Articles tagged as "Uganda"

Showing they care: lay-counsellors, home-based testing and the value of follow-up support

How home HIV testing and counselling with follow-up support achieves high testing coverage and linkage to treatment and prevention: a qualitative analysis from Uganda.

Ware NC, Wyatt MA, Asiimwe S, Turyamureeba B, Tumwesigye E, van Rooyen H, Barnabas RV, Celum CL. J Int AIDS Soc. 2016 Jun 28;19(1):20929. doi: 10.7448/IAS.19.1.20929. eCollection 2016.

Introduction: The successes of HIV treatment scale-up and the availability of new prevention tools have raised hopes that the epidemic can finally be controlled and ended. Reduction in HIV incidence and control of the epidemic requires high testing rates at population levels, followed by linkage to treatment or prevention. As effective linkage strategies are identified, it becomes important to understand how these strategies work. We use qualitative data from The Linkages Study, a recent community intervention trial of community-based testing with linkage interventions in sub-Saharan Africa, to show how lay counsellor home HIV testing and counselling (home HTC) with follow-up support leads to linkage to clinic-based HIV treatment and medical male circumcision services.

Methods: We conducted 99 semi-structured individual interviews with study participants and three focus groups with 16 lay counsellors in Kabwohe, Sheema District, Uganda. The participant sample included both HIV+ men and women (N=47) and HIV-uncircumcised men (N=52). Interview and focus group audio-recordings were translated and transcribed. Each transcript was summarized. The summaries were analyzed inductively to identify emergent themes. Thematic concepts were grouped to develop general constructs and framing propositional statements.

Results: Trial participants expressed interest in linking to clinic-based services at testing, but faced obstacles that eroded their initial enthusiasm. Follow-up support by lay counsellors intervened to restore interest and inspire action. Together, home HTC and follow-up support improved morale, created a desire to reciprocate, and provided reassurance that services were trustworthy. In different ways, these functions built links to the health service system. They worked to strengthen individuals' general sense of capability, while making the idea of accessing services more manageable and familiar, thus reducing linkage barriers.

Conclusions: Home HTC with follow-up support leads to linkage by building "social bridges," interpersonal connections established and developed through repeated face-to-face contact between counsellors and prospective users of HIV treatment and male circumcision services. Social bridges link communities to the service system, inspiring individuals to overcome obstacles and access care.

Abstract  Full-text [free] access 

Editor’s notes: How can people be encouraged once they have received a positive HIV-test result to link and stay in treatment? This is a crucial question as the momentum for everyone living with HIV to be on antiretroviral therapy grows.  The authors of this paper demonstrate clearly and succinctly the value of personal contact in supporting people to test and the link to care. Lay-counsellors paying visits to people’s homes provided the encouragement to help some people to link to care. The home visits were seen by people visited as a sign that ‘someone cared’.  The personal attention and information provided promoted trust. The visits also created a sense of obligation: the person visited felt they should do something in return to please the counsellor.

Increasing numbers of people living with HIV does not necessarily mean that it is easier for someone coping with a positive-test result to link to care. We should not underestimate the continued burden that an HIV-positive test result places on individuals.  Many barriers remain both to testing and sustaining a link to care. The authors of this paper provide examples of how to overcome some of those barriers. However, while this paper provides encouraging findings on the value of the home-based activity, the findings also pose a challenge. Can such follow-up support services, which demand more than a single visit, be provided widely enough to benefit all people who need such attention and support? 

Africa
Uganda
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Demand-side activities are essential for achieving population level impact of HIV prevention tools

Interventions to strengthen the HIV prevention cascade: a systematic review of reviews.

Krishnaratne S, Hensen B, Cordes J, Enstone J, Hargreaves JR. Lancet HIV. 2016 Jul;3(7):e307-17. doi: 10.1016/S2352-3018(16)30038-8.

Background: Much progress has been made in interventions to prevent HIV infection. However, development of evidence-informed prevention programmes that translate the efficacy of these strategies into population effect remain a challenge. In this systematic review, we map current evidence for HIV prevention against a new classification system, the HIV prevention cascade.

Methods: We searched for systematic reviews on the effectiveness of HIV prevention interventions published in English from Jan 1, 1995, to July, 2015. From eligible reviews, we identified primary studies that assessed at least one of: HIV incidence, HIV prevalence, condom use, and uptake of HIV testing. We categorised interventions as those seeking to increase demand for HIV prevention, improve supply of HIV prevention methods, support adherence to prevention behaviours, or directly prevent HIV. For each specific intervention, we assigned a rating based on the number of randomised trials and the strength of evidence.

Findings: From 88 eligible reviews, we identified 1964 primary studies, of which 292 were eligible for inclusion. Primary studies of direct prevention mechanisms showed strong evidence for the efficacy of pre-exposure prophylaxis (PrEP) and voluntary medical male circumcision. Evidence suggests that interventions to increase supply of prevention methods such as condoms or clean needles can be effective. Evidence arising from demand-side interventions and interventions to promote use of or adherence to prevention tools was less clear, with some strategies likely to be effective and others showing no effect. The quality of the evidence varied across categories.

Interpretation: There is growing evidence to support a number of efficacious HIV prevention behaviours, products, and procedures. Translating this evidence into population impact will require interventions that strengthen demand for HIV prevention, supply of HIV prevention technologies, and use of and adherence to HIV prevention methods.

Abstract  Full-text [free] access

Editor’s notes: Demand, supply and use of programmes are crucial for the uptake and effective use of HIV prevention strategies. This paper presents an impressive undertaking in which the authors conducted a review of systematic reviews on the evidence for the effectiveness of HIV prevention programmes across the multiple steps in an HIV prevention cascade. This particular prevention cascade allocates programmes into demand-side, supply-side, adherence, and direct HIV prevention technologies. This was published in a separate paper in conjunction with this review. The review found that there is strong evidence with regards to which direct HIV prevention technologies are efficacious, as well as maps where adherence and supply-side programmes have been effective. A primary gap was noted on the demand-side of the cascade (e.g. information, education and communication, and peer-based activities to increase demand for medical male circumcision) where studies have not resulted in reducing HIV incidence or prevalence. There remains a need to understand why, despite supply, there is low uptake of some HIV prevention strategies, and for evaluation of novel activities to increase demand.  

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Negative police activity a structural determinant of HIV

Policing practices as a structural determinant for HIV among sex workers: a systematic review of empirical findings.

Footer KH, Silberzahn BE, Tormohlen KN, Sherman SG. J Int AIDS Soc. 2016 Jul 18;19(4 Suppl 3):20883. doi: 10.7448/IAS.19.4.20883. eCollection 2016.

Introduction: Sex workers are disproportionately infected with HIV worldwide. Significant focus has been placed on understanding the structural determinants of HIV and designing related interventions. Although there is growing international evidence that policing is an important structural HIV determinant among sex workers, the evidence has not been systematically reviewed.

Methods: We conducted a systematic review of quantitative studies to examine the effects of policing on HIV and STI infection and HIV-related outcomes (condom use; syringe use; number of clients; HIV/STI testing and access) among cis and trans women sex workers. Databases included PubMed, Embase, Scopus, Sociological Abstracts, Popline, Global Health (OVID), Web of Science, IBSS, IndMed and WHOLIS. We searched for studies that included police practices as an exposure for HIV or STI infection or HIV-related outcomes.

Results: Of the 137 peer-reviewed articles identified for full text review, 14 were included, representing sex workers' experiences with police across five settings. Arrest was the most commonly explored measure with between 6 and 45% of sex workers reporting having ever been arrested. Sexual coercion was observed between 3 and 37% of the time and police extortion between 12 and 28% across studies. Half the studies used a single measure to capture police behaviours. Studies predominantly focused on "extra-legal policing practices," with insufficient attention to the role of "legal enforcement activities". All studies found an association between police behaviours and HIV or STI infection, or a related risk behaviour.

Conclusions: The review points to a small body of evidence that confirms policing practices as an important structural HIV determinant for sex workers, but studies lack generalizability with respect to identifying those police behaviours most relevant to women's HIV risk environment.

Abstract  Full-text [free] access 

Editor’s notes: The paper reports on a systematic review, which explored how quantitative research to date has operationalized the measurement of law enforcement practices as a structural determinant of HIV for female (including transgender) sex workers. The authors reviewed 14 quantitative studies using policing practices as a micro-structural determinant for HIV risk among sex workers. They found substantial heterogeneity in both the police measures and the health outcomes considered by the different studies. Overall, the studies found that police measures were regularly reported by sex workers, with an average of 34% of sex workers experiencing at least one police measure. They found that arrest was the most commonly explored measure in the studies. Following this, sexual coercion and then police extortion were important.

The studies reported that these police measures were consistently, positively, associated with either HIV infection or STI symptoms or with inconsistent condom use. Having ever been arrested, sexual coercion, police extortion, and syringe confiscation was associated with an increased risk of acquiring an HIV infection or an STI. These measures, and displacement by the police, were also associated with inconsistent condom use. Intervening on interactions between sex workers and the police reduced HIV risk over the time of the programme.

The authors argue that these findings point to the potentially pivotal role that the police have as a structural determinant for HIV in vulnerable populations. However, they argue that nearly all the papers identified in this review fail to take account of the complexities of the risk environment in which law enforcement occurs. The authors thus suggest a need for better measures for legal and extra-legal enforcement practices as mechanisms through which sex workers’ HIV risk is mediated.

Africa, Asia, Europe, Latin America
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Research on intimate partner violence prevention - complex ethical issues

Ethical challenges of randomized violence intervention trials: examining the SHARE intervention in Rakai, Uganda.

Wagman JA, Paul A, Namatovu F, Ssekubugu R, Nalugoda F. Psychol Violence. 2016 Jul;6(3):442-451.

Objective: We identify complexities encountered, including unanticipated crossover between trial arms and inadequate 'standard of care' violence services, during a cluster randomized trial (CRT) of a community-level intimate partner violence (IPV) and HIV prevention intervention in Uganda.

Methods: Concepts in public health ethics - beneficence, social value of research, fairness, standard of care, and researcher responsibilities for post-trial benefits - are used to critically reflect on lessons learned and guide discussion on practical and ethical challenges of violence intervention CRTs.

Results: Existing ethical guidelines provide incomplete guidance for responding to unexpected crossover in CRTs providing IPV services. We struggled to balance duty of care with upholding trial integrity, and identifying and providing appropriate standard of care. While we ultimately offered short-term IPV services to controls, we faced additional challenges related to sustaining services beyond the 'short-term' and post-trial.

Conclusion: Studies evaluating community-level violence interventions, including those combined with HIV reduction strategies, are limited yet critical for developing evidence-based approaches for effectively preventing IPV. Although CRTs are a promising design, further guidance is needed to implement trials that avoid introducing tensions between validity of findings, researchers' responsibilities to protect participants, and equitable distribution of CRT benefits.

Abstract access

Editor’s notes: Data from 81 countries indicate that 30% of women aged 15 and above have experienced physical and/or sexual intimate partner violence in their lifetime. Settings with the highest intimate partner violence prevalence were found to be in sub-Saharan Africa, the region most affected by HIV.  Intimate partner violence is now widely accepted to be both a precursor to and sequelae of HIV infection. In response, a growing number of combination intimate partner violence and HIV prevention programmes have been implemented and systematically evaluated through randomised trials. The authors of this paper discuss some of the practical, ethical and safety challenges introduced by randomised trials on violence prevention, drawing on experience from a project in rural Uganda.

International guidelines have been established for the ethical conduct of biomedical research involving human subjects. The subject of violence against women and the method of randomised controlled trials are not easily resolved with these standard guidelines. In response, specialised recommendations for conducting safe and ethical population-based survey research on violence against women have been developed. These guidelines are an important development, but randomised trials to evaluate intimate partner violence prevention programmes face practical challenges in responding to common research ethics and safety considerations. These include: what to offer control communities in a trial investigating the optimal delivery approach for an activity likely to be effective in a setting with no standard of care. This needs to be done while maintaining the integrity of the study.

Drawing from their experience of the SHARE trial in the Rakai District in Uganda, the authors offer three reflections from lessons learned. (1) Ongoing need to formally update programmes that address multiple and overlapping vulnerabilities of individuals experiencing intimate partner violence and at risk of, or living with, HIV. (2) Cluster-randomised trials are a promising approach for programme evaluation but introduce numerous challenges with practical and ethical implications. (3) Given widespread underreporting of intimate partner violence, evaluation of violence programmes may have particularly high levels of unanticipated demand. The authors advocate for a framework of relevant considerations to be developed to guide researchers working on activities to reduce intimate partner violence. These guidelines should address potentially common challenges. They also encourage researchers to share field lessons arising from their studies in order to a) contribute to the development of this framework b) for revising and improving guidelines for the ethical conduct of intimate partner violence programmes in low resource settings.

Africa
Uganda
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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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Increased adolescent testing

Increased adolescent HIV testing with a hybrid mobile strategy in Uganda and Kenya.

Kadede K, Ruel T, Kabami J, Ssemmondo E, Sang N, Kwarisiima D, Bukusi E, Cohen CR, Liegler T, Clark TD, Charlebois ED, Petersen ML, Kamya MR, Havlir DV, Chamie G, SEARCH team. AIDS. 2016 Jun 1. [Epub ahead of print]

Objective: We sought to increase adolescent HIV testing across rural communities in east Africa and identify predictors of undiagnosed HIV.

Design: Hybrid mobile testing.

Methods: We enumerated 116 326 adolescents (10-24 years) in 32 communities of Uganda and Kenya (SEARCH: NCT01864603): 98 694 (85%) reported stable (≥6 months of prior year) residence. In each community we performed hybrid testing: 2- week multi-disease community health campaign (CHC) that included HIV testing, followed by home-based testing of CHC non-participants. We measured adolescent HIV testing coverage and prevalence, and determined predictors of newly-diagnosed HIV among HIV+ adolescents using multivariable logistic regression.

Results: 86 421 (88%) stable adolescents tested for HIV; coverage was 86%, 90%, and 88% in early (10-14), mid (15-17) and late (18-24) adolescents, respectively. Self- reported prior testing was 9%, 26%, and 55% in early, mid and late adolescents tested, respectively. HIV prevalence among adolescents tested was 1.6% and 0.6% in Ugandan women and men, and 7.1% and 1.5% in Kenyan women and men, respectively. Prevalence increased in mid-adolescence for women, and late adolescence for men. Among HIV+ adolescents, 58% reported newly-diagnosed HIV. In multivariate analysis of HIV+ adolescents, predictors of newly-diagnosed HIV included male gender (OR = 1.97 [95%CI: 1.42-2.73]), Ugandan residence (OR = 2.63 [95%CI: 2.08-3.31]), and single status (OR = 1.62 [95%CI: 1.23-2.14] vs. married).

Conclusions: The SEARCH hybrid strategy tested 88% of stable adolescents for HIV, a substantial increase over the 28% reporting prior testing. The majority (57%) of HIV+ adolescents were new diagnoses. Mobile HIV testing for adults should be leveraged to reach adolescents for HIV treatment and prevention.

Abstract access 

Editor’s notes: Ending the AIDS epidemic requires much greater focus on adolescents, among whom HIV associated deaths is a leading cause of death in sub-Saharan Africa. Critical behaviours that are likely to impact on future health, such as risky sexual behaviour, often begin in adolescence. However, it is estimated that less than a third of adolescents in sub-Saharan Africa have been tested for HIV. In this paper, the authors report the impact of a hybrid community-based mobile testing approach to increase HIV testing among adolescents in rural communities in East Africa. This model, which does not rely on accessing schools or clinics, is very suitable for this age group, given the low rates of school attendance among female adolescents and the low use of clinic-based services by adolescents. A high rate of HIV testing was achieved, and testing for HIV in a multi-disease context may have enabled adolescents to access testing without fear of being stigmatised. However, uptake of testing is only the first stage in the HIV prevention and treatment cascade, and further data on the proportion of people testing positive who link to care and start treatment, and people testing negative who link to prevention services, are necessary. 

Africa
Kenya, Uganda
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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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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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Intimate partner violence is a challenge to PrEP adherence

Intimate partner violence and adherence to HIV pre-exposure prophylaxis (PrEP) in African women in HIV serodiscordant relationships: a prospective cohort study.

Roberts ST, Haberer J, Celum C, Mugo N, Ware NC, Cohen CR, Tappero JW, Kiarie J, Ronald A, Mujugira A, Tumwesigye E, Were E, Irungu E, Baeten JM. J Acquir Immune Defic Syndr. 2016 May 26. [Epub ahead of print]

Background: Intimate partner violence (IPV) is associated with higher HIV incidence, reduced condom use, and poor adherence to antiretroviral therapy and other medications. IPV may also affect adherence to pre-exposure prophylaxis (PrEP).

Methods: We analyzed data from 1785 HIV-uninfected women enrolled in a clinical trial of PrEP among African HIV-serodiscordant couples. Experience of verbal, physical, or economic IPV was assessed at monthly visits by face-to-face interviews. Low PrEP adherence was defined as clinic-based pill count coverage <80% or plasma tenofovir levels <40 ng/mL. The association between IPV and low adherence was analyzed using generalized estimating equations, adjusting for potential confounders. In-depth interview transcripts were examined to explain how IPV could impact adherence.

Results: 16% of women reported IPV during a median of 34.8 months of follow-up (IQR 27.0 - 35.0). Overall, 7% of visits had pill count coverage <80% and 32% had plasma tenofovir <40 ng/mL. Women reporting IPV in the past 3 months had increased risk of low adherence by pill count (adjusted RR 1.49, 95% CI 1.17-1.89) and by plasma tenofovir (adjusted RR 1.51, 95% CI 1.06-2.15). Verbal, economic, and physical IPV were all associated with low adherence. However, the impact of IPV diminished and was not statistically significant 3 months after the reported exposure. In qualitative interviews, women identified several ways in which IPV affected adherence, including stress and forgetting, leaving home without pills, and partners throwing pills away.

Conclusion: Women who reported recent IPV in the Partners PrEP Study were at increased risk of low PrEP adherence. Strategies to mitigate PrEP non-adherence in the context of IPV should be evaluated.

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Editor’s notes: The high rates of HIV infection in women underscore persistent gender inequalities, in particular that of violence against women. Intimate partner violence (IPV) puts women at increased risk of HIV infection. Further, among women living with HIV, IPV has also been associated with lower rates of treatment uptake and adherence to antiretroviral therapy (ART). The interaction between IPV and HIV is complex, and includes biological, socio-economic and cultural mechanisms. This is the first study to examine the association between IPV and adherence to HIV pre-exposure prophylaxis (PrEP).  Women who had experienced IPV in the past three months were 50% more likely than women who had never experienced IPV to have poor adherence, as measured by both pills counts and drug levels in the blood.  Recent IPV was also associated with an increase in the risk of HIV infection.  Women in the study were in stable, serodiscordant relationships, had enrolled in the study together with their partners, and were using PrEP with their partner’s consent. The proportion of women reporting IPV during the study was much lower than national estimates in the region.  These findings are thus of concern for PrEP demonstration projects focusing on key populations at high risk of HIV, who may experience higher rates of IPV and be less likely to have partner support. 

PrEP is a key element of combination HIV prevention strategies in high-risk populations, but requires high adherence in order to be effective. Programmes focusing on promoting PrEP adherence in women who have experienced violence are urgently needed.  More broadly, HIV prevention programmes should be expanded to integrate IPV prevention as an important component to reducing women’s risk of HIV.

Africa
Kenya, Uganda
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