Articles tagged as "Africa"

A cohort-based approach to the HIV treatment cascade finds linkage the major bottleneck

From HIV infection to therapeutic response: a population-based longitudinal HIV cascade-of-care study in KwaZulu-Natal, South Africa.

Haber N, Tanser F, Bor J, Naidu K, Mutevedzi T, Herbst K, Porter K, Pillay D, Barnighausen T. Lancet HIV. 2017 Jan 30. pii: S2352-3018(16)30224-7. doi: 10.1016/S2352-3018(16)30224-7. [Epub ahead of print]

Background: Standard approaches to estimation of losses in the HIV cascade of care are typically cross-sectional and do not include the population stages before linkage to clinical care. We used individual-level longitudinal cascade data, transition by transition, including population stages, both to identify the health-system losses in the cascade and to show the differences in inference between standard methods and the longitudinal approach.

Methods: We used non-parametric survival analysis to estimate a longitudinal HIV care cascade for a large population of people with HIV residing in rural KwaZulu-Natal, South Africa. We linked data from a longitudinal population health surveillance (which is maintained by the Africa Health Research Institute) with patient records from the local public-sector HIV treatment programme (contained in an electronic clinical HIV treatment and care database, ARTemis). We followed up all people who had been newly detected as having HIV between Jan 1, 2006, and Dec 31, 2011, across six cascade stages: three population stages (first positive HIV test, HIV status knowledge, and linkage to care) and three clinical stages (eligibility for antiretroviral therapy [ART], initiation of ART, and therapeutic response). We compared our estimates to cross-sectional cascades in the same population. We estimated the cumulative incidence of reaching a particular cascade stage at a specific time with Kaplan-Meier survival analysis.

Findings: Our population consisted of 5205 individuals with HIV who were followed up for 24 031 person-years. We recorded 598 deaths. 4539 individuals gained knowledge of their positive HIV status, 2818 were linked to care, 2151 became eligible for ART, 1839 began ART, and 1456 had successful responses to therapy. We used Kaplan-Meier survival analysis to adjust for censorship due to the end of data collection, and found that 8 years after testing positive in the population health surveillance, 16% had died. Among living patients, 82% knew their HIV status, 45% were linked to care, 39% were eligible for ART, 35% initiated ART, and 33% had reached therapeutic response. Median times to transition for these cascade stages were 52 months, 52 months, 20 months, 3 months, and 9 months, respectively. Compared with the population stages in the cascade, the transitions across the clinical stages were fast. Over calendar time, rates of linkage to care have decreased and patients presenting for the first time for care were, on average, healthier.

Interpretation: HIV programmes should focus on linkage to care as the most important bottleneck in the cascade. Cascade estimation should be longitudinal rather than cross-sectional and start with the population stages preceding clinical care.

Abstract access  

Editor’s notes: The HIV treatment cascade outlines the stages required to effectively treat HIV, starting with HIV testing and ending with viral suppression. The cascade has become a widely-used framework to evaluate the performance of HIV care programmes, to measure progress towards universal treatment coverage, and to identify gaps in care. However, methods for constructing the HIV treatment cascade vary considerably. The majority of cascade analyses rely on cross-sectional data obtained from different sources. The authors present the first analysis of the HIV treatment cascade that follows individuals longitudinally from the time of HIV infection across all stages of the cascade. By linking data from a demographic surveillance system with electronic clinical records, they are able to describe the cascade for a large population-based cohort of people living with HIV in rural KwaZulu-Natal, South Africa.  They demonstrate that, once people became eligible for ART, the rates of ART initiation, and of viral suppression after initiation, were high. Half of individuals started ART within three months of becoming eligible, and 94% of people on therapy achieved virologic suppression. In addition, retention in care improved over time. However, a key finding is that rates of HIV diagnosis and linkage to care worsened over time, and less than 50% of people had linked to care within eight years of HIV infection, despite 82% being aware of their status. As illustrated by cascade analyses in other settings, increasing linkage to care remains a major challenge for reaching the UNAIDS 90-90-90 treatment target in sub-Saharan Africa.  

In addition to highlighting linkage as the most important bottleneck in the HIV care cascade in this part of rural KwaZulu-Natal, the study illustrates some of the weaknesses in traditional cascade analyses based on cross-sectional data. The cross-sectional cascade is constructed from snapshots of different groups of people in a particular moment in time, rather than describing what happens to the same group of people over time. The authors illustrate how a cross-sectional analysis can give a misleading impression of improvement in the cascade over time, because it fails to take account of changes in the population. The longitudinal cascade, by following the same group of people, provides important insights into the true progression of the cascade over time, and identification of losses along each stage. However, the individual-level longitudinal data necessary for this type of analysis requires a large investment in data collection, and is unlikely to be feasible in most resource-limited settings.

Africa
South Africa
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Adolescents and PMTCT services: where are the gaps?

PMTCT service uptake among adolescents and adult women attending antenatal care in selected health facilities in Zimbabwe.

Musarandega R, Machekano R, Chideme M, Muchuchuti C, Mushavi A, Mahomva A, Guay L. J Acquir Immune Defic Syndr. 2017 Feb 20. doi: 10.1097/QAI.0000000000001327. [Epub ahead of print]

Background: Age-disaggregated analyses of prevention of mother-to-child transmission (PMTCT) program data to assess the uptake of HIV services by pregnant adolescent women are limited but are critical to understanding the unique needs of this vulnerable, high risk population.

Methods: We conducted a retrospective analysis of patient-level PMTCT data collected from 2011 to 2013 in 36 health facilities in 5 districts of Zimbabwe using an electronic database. We compared uptake proportions for PMTCT services between adolescent (< 19 years) and adult (> 19 years) women. Multivariable binomial regression analysis was used to estimate the association of the women's age group with each PMTCT service indicator.

Results: The study analysed data from 22 215 women aged 12 to 50 years (22.5% adolescents). Adolescents were more likely to present to ANC before 14 weeks gestational age compared to older women (adjusted relative risk (aRR)=1.34; 95% confidence interval (CI): 1.22-1.47) with equally low rates of completion of four ANC visits. Adolescents were less likely to present with known HIV status (aRR=0.34; 95% CI: 0.29-0.41) but equally likely to be HIV tested in ANC. HIV prevalence was 5.5% in adolescents versus 20.1% in adults. While > 84% of both HIV-positive groups received ARVs for PMTCT, 44% of eligible adolescents were initiated on ART versus 51.3% of eligible adults, though not statistically significant.

Conclusions: Pregnant adolescents must be a priority for primary HIV prevention services and expanded HIV treatment services among pregnant women to achieve an AIDS-free generation in Zimbabwe and similar high HIV burden countries.

Abstract access  

Editor’s notes: Young women continue to be a key population at risk of acquiring HIV, and contribute approximately one-third of all new infections in sub-Saharan Africa. Young women face multiple legal, economic and social vulnerabilities that place them not only at higher risk of acquiring HIV but may also have an impact on their ability to access antenatal care (ANC) services and programmes to prevent mother-to-child HIV transmission (PMTCT) if they get pregnant. This in turn has implications for the goal of eliminating paediatric HIV infection.

This retrospective study compared the uptake of PMTCT services between adolescents (people aged 19 years and below) and older women accessing ANC in 36 public sector services across Zimbabwe. The study was conducted between 2011 and 2013, when PMTCT guidelines recommended Option A. Option A called for life-long antiretroviral therapy (ART) for women who were ART-eligible based on immunological or clinical criteria; or, for people ineligible, zidovudine monotherapy through pregnancy followed by single dose nevirapine at the onset of labour. It is no longer formally recommended by World Health Organization (WHO), although it is still used in some countries.      

Nearly a quarter of all women were adolescents and over 80% were on their first pregnancy or primigravid. Adolescent women were 34% more likely to attend their first ANC visit by 14 weeks of gestational age compared to adult women. But among both groups, only about 10% attended their first ANC visit in the first trimester and less than 40% attended the four antenatal visits recommended by WHO. Notably, knowledge of HIV status prior to the first ANC attendance was 66% lower in adolescent women, even after adjusting for parity and facility type, with only 3.1% aware of their HIV status. In addition, the proportion of women who were known HIV-positive and taking ART was also lower, although this may be due partly to fewer adolescents being eligible for ART. The uptake of HIV testing (over 95%) and uptake of zidovudine prophylaxis was high among all women. However, there was a suggestion that adolescents were less likely than older women to start ART if they were eligible, although this was not statistically significant. Indeed, several studies in the region have demonstrated lower levels of ART initiation among pregnant adolescents compared to older women.  

Older women would have been more likely to have undergone HIV testing in previous pregnancies. However, even after adjusting for parity, this study demonstrates that adolescents are less likely to have previously accessed HIV testing. Common barriers to testing highlighted by other studies include lack of information, unavailability of HIV testing services, unfriendly HIV testing environments in health facilities and the need for parental consent. Lack of knowledge of HIV status prior to pregnancy is also a missed opportunity for family planning, and initiation of ART prior to pregnancy. The substantial difference in HIV prevalence among adolescents compared to older women highlights the critical need for implementing prevention programmes such as pre-exposure prophylaxis among young women in high HIV prevalence settings. While adolescents are less likely to be tested for HIV in the general population than adults, this study illustrates that when HIV testing is offered in appropriate, supportive environments, uptake is high.

Overall, the uptake of HIV testing and of prophylaxis were high, demonstrating the potential for eliminating infections in children. A major limitation is that this analysis was limited to women who had sought antenatal care. Promoting early ANC attendance is important to allow early ART initiation, to reduce the risk of intrauterine HIV transmission. Following a positive HIV test result, particular attention is necessary to ensure linkage to care and support for sustained adherence to ART.

Africa
Zimbabwe
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Gender and sexuality are central considerations in voluntary medical male circumcision campaigns

Discourses of masculinity, femininity and sexuality in Uganda's Stand Proud, Get Circumcised campaign.

Rudrum S, Oliffe JL, Benoit C. Cult Health Sex. 2017 Feb;19(2):225-239. doi: 10.1080/13691058.2016.1214748. Epub 2016 Aug 11.

This paper analyses discourses of masculinity, femininity and sexuality in Stand Proud, Get Circumcised, a public health campaign promoting circumcision as an HIV-prevention strategy in Uganda. The campaign includes posters highlighting the positive reactions of women to circumcised men, and is intended to support the national rollout of voluntary medical male circumcision. We offer a critical discourse analysis of representations of masculinity, femininity and sexuality in relation to HIV prevention. The campaign materials have a playful feel and, in contrast to ABC (Abstain, Be faithful, Use condoms) campaigns, acknowledge the potential for pre-marital and extra-marital sex. However, these posters exploit male anxieties about appearance and performance, drawing on hegemonic masculinity to promote circumcision as an idealised body aesthetic. Positioning women as the campaign's face reasserts a message that women are the custodians of family health and simultaneously perpetuates a norm of estrangement between men and their health. The wives' slogan, 'we have less chance of getting HIV', is misleading, because circumcision only directly prevents female-to-male HIV transmission. Reaffirming hegemonic notions of appearance- and performance-based heterosexual masculinity reproduces existing unsafe norms about masculinity, femininity and sexuality. In selling male circumcision, the posters fail to promote an overall HIV-prevention message.

Abstract access  

Editor’s notes: In this article, the authors provide a feminist, critical discourse analysis of Uganda’s 2012 ‘Stand Proud, Get Circumcised’ campaign. The campaign promoted voluntary medical male circumcision as an HIV prevention strategy. The authors look at how masculinity, femininity, gender relations and acceptable sexuality are configured.

The authors note that even within this prevention strategy that is male-only, men were largely absent with women representing the campaign’s public face. They argue that this is in keeping with widespread messages about gender and HIV in the region that position women as the central actors. That said, messages about normative masculinity were evident and focussed on anxieties about men’s penises as a site for the physical assessment of masculine sexual prowess or failure. Together with a lack of reference to gay men, this positioning affirms dominant ideals of what a ‘man’ is: straight, circumcised, sexually active. The authors also observe that discourses of femininity, while departing from women-as-victims and introducing sexual pleasure, were relevant only for women’s ability to impose conditions for sex, thereby influencing men to circumcise. The authors therefore argue that the discourses around gender and sexuality, rather than being socially transformative, were instead positioned to produce existing norms around sex. This positioning offers little hope for creating structural changes to gender relations that might hinder HIV transmission. The authors also express concern that the posters sell circumcision, but neglect to highlight the evidence that women are not directly protected, or that other tools of prevention including condoms remain important. 

Africa
Uganda
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Sexual risk behaviour, HIV prevalence unchanged in Kenya as more men are circumcised

Changes in male circumcision prevalence and risk compensation in the Kisumu, Kenya population, 2008-2013.

Westercamp M, Jaoko W, Mehta S, Abuor P, Siambe P, Bailey RC. J Acquir Immune Defic Syndr. 2017 Feb 1;74(2):e30-e37. doi: 10.1097/QAI.0000000000001180.

Background: Three randomized controlled trials showed that voluntary medical male circumcision (VMMC) reduces the risk of female-to-male HIV transmission by approximately 60%. However, data from communities where VMMC programs have been implemented are needed to assess changes in circumcision prevalence and whether men and women compensate for perceived reductions in risk by increasing their HIV risk behaviors.

Methods: Scale-up of free VMMC began in Kisumu, Kenya in 2008. Between 2009 and 2013, a sequence of 3 unlinked cross-sectional surveys were conducted. All individuals 15-49 years of age residing in randomly selected households were interviewed and offered HIV testing. Male circumcision status was confirmed by examination. Design-adjusted bivariate comparisons and multivariable analyses were used for statistical inference.

Results: The prevalence of male circumcision increased from 32% (95% CI: 26% to 38%) in 2009 to 60% (95% CI: 56% to 63%) in 2013. The adjusted prevalence ratio of HIV and genital ulcer disease in circumcised compared with uncircumcised men was 0.48 (95% CI: 0.36 to 0.66) and 0.51 (95% CI: 0.37 to 0.69), respectively. There was no association between circumcision status and sexual behaviors, HIV knowledge, or indicators of risk perception.

Conclusions: The conditions necessary for the VMMC program to have a significant public health impact are present in Kisumu, Kenya. Between 2009 and 2013, circumcision prevalence increased from 30% to 60%; HIV prevalence in circumcised men was half that of uncircumcised men, and there was no or minimal sexual risk compensation.

Abstract access  

Editor’s notes: Evidence of the protective effect of male circumcision on HIV incidence has led many countries in sub-Saharan Africa to promote voluntary medical male circumcision (VMMC). Mathematical models have illustrated that VMMC programmes will reduce HIV prevalence over time when VMMC uptake is high, and when men who have had VMMC do not substantially increase their sexual risk behaviours. In Kenya, the VMMC programme has exceeded its targets, with over 1.1 million procedures conducted between 2008 and 2015. In this paper, the authors assessed the assumptions behind the models, using data from three population-based cross-sectional surveys conducted among male and female adult residents of Kisumu, Kenya between 2009 and 2013. During this time, VMMC prevalence among men almost doubled from 32% to 60%, yet, HIV prevalence did not change for men or women. In addition, men who had VMMC reported the same levels of sexual risk behaviours as men who were not circumcised, yet had half the prevalence of HIV and genital ulcer disease. This study re-confirms the individual benefit of VMMC in a non-trial population, while demonstrating no evidence for sexual risk compensation. This study is notable for its large sample size, population-based sampling design, visual confirmation of circumcision status, and HIV testing protocol. Studies of longer duration are required to confirm the population-level impacts of VMMC– i.e. a protection benefit beyond men who had VMMC - on HIV prevalence, and to monitor the longer-term trend in sexual risk behaviours.

Africa
Kenya
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The value of religious leaders in promoting healthy behaviour

Educating religious leaders to promote uptake of male circumcision in Tanzania: a cluster randomised trial.

Downs JA, Mwakisole AH, Chandika AB, Lugoba S, Kassim R, Laizer E, Magambo KA, Lee MH, Kalluvya SE, Downs DJ, Fitzgerald DW. Lancet. 2017 Mar 18;389(10074):1124-1132.doi: 10.1016/S0140-6736(16)32055-4. Epub 2017 Feb 15

Background: Male circumcision is being widely deployed as an HIV prevention strategy in countries with high HIV incidence, but its uptake in sub-Saharan Africa has been below targets. We did a study to establish whether educating religious leaders about male circumcision would increase uptake in their village.

Methods: In this cluster randomised trial in northwest Tanzania, eligible villages were paired by proximity (<60 km) and the time that a free male circumcision outreach campaign from the Tanzanian Ministry of Health became available in their village. All villages received the standard male circumcision outreach activities provided by the Ministry of Health. Within the village pairs, villages were randomly assigned by coin toss to receive either additional education for Christian church leaders on scientific, religious, and cultural aspects of male circumcision (intervention group), or standard outreach only (control group). Church leaders or their congregations were not masked to random assignment. The educational intervention consisted of a 1-day seminar co-taught by a Tanzanian pastor and a Tanzanian clinician who worked with the Ministry of Health, and meetings with the study team every 2 weeks thereafter, for the duration of the circumcision campaign. The primary outcome was the proportion of male individuals in a village who were circumcised during the campaign, using an intention-to-treat analysis that included all men in the village. This trial is registered with ClinicalTrials.gov, number NCT 02167776.

Findings: Between June 15, 2014, and Dec 10, 2015, we provided education for church leaders in eight intervention villages and compared the outcomes with those in eight control villages. In the intervention villages, 52.8% (30 889 of 58 536) of men were circumcised compared with 29.5% (25 484 of 86 492) of men in the eight control villages (odds ratio 3.2 [95% CI, 1.4-7.3]; p=0.006).

Interpretation: Education of religious leaders had a substantial effect on uptake of male circumcision, and should be considered as part of male circumcision programmes in other sub-Saharan African countries. This study was conducted in one region in Tanzania; however, we believe that our intervention is generalisable. We equipped church leaders with knowledge and tools, and ultimately each leader established the most culturally-appropriate way to promote male circumcision. Therefore, we think that the process of working through religious leaders can serve as an innovative model to promote healthy behaviour, leading to HIV prevention and other clinically relevant outcomes, in a variety of settings.

Abstract  Full-text [free] access 

Editor’s notes: Voluntary medical male circumcision is recommended for HIV prevention in settings with high prevalence of HIV. However, uptake of male circumcision has been lower in some settings than is optimal to reduce population-level HIV incidence. Religious beliefs can be an important barrier to acceptance of VMMC. In this community randomised trial, the investigators sought to improve uptake of male circumcision in Tanzania through an education programme delivered to religious leaders alongside a VMMC outreach campaign. Following educational seminars, each religious leader was asked to decide how best to address issues of male circumcision in his or her own community. Overall, there was a three-fold increase in uptake of male circumcision in the programme villages compared with control villages.

Deep commitment to religious faith and practices is common in many sub-Saharan countries. In this study, investigators used an innovative approach to promote healthy behaviour by tapping into the power of religious leaders. The impressive results illustrate the importance of addressing social and structural determinants of behaviour. This is a model that could be extended to address other challenging health behaviours in this and other similar settings. 

Africa
United Republic of Tanzania
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Peer led activities increase HIV testing uptake among MSM

Effectiveness of peer-led interventions to increase HIV testing among men who have sex with men: a systematic review and meta-analysis.

Shangani S, Escudero D, Kirwa K, Harrison A, Marshall B, Operario D. AIDS Care. 2017 Feb 2:1-11. doi: 10.1080/09540121.2017.1282105. [Epub ahead of print]

HIV testing constitutes a key step along the continuum of HIV care. Men who have sex with men (MSM) have low HIV testing rates and delayed diagnosis, especially in low-resource settings. Peer-led interventions offer a strategy to increase testing rates in this population. This systematic review and meta-analysis summarizes evidence on the effectiveness of peer-led interventions to increase the uptake of HIV testing among MSM. Using a systematic review protocol that was developed a priori, we searched PubMed, PsycINFO and CINAHL for articles reporting original results of randomized or non-randomized controlled trials (RCTs), quasi-experimental interventions, and pre- and post-intervention studies. Studies were eligible if they targeted MSM and utilized peers to increase HIV testing. We included studies published in or after 1996 to focus on HIV testing during the era of combination antiretroviral therapy. Seven studies encompassing a total of 6205 participants met eligibility criteria, including two quasi-experimental studies, four non-randomized pre- and-post intervention studies, and one cluster randomized trial. Four studies were from high-income countries, two were from Asia and only one from sub-Saharan Africa. We assigned four studies a "moderate" methodological rigor rating and three a "strong" rating. Meta-analysis of the seven studies found HIV testing rates were statistically significantly higher in the peer-led intervention groups versus control groups (pooled OR 2.00, 95% CI 1.74-2.31). Among randomized trials, HIV testing rates were significantly higher in the peer-led intervention versus control groups (pooled OR: 2.48, 95% CI 1.99-3.08). Among the non-randomized pre- and post-intervention studies, the overall pooled OR for intervention versus control groups was 1.71 (95% CI 1.42-2.06), with substantial heterogeneity among studies (I2 = 70%, p < 0.02). Overall, peer-led interventions increased HIV testing among MSM but more data from high-quality studies are needed to evaluate effects of peer-led interventions on HIV testing among MSM in low- and middle-income countries.

Abstract access  

Editor’s notes: A key driver of the HIV epidemic is low uptake of HIV testing in many settings. This leads to a high proportion of individuals living with HIV being unaware of their status, failing to engage with care and treatment and hence being at risk of transmitting HIV to others. Recent reviews have illustrated that programmes led by members of the same peer group can be effective in promoting HIV-associated behavioural change and improving clinical outcomes. Gay men and other men who have sex with men can experience specific challenges associated with engagement with HIV care. This problem is particularly acute in resource poor regions due to very high levels of stigma.

This systematic review is the first to look specifically at the effectiveness of peer-led activities among gay men and other men who have sex with men. Seven studies were found which fulfilled the inclusion criteria of assessing the impact of peer-led activities on HIV testing uptake among gay men and other men who have sex with men. Four of these were in high income settings, and the others in Peru, Taiwan and Kenya. Each study illustrated a positive effect of peer-led activities on increasing HIV testing rates, and meta-analyses illustrated consistent effects when data were stratified by sub-groups (study methodology, study quality or setting). However, the generalizability of these studies to the entire population of gay men and other men who have sex with men is a concern recognized by the authors as the majority used gay-centric community venues to recruit participants. This is likely to exclude individuals who do not self-identify as being part of this community. Two studies, one in Taiwan and the other in Peru, used social-media as a mechanism of recruitment. This approach may lead to a wider recruitment, although not accessible to people without access to the internet.

Overall, this review emphasizes the potential of peer-led activities to overcome barriers to engage with testing and treatment experienced by gay men and other men who have sex with men and other hard to reach and high-risk sub-populations. It also illustrated the very limited current evidence available to assess such programmes.

 

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How did SASA! reduce violence against women?

Exploring couples' processes of change in the context of SASA!, a violence against women and HIV prevention intervention in Uganda.

Starmann E, Collumbien M, Kyegombe N, Devries K, Michau L, Musuya T, Watts C, Heise L. Prev Sci. 2017 Feb; 18(2): 233–244. doi:  10.1007/s11121-016-0716-6. Epub 2016 Sep 29. 

There is now a growing body of research indicating that prevention interventions can reduce intimate partner violence (IPV); much less is known, however, about how couples exposed to these interventions experience the change process, particularly in low-income countries. Understanding the dynamic process that brings about the cessation of IPV is essential for understanding how interventions work (or don't) to reduce IPV. This study aimed to provide a better understanding of how couples' involvement with SASA!-a violence against women and HIV-related community mobilisation intervention developed by Raising Voices in Uganda-influenced processes of change in relationships. Qualitative data were collected from each partner in separate in-depth interviews following the intervention. Dyadic analysis was conducted using framework analysis methods. Study findings suggest that engagement with SASA! contributed to varied experiences and degrees of change at the individual and relationship levels. Reflection around healthy relationships and communication skills learned through SASA! activities or community activists led to more positive interaction among many couples, which reduced conflict and IPV. This nurtured a growing trust and respect between many partners, facilitating change in longstanding conflicts and generating greater intimacy and love as well as increased partnership among couples to manage economic challenges. This study draws attention to the value of researching and working with both women, men and couples to prevent IPV and suggests IPV prevention interventions may benefit from the inclusion of relationship skills building and support within the context of community mobilisation interventions.

Abstract  Full-text [free] access 

Editor’s notes: Evidence from sub-Saharan Africa suggests community mobilization approaches work at many different levels to prevent intimate partner violence. However it is unclear how they work. This study interviewed ten couples (men and women interviewed separately) who participated in the SASA! activities and reported reductions in intimate partner violence over time. Findings suggest that engagement with SASA! by one or both members of the couple resulted in a range of change processes at the individual and relational levels. The biggest changes were seen in couples with severe intimate partner violence and in couples where one or both partners experienced high-intensity exposure to SASA! Changes were not usually universal or rapid but often uneven and slow. Overall, greater awareness of healthy relationship values and increased relational resources – communication and self-regulation skills – led to improved relationships.

Of interest to people involved in programmes on intimate partner violence, is that focusing on promoting positive relationship values and dynamics - such as love, respect and trust are effective.  Indeed, they were far more effective, than focusing on gender roles such as sharing of household tasks – which created conflict. The findings suggest intimate partner violence programmes should consider mixed-sex approaches that work with both men and women. These programmes should include promoting love and intimacy as a mechanism to achieve more balanced power in relationships and reduce violence. 

 

Africa
Uganda
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Female sex workers in Cote d’Ivoire experience high levels of physical and sexual violence alongside intimidation from the police

Physical and sexual violence affecting female sex workers in Abidjan, Cote d'Ivoire: Prevalence, and the relationship between violence, the work environment, HIV and access to health services.

Lyons C, Ketende S, Drame F, Grosso A, Diouf D, Ba I, Shannon K, Ezouatchi R, Bamba A, Kouame A, Baral S. J Acquir Immune Defic Syndr. 2017 Feb 6. doi: 10.1097/QAI.0000000000001310. [Epub ahead of print]

Background: Violence is a human rights violation, and an important measure in understanding HIV among female sex workers (FSW). However, limited data exist regarding correlates of violence among FSW in Cote d'Ivoire. Characterizing prevalence and determinants of violence and the relationship with structural risks for HIV can inform development and implementation of comprehensive HIV prevention and treatment programs.

Methods: FSW > 18 years were recruited through respondent driven sampling (RDS) in Abidjan, Cote d'Ivoire. In total, 466 participants completed a socio-behavioral questionnaire and HIV testing. Prevalence estimates of violence were calculated using crude and RDS adjusted estimates. Relationships between structural risk factors and violence were analyzed using chi squared tests, and multivariable logistic regression.

Results: RDS Police refusal of protection was associated with physical (adjusted Odds Ratio [aOR]:2.6; 95%CI: 1.7,4.4) and sexual violence (aOR: 3.0; 95%CI: 1.9,4.8). Blackmail was associated with physical (aOR: 2.5; 95%CI: 1.5,4.2) and sexual violence (aOR: 2.4; 95%CI: 1.5,4.0). Physical violence was associated with fear (aOR: 2.2; 95%CI: 1.3,3.1) and avoidance of seeking health services (aOR:1.7; 95%CI:1.1-2.6).

Conclusions: Violence is prevalent among FSW in Abidjan and associated with features of the work environment. These relationships highlight layers of rights violations affecting FSW, underscoring the need for structural interventions and policy reforms to improve work environments; and to address police harassment, stigma, and rights violations to reduce violence and improve access to HIV interventions.

Abstract access  

Editor’s notes: The authors report the findings of a study with female sex workers in Cote d’Ivoire.  They explored prevalence and determinants of violence and the relationship with structural risks for HIV. Of the women interviewed, 60% had experienced physical violence and, for these women, 85% had experienced physical violence in the last 12 months. Of these women around 70% reported violence after starting sex work. Almost half of the women surveyed had experienced sexual violence. The main perpetrators were clients. There were associations between being HIV positive and physical violence. Around 11% of the women were HIV positive but a quarter feared seeking health services due to their engagement in sex work.

A quarter of the women reported that police had refused them protection. Around a third had been intimidated or harassed by the police, and there were associations between experiences of physical or sexual violence and arrest, blackmail or condom refusal. The authors conclude that these findings illustrate an urgent need for improving the work environments for female sex workers in Cote d’Ivoire.  There is also a need to address police harassment and violence. The authors argue for the need for policy reforms to address legal barriers focussing on sex work.

Africa
Côte d'Ivoire
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Providing HIV treatment in Tanzania costs relatively little, but means a large increase in current health spending

The costs of providing antiretroviral therapy services to HIV-infected individuals presenting with advanced HIV disease at public health centres in Dar es Salaam, Tanzania: Findings from a randomised trial evaluating different health care strategies.

Kimaro GD, Mfinanga S, Simms V, Kivuyo S, Bottomley C, Hawkins N, Harrison TS, Jaffar S, Guinness L, on behalf of the REMSTART trial team. PLoS One. 2017 Feb 24;12(2):e0171917. doi: 10.1371/journal.pone.0171917. eCollection 2017.

Background: Understanding the costs associated with health care delivery strategies is essential for planning. There are few data on health service resources used by patients and their associated costs within antiretroviral (ART) programmes in Africa.

Material and methods: The study was nested within a large trial, which evaluated screening for cryptococcal meningitis and tuberculosis and a short initial period of home-based adherence support for patients initiating ART with advanced HIV disease in Tanzania and Zambia. The economic evaluation was done in Tanzania alone. We estimated costs of providing routine ART services from the health service provider's perspective using a micro-costing approach. Incremental costs for the different novel components of service delivery were also estimated. All costs were converted into US dollars (US$) and based on 2012 prices.

Results: Of 870 individuals enrolled in Tanzania, 434 were enrolled in the intervention arm and 436 in the standard care/control arm. Overall, the median (IQR) age and CD4 cell count at enrolment were 38 [31, 44] years and 52 [20, 89] cells/mm3, respectively. The mean per patient costs over the first three months and over a one year period of follow up following ART initiation in the standard care arm were US$ 107 (95%CI 101-112) and US$ 265 (95%CI 254-275) respectively. ART drugs, clinic visits and hospital admission constituted 50%, 19%, and 19% of the total cost per patient year, while diagnostic tests and non-ART drugs (co-trimoxazole) accounted for 10% and 2% of total per patient year costs. The incremental costs of the intervention to the health service over the first three months was US$ 59 (p<0.001; 95%CI 52-67) and over a one year period was US$ 67(p<0.001; 95%CI 50-83). This is equivalent to an increase of 55% (95%CI 51%-59%) in the mean cost of care over the first three months, and 25% (95%CI 20%-30%) increase over one year of follow up.

Abstract  Full-text [free] access 

Editor’s notes: There are very few data on the cost of providing HIV treatment in sub-Saharan Africa. The authors of this paper analysed cost data from a trial of screening services for opportunistic infections, to estimate the additional costs of HIV treatment to the health service. The most costly part of treatment was the antiretroviral medicines themselves, followed by clinic visits and hospital admissions. Diagnostic tests and treatments for other conditions were relatively inexpensive. The overall costs of treatment to the health system were fairly low in absolute terms. At around US$67 per year this is on the cheaper side of many cost studies. However, HIV treatment increases overall health system costs by a quarter. This could have significant implications for health system funding requirements in Tanzania as treatment is offered to the many people who need it in the UNAIDS 90-90-90 treatment target.

Africa
United Republic of Tanzania
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Anti-malarial effect of HIV protease inhibitors

Effect of antiretroviral therapy on malaria incidence in HIV-infected Ugandan adults.

Kasirye RP, Grosskurth H, Munderi P, Levin J, Anywaine Z, Nunn A, Kamali A, Baisley K. AIDS. 2017 Feb 20;31(4):577-582. doi: 10.1097/QAD.0000000000001344.

Introduction: Using the data of a trial on cotrimoxazole (CTX) cessation, we investigated the effect of different antiretroviral therapy (ART) regimens on the incidence of clinical malaria.

Methods: During the cotrimoxazole cessation trial (ISRCTN44723643), HIV-infected Ugandan adults with CD4 at least 250 cells/µl were randomized to receive either CTX prophylaxis or placebo and were followed for a median of 2.5 years. Blood slides for malaria microscopy were examined at scheduled visits and at unscheduled visits when the participant felt unwell. CD4 cell counts were done 6-monthly. Malaria was defined as fever with a positive blood slide. ART regimens were categorized as nucleoside reverse transcriptase inhibitor (NRTI) only, non-nucleoside reverse transcriptase inhibitor (NNRTI)-containing or protease inhibitor containing. Malaria incidence was calculated using random effects Poisson regression to account for clustering of events.

Results: Malaria incidence in the three ART regimen groups was 9.9 (3.6-27.4), 9.3 (8.3-10.4), and 3.5 (1.6-7.6) per 100 person-years, respectively. Incidence on protease inhibitors was lower than that on the other regimens with the results just reaching significance (adjusted rate ratio 0.4, 95% confidence interval = 0.2-1.0, comparing with NNRTI regimens). Stratification by CTX/placebo use gave similar results, without evidence of an interaction between the effects of CTX/placebo use and ART regimen. There was no evidence of an interaction between ART regimen and CD4 cell count.

Conclusion: There was some evidence that protease inhibitor-containing ART regimens may be associated with a lower clinical malaria incidence compared with other regimens. This effect was not modified by CTX use or CD4 cell count. The antimalarial properties of protease inhibitors may have clinical and public health importance.

Abstract  Full-text [free] access 

Editor’s notes: HIV protease inhibitors (PIs) have been shown to kill various life cycle stages of the malaria parasite both in vitro and in vivo at therapeutic drug levels.  A randomized controlled trial in children previously illustrated that PI-based antiretroviral therapy (ART) was associated with a lower risk of recurrent malaria compared to non-nucleoside reverse transcriptase inhibitor (NNRTI)-based ART.

This study is the first to present data illustrating a reduction in clinical malaria incidence in adults on a PI-based regimen. The authors used data from the COSTOP trial, which was originally designed to look at the safety of discontinuing trimethoprim-sulfamethoxazole (TMP-SMX, Septrin) in HIV-positive Ugandan adults with a CD4 cell count ≥250 cells/µL. A limitation is that only 4% of study participants were on a PI-based ART regimen, so numbers are small. In addition, the authors were unable to adjust for potential confounders relating to individual health status. However, this analysis is a useful addition to the evidence base, suggesting that PIs may have antimalarial properties of clinical and public health importance, especially settings with high malaria transmission and moderate to high HIV prevalence.

Comorbidity, HIV Treatment
Africa
Uganda
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