaba B. Bull World Health Organ. 2015 Jul 1;93(7):457-67. doi: 10.2471/BLT.14.147215. Epub 2015 Apr 28.

Objective: To compare national human immunodeficiency virus (HIV) policies influencing access to HIV testing and treatment services in six sub-Saharan African countries.

Methods: We reviewed HIV policies as part of a multi-country study on adult mortality in sub-Saharan Africa. A policy extraction tool was developed and used to review national HIV policy documents and guidelines published in Kenya, Malawi, South Africa, Uganda, the United Republic of Tanzania and Zimbabwe between 2003 and 2013. Key informant interviews helped to fill gaps in findings. National policies were categorized according to whether they explicitly or implicitly adhered to 54 policy indicators, identified through literature and expert reviews. We also compared the national policies with World Health Organization (WHO) guidance.

Findings: There was wide variation in policies between countries; each country was progressive in some areas and not in others. Malawi was particularly advanced in promoting rapid initiation of antiretroviral therapy. However, no country had a consistently enabling policy context expected to increase access to care and prevent attrition. Countries went beyond WHO guidance in certain areas and key informants reported that practice often surpassed policy.

Conclusion: Evaluating the impact of policy differences on access to care and health outcomes among people living with HIV is challenging. Certain policies will exert more influence than others and official policies are not always implemented. Future research should assess the extent of policy implementation and link these findings with HIV outcomes.

Abstract  Full-text [free] access

Editor’s notes: Despite evidence on reduction in HIV attributable mortality, concerns still remain on the high attrition rates across the diagnosis-to-treatment cascade. This paper uses a comparative policy analysis to track differences in national HIV policy responses to the HIV epidemic. The methodology used is notable as it offers a helpful conceptual framework for the HIV policy and service factors influencing specific differences in HIV-associated adult mortality across the diagnosis-to-treatment cascade.

The range of policies between countries was unexpected, given the explanation offered by the authors that African countries tend to adopt standards and guidance from WHO. Furthermore, while countries showed progressive elements, no country had the comprehensive policy context necessary for a decisive impact on service access. Important differences were also noted in the influential weight given to some policies, in the timing of policy implementation in some indicators, and in whether WHO national standards were or were not adopted by countries.

These findings are particularly useful in better understanding the incentives and barriers to accessing antiretroviral therapy in different contexts.

Africa
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Switching to second-line ART – we need to do better

Monitoring and switching of first-line antiretroviral therapy in sub-Saharan Africa: collaborative analysis of adult treatment cohorts.

Haas AD, Keiser O, Balestre E, Brown S, Bissagnene E, Chimbetete C, Dabis F, Davies MA, Hoffmann CJ, Oyaro P, Parkes-Ratanshi R, Reynolds SJ, Sikazwe I, Wools-Kaloustian K, Zannou DM, Wandeler G, Egger M, for IeDea Southern Africa EA, West A. Lancet HIV. 2015 Jul 1;2(7):e271-e278.

Background: HIV-1 viral load testing is recommended to monitor antiretroviral therapy (ART) but is not universally available. The aim of our study was to assess monitoring of first-line ART and switching to second-line ART in sub-Saharan Africa.

Methods: We did a collaborative analysis of cohort studies from 16 countries in east Africa, southern Africa, and west Africa that participate in the international epidemiological database to evaluate AIDS (IeDEA). We included adults infected with HIV-1 who started combination ART between January, 2004, and January, 2013. We defined switching of ART as a change from a non-nucleoside reverse-transcriptase inhibitor (NNRTI)-based regimen to one including a protease inhibitor, with adjustment of one or more nucleoside reverse-transcriptase inhibitors (NRTIs). Virological and immunological failures were defined according to WHO criteria. We calculated cumulative probabilities of switching and hazard ratios with 95% CIs comparing routine viral load monitoring, targeted viral load monitoring, CD4 monitoring, and clinical monitoring, adjusting for programme and individual characteristics.

Findings: Of 297 825 eligible patients, 10 352 (3%) switched to second-line ART during 782 412 person-years of follow-up. Compared with CD4 monitoring, hazard ratios for switching were 3·15 (95% CI 2·92–3·40) for routine viral load monitoring, 1·21 (1·13–1·30) for targeted viral load monitoring, and 0·49 (0·43–0·56) for clinical monitoring. Of 6450 patients with confirmed virological failure, 58·0% (95% CI 56·5–59·6) switched by 2 years, and of 15 892 patients with confirmed immunological failure, 19·3% (18·5–20·0) switched by 2 years. Of 10 352 patients who switched, evidence of treatment failure based on one CD4 count or viral load measurement ranged from 86 (32%) of 268 patients with clinical monitoring to 3754 (84%) of 4452 with targeted viral load monitoring. Median CD4 counts at switching were 215 cells per μL (IQR 117–335) with routine viral load monitoring, but were lower with other types of monitoring (range 114–133 cells per μL).

Interpretation: Overall, few patients switched to second-line ART and switching happened late in the absence of routine viral load monitoring. Switching was more common and happened earlier after initiation of ART with targeted or routine viral load testing.

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Editor’s notes: Routine viral load monitoring should allow the early identification of first-line antiretroviral therapy (ART) failure, allowing prompt switch to second-line ART. Prolongation of treatment with a failing regimen compromises future therapeutic options (through the accumulation of drug resistance mutations) and potentially leads to increased morbidity and mortality. Previous reports from Africa have suggested that surprisingly few people switch to second-line therapy, even in programmes with routine viral load monitoring. This raises concerns that there are challenges on the ground with identification and management of ART failure.

This is a comprehensive analysis bringing together data from a number of well-characterised cohorts in Africa. In this analysis, switching to second-line ART was rare (3% over an average of almost three years follow-up). In programmes with routine viral load monitoring, only half of the people with confirmed virologic failure on first-line ART (two viral loads >1000 copies/ml) were recorded as having been switched to second-line ART. Furthermore, half of the people that were switched to a second-line regimen did not have evidence of confirmed virologic failure, suggesting that some may have been switched too early without first attempting adherence programmes which may achieve re-suppression on first-line ART. Unsurprisingly, rates of switching were lower in programmes with CD4+ monitoring (with or without targeted viral load testing) or clinical monitoring alone. 

While guidelines and algorithms around identification and management of first-line ART failure are relatively clear and straightforward, translating this into action on the ground seems to be difficult. At least part of this is likely to be due to the lack of tools to reliably measure adherence and the consequent difficulty that frontline health care workers have in identifying people that truly require a switch to second-line ART. Moreover, most programmes still do not routinely monitor indicators relating to virologic suppression or treatment failure and so this might not be seen as a priority by health care workers and programme managers. There is a need for research to explore how best to maximise virologic suppression in resource-constrained settings, as well as studies to evaluate the impact of programmes such as point-of-care viral load testing.

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Heterosexual anal sex is perceived to be a common practice in southern Tanzania

How long-distance truck drivers and villagers in rural southeastern Tanzania think about heterosexual anal sex: a qualitative study.

Mtenga S, Shamba D, Wamoyi J, Kakoko D, Haafkens J, Mongi A, Kapiga S, Geubbels E. Sex Transm Infect. 2015 Jun 25. pii: sextrans-2015-052055. doi: 10.1136/sextrans-2015-052055. [Epub ahead of print]

Objective: To explore ideas of truck drivers and villagers from rural Tanzania about heterosexual anal sex (HAS) and the associated health risks.

Methods: Qualitative study using 8 in-depth interviews (IDIs) and 2 focus group discussions (FGDs) with truck drivers and 16 IDIs and 4 FGDs with villagers from the Morogoro region. Study participants included 24 women and 46 men. Data analysis was performed thematically employing standard qualitative techniques.

Results: Reasons why men would practice HAS included sexual pleasure, the belief that anal sex is safer than vaginal sex, alternative sexual practice, exploration and proof of masculinity. Reasons why women would practice HAS included financial need, retaining a partner, alternative for sex during menses, pregnancy prevention and beauty enhancement because HAS is believed to 'fatten the female buttocks'. Most participants believed that condoms are not needed during HAS. This was linked to the ideas that infections only 'reside in wet places' (vagina) and that the anus is not 'conducive' for condom use; condoms reduce 'dryness' and 'friction' (pleasure) and may 'get stuck inside'.

Conclusions: The study participants reported practices and ideas about HAS that put them at risk for HIV and sexually transmitted infections. Greater attention to education about HAS is urgently needed in Tanzania, where this sexual practice is still regarded as a taboo. This study offers useful information that could be included in sex education programmes.

Abstract access

Editor’s notes: This paper explores the views of truck drivers and villagers on heterosexual anal sex. During in-depth interviews and focus group discussions in the Morogoro region of the United Republic of Tanzania the researchers asked participants about their opinions on sexual practices more broadly and specifically on heterosexual anal sex. The findings reveal that the participants perceive that heterosexual anal sex is becoming a common practice. In discussing why men practice heterosexual anal sex, the participants suggested that sexual pleasure, fulfilment of ideas of masculinity, and sexual exploration were the main reasons. For women, however, the participants suggested that the main reasons were financial, maintaining their relationships, pregnancy prevention, for sex during menstruation, and ‘fattening female buttocks’. When asked about HIV protection, many participants did not perceive that condom protection was feasible or required during heterosexual anal sex. The findings, while based on perceptions of the behaviour of ‘others’ and not on own accounts, suggest that heterosexual anal sex is more widespread in Tanzania than often assumed. And if it is a widespread and unprotected sexual practice, it is an important route of HIV infection.

Africa
United Republic of Tanzania
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Expansions in HIV treatment believed to reduce HIV stigma

HIV treatment scale-up and HIV-related stigma in sub-Saharan Africa: a longitudinal cross-country analysis.

Chan BT, Tsai AC, Siedner MJ. Am J Public Health. 2015 Jun 11:e1-e7. [Epub ahead of print] doi:10.2105/AJPH.2015.302716

Objectives: We estimated the association between antiretroviral therapy (ART) uptake and HIV-related stigma at the population level in sub-Saharan Africa.

Methods: We examined trends in HIV-related stigma and ART coverage in sub-Saharan Africa during 2003 to 2013 using longitudinal, population-based data on ART coverage from the Joint United Nations Program on HIV/AIDS and on HIV-related stigma from the Demographic and Health Surveys and AIDS Indicator Surveys. We fitted 2 linear regression models with country fixed effects, with the percentage of men or women reporting HIV-related stigma as the dependent variable and the percentage of people living with HIV on ART as the explanatory variable.

Results: Eighteen countries in sub-Saharan Africa were included in our analysis. For each 1% increase in ART coverage, we observed a statistically significant decrease in the percentage of women (b = -0.226; P = .007; 95% confidence interval [CI] = -0.383, -0.070) and men (b = -0.281; P = .009; 95% CI = -0.480, -0.082) in the general population reporting HIV-related stigma.

Conclusions: An important benefit of ART scale-up may be the diminution of HIV-related stigma in the general population. .

Abstract access 

Editor’s notes: Focused on sub-Saharan Africa, this study suggests that a benefit of the scale-up of antiretroviral therapy (ART) may have been a reduction in HIV-associated stigma. The authors combine data on HIV-associated stigma from the Demographic and Health Surveys and AIDS Indicator Surveys with data on ART coverage from UNAIDS. The results are presented for each of 18 countries and the authors suggest that increases in ART coverage are correlated with decreasing stigma, especially among countries with high HIV prevalence. The authors hypothesise that by allowing a person with HIV to experience a healthier life, ART reduces the stigma of HIV’s association with moral deviance. The authors also attribute knowledge to decreases in stigma.

While addressing an interesting and important question, the paper has some limitations. We suggest that participant responses to questions about whether they would be willing to care for someone “sick with AIDS”, and whether they would want a family member to keep an AIDS diagnosis “secret” cannot safely be interpreted as reflecting stigmatising attitudes or anticipated stigma. It would have been interesting to know if the methods used in the analysis could assess the role of ART relative to other factors in being associated with any changes over time in HIV-associated stigma.

Africa
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