Articles tagged as "Africa"

Tell it like it is: risky sex after 40

Sexual behaviors and HIV status: a population-based study among older adults in rural South Africa.

Rosenberg MS, Gomez-Olive FX, Rohr JK, Houle BC, Kabudula CW, Wagner RG, Salomon JA, Kahn K, Berkman LF, Tollman SM, Barnighausen T. J Acquir Immune Defic Syndr. 2017 Jan 1;74(1):e9-e17.

Objective: To identify the unmet needs for HIV prevention among older adults in rural South Africa.

Methods: We analyzed data from a population-based sample of 5059 men and women aged 40 years and older from the study Health and Aging in Africa: Longitudinal Studies of INDEPTH Communities (HAALSI), which was carried out in the Agincourt health and sociodemographic surveillance system in the Mpumalanga province of South Africa. We estimated the prevalence of HIV (laboratory-confirmed and self-reported) and key sexual behaviors by age and sex. We compared sexual behavior profiles across HIV status categories with and without age-sex standardization.

Results: HIV prevalence was very high among HAALSI participants (23%, 95% confidence interval [CI]: 21 to 24), with no sex differences. Recent sexual activity was common (56%, 95% CI: 55 to 58) across all HIV status categories. Condom use was low among HIV-negative adults (15%, 95% CI: 14 to 17), higher among HIV-positive adults who were unaware of their HIV status (27%, 95% CI: 22 to 33), and dramatically higher among HIV-positive adults who were aware of their status (75%, 95% CI: 70 to 80). Casual sex and multiple partnerships were reported at moderate levels, with slightly higher estimates among HIV-positive compared to HIV-negative adults. Differences by HIV status remained after age-sex standardization.

Conclusions: Older HIV-positive adults in an HIV hyperendemic community of rural South Africa report sexual behaviors consistent with high HIV transmission risk. Older HIV-negative adults report sexual behaviors consistent with high HIV acquisition risk. Prevention initiatives tailored to the particular prevention needs of older adults are urgently needed to reduce HIV risk in this and similar communities in sub-Saharan Africa.

Abstract  Full-text [free] access 

Editor’s notes: This large population-based survey was designed to collect data on well-being, health status, cognitive functioning, and aspects of ageing among men and women 40 years of age or older (40+) in Mpumalanga, South Africa. The survey documented an unexpectedly high HIV prevalence of 23% in this age group. In the 50+ age group, almost one in five people (20%) was HIV-positive. This compares to an overall South African national estimate for adults 50 and over in 2012 of 7.6%, the Africa Centre KwaZulu-Natal estimate of 9.5%, and the previous Agincourt estimate of 16.5% in 2010-11. One explanation is that HIV prevalence among older South Africans is climbing as more people access life-prolonging antiretroviral treatment. In addition to this, each year people with HIV are ageing into the older age group. This study focused on the 40+ age group because life expectancy in the Agincourt study area had been low and collected sexual behaviour information for the previous two-year period, rather than the usual time period of 12 months. Nonetheless, the data obtained through computer-assisted personal interviews reveal ‘recent’ sexual behaviour that both challenges stereotypes that older people are not sexually active and suggests significant risk of HIV transmission and HIV acquisition. Two-thirds reported more than one lifetime sexual partner and although sexual activity did tend to decrease with age, 52% of men and 6% of women age 80 years and older had been sexually active in the previous two years. Only about half of people found to be HIV-positive knew their status (12%). This group of people living with HIV were far more likely to use condoms. This suggests that an offer of HIV testing in ways that can reach older people would assist in avoiding transmission to partners and in accessing antiretroviral therapy. Only one in seven sexually active HIV-negative people 40+ are using condoms in this setting. This highlights the urgent need for awareness raising to foster new sexual norms to avoid HIV acquisition by practising safer sex. It is time to get our heads out of the sand, recognise the sexuality of older people, and work with them to tailor specific HIV strategies to reduce HIV transmission and acquisition – they too are key to ending AIDS. 

Africa
South Africa
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Violence and sex work in Uganda

Policing the epidemic: high burden of workplace violence among female sex workers in conflict-affected northern Uganda.

Muldoon KA, Akello M, Muzaaya G, Simo A, Shoveller J, Shannon K. Glob Public Health. 2017 Jan;12(1):84-97. Epub 2015 Oct 27.

Sex workers in sub-Saharan Africa experience a high burden of HIV with a paucity of data on violence and links to HIV risk among sex workers, and even less within conflict-affected environments. Data are from a cross-sectional survey of female sex workers in Gulu, northern Uganda (n = 400). Logistic regression was used to determine the specific association between policing and recent physical/sexual violence from clients. A total of 196 (49.0%) sex workers experienced physical/sexual violence by a client. From those who experienced client violence the most common forms included physical assault (58.7%), rape (38.3%), and gang rape (15.8%) Police harassment was very common, a total of 149 (37.3%) reported rushing negotiations with clients because of police presence, a practice that was significantly associated with increased odds of client violence (adjusted odds ratio: 1.61, 95% confidence intervals: 1.03-2.52). Inconsistent condom use with clients, servicing clients in a bar, and working for a manager/pimp were also independently associated with recent client violence. Structural and community-led responses, including decriminalisation, and engagement with police and policy stakeholders, remain critical to addressing violence, both a human rights and public health imperative.

Abstract access  

Editor’s notes: Sex workers are at increased risk of HIV and of violence from multiple perpetrators. There is a paucity of research examining violence among sex workers in conflict-affected areas. Sex work in Uganda is illegal. A police presence can reduce sex workers ability to screen for dangerous clients, negotiate sex acts, price and condom use. This study is from northern Uganda. The site, now at peace, has experienced 20 years of war. A quarter of sex workers are living with HIV. The paper examines the prevalence of client violence, police arrest and other factors, and how they interrelate.

Participants in the study were usually young (median age 21 years), poorly educated and had ≥1 child. One third had been abducted into the Lord’s Resistance Army and two thirds had lived in an Internal Displacement Camp. Some 49% had experienced recent physical or sexual violence from clients.  Eight percent had been gang raped in the past six months. Policing, inconsistent condom use, having sex in a bar and working for a manager or pimp were significantly associated with client violence. Sex workers in this survey face a high prevalence of violence and HIV. Decriminalisation of sex work is vital if sex workers are to access labour and human rights protection and to reduce the high prevalence of violence and HIV

Africa
Uganda
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Improving education about HIV transmission among health workers could reduce stigmatizing attitudes

Another generation of stigma? Assessing healthcare student perceptions of HIV-positive patients in Mwanza, Tanzania.

Aggarwal S, Lee DH, Minteer WB, Fenning RT, Raja SK, Bernstein ME, Raman KR, Denny SP, Patel PA, Lieber M, Farfel AO, Diamond CA. AIDS Patient Care STDS. 2017 Feb;31(2):87-95. doi: 10.1089/apc.2016.0175. Epub 2017 Jan 18.

HIV-related stigma remains a persistent global health concern among people living with HIV/AIDS (PLWA) in developing nations. The literature is lacking in studies about healthcare students' perceptions of PLWA. This study is the first effort to understand stigmatizing attitudes toward HIV-positive patients by healthcare students in Mwanza, Tanzania, not just those who will be directly treating patients but also those who will be indirectly involved through nonclinical roles, such as handling patient specimens and private health information. A total of 208 students were drawn from Clinical Medicine, Laboratory Sciences, Health Records and Information Management, and Community Health classes at the Tandabui Institute of Health Sciences and Technology for a voluntary survey that assessed stigmatizing beliefs toward PLWA. Students generally obtained high scores on the overall survey instrument, pointing to low stigmatizing beliefs toward PLWA and an overall willingness to treat PLWA with the same standard of care as other patients. However, there are gaps in knowledge that exist among students, such as a comprehensive understanding of all routes of HIV infection. The study also suggests that students who interact with patients as part of their training are less likely to exhibit stigmatizing beliefs toward PLWA. A comprehensive course in HIV infection, one that includes classroom sessions focused on the epidemiology and routes of transmission as well as clinical opportunities to directly interact with PLWA-perhaps through teaching sessions led by PLWA-may allow for significant reductions in stigma toward such patients and improve clinical outcomes for PLWA around the world.

Abstract access 

Editor’s notes: This paper reports on a survey of students who were undergoing training in Clinical Medicine, Laboratory Sciences, Health Records and Information Management, Nursing, and Community Health in Mwanza, Tanzania. The survey aimed to explore attitudes about people living with HIV. The authors report that their results illustrate low stigmatizing beliefs towards people living with HIV. However, around a quarter believed that HIV is a punishment for bad behaviour. A third believed that people who acquired HIV from drug use or sex deserved to become infected. Further to this, nearly three quarters believed that individuals who were HIV positive could have avoided infection if they wanted to. A quarter believed that people living with HIV have been promiscuous. There were no differences in response by gender but students under 24 were more likely to have negative attitudes. The authors suggest that this could be due to lower education levels than the older students, although they had not measured this. Students studying Clinical Medicine were less likely to have negative attitudes. On a positive note the students reported that they would treat people living with HIV as equal with other people.

The students displayed some lack of knowledge about routes of HIV infection beyond sex and drug use, especially mother-to-child HIV transmission. The authors suggest that better education in this area may reduce the negative attitudes about people living with HIV, reported by many of the students. Overall, this survey reveals some gaps in education, that if addressed could reduce stigma by health workers against people living with HIV.

Africa
United Republic of Tanzania
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Person-to-person spread driving XDR-TB epidemic in KwaZulu-Natal

Transmission of extensively drug-resistant tuberculosis in South Africa.

Shah NS, Auld SC, Brust JC, Mathema B, Ismail N, Moodley P, Mlisana K, Allana S, Campbell A, Mthiyane T, Morris N, Mpangase P, van der Meulen H, Omar SV, Brown TS, Narechania A, Shaskina E, Kapwata T, Kreiswirth B, Gandhi NR. N Engl J Med. 2017 Jan 19;376(3):243-253. doi: 10.1056/NEJMoa1604544.

Background: Drug-resistant tuberculosis threatens recent gains in the treatment of tuberculosis and human immunodeficiency virus (HIV) infection worldwide. A widespread epidemic of extensively drug-resistant (XDR) tuberculosis is occurring in South Africa, where cases have increased substantially since 2002. The factors driving this rapid increase have not been fully elucidated, but such knowledge is needed to guide public health interventions.

Methods: We conducted a prospective study involving 404 participants in KwaZulu-Natal Province, South Africa, with a diagnosis of XDR tuberculosis between 2011 and 2014. Interviews and medical-record reviews were used to elicit information on the participants' history of tuberculosis and HIV infection, hospitalizations, and social networks. Mycobacterium tuberculosis isolates underwent insertion sequence (IS)6110 restriction-fragment-length polymorphism analysis, targeted gene sequencing, and whole-genome sequencing. We used clinical and genotypic case definitions to calculate the proportion of cases of XDR tuberculosis that were due to inadequate treatment of multidrug-resistant (MDR) tuberculosis (i.e., acquired resistance) versus those that were due to transmission (i.e., transmitted resistance). We used social-network analysis to identify community and hospital locations of transmission.

Results: Of the 404 participants, 311 (77%) had HIV infection; the median CD4+ count was 340 cells per cubic millimeter (interquartile range, 117 to 431). A total of 280 participants (69%) had never received treatment for MDR tuberculosis. Genotypic analysis in 386 participants revealed that 323 (84%) belonged to 1 of 31 clusters. Clusters ranged from 2 to 14 participants, except for 1 large cluster of 212 participants (55%) with a LAM4/KZN strain. Person-to-person or hospital-based epidemiologic links were identified in 123 of 404 participants (30%).

Conclusions: The majority of cases of XDR tuberculosis in KwaZulu-Natal, South Africa, an area with a high tuberculosis burden, were probably due to transmission rather than to inadequate treatment of MDR tuberculosis. These data suggest that control of the epidemic of drug-resistant tuberculosis requires an increased focus on interrupting transmission.

Abstract   Full-text [free] access

Editor’s notes: This paper provides further evidence to support person-to-person transmission being the main driver of the XDR-TB epidemic in KwaZulu-Natal, the most populous province of South Africa. The study combined classical and molecular epidemiology: detailed characterisation of people’s clinical history and social networks alongside genotypic methods to characterise their TB strains. With the most conservative estimate, almost seven in ten XDR-TB cases resulted from transmission. However, combining the clinical and genotypic information, as many as nine in ten cases may have been attributable to transmission.

So where was transmission happening? This unfortunately was more difficult to answer. Although epidemiological links (mainly at home or at hospitals) could be defined for around one in three cases, many did not share the same TB strain. More detailed understanding of transmission may have been affected by the relatively low coverage of XDR-TB cases by this study. Full information was available for just over one in three laboratory-confirmed XDR-TB cases in the province over the study period. Also, although there was some genetic diversity in the TB strains, there was one dominant strain (LAM4/KZN). This is the strain responsible for the well-characterised clonal outbreak of XDR-TB involving Tugela Ferry.

Most people with XDR-TB in this study were HIV positive. Interestingly, three-quarters of people living with HIV were on ART at the time of their XDR-TB diagnosis, and two-thirds of people had undetectable viral load. This flags up two things. Firstly, it is a reminder that ART alone is unlikely to control the TB (or drug-resistant TB) epidemic in South Africa. Secondly, it raises further questions that could not be definitively answered here as to whether some of these people might have been infected with XDR-TB while accessing HIV treatment and care in the public health system. 

So what do we do with this new information? These findings should encourage us to focus on developing strategies to interrupt drug-resistant TB transmission. We need better evidence of what works in community settings and health care settings. We need better evidence of how to deliver proven programmes. We still do not know whether we might need different activities to interrupt MDR- and XDR-TB transmission, or whether this should just be encompassed within broader strategies to interrupt all TB transmission. South Africa is leading the way in implementing molecular diagnostics to help with earlier detection of drug-resistant TB, and is at the forefront of developing and testing new drug regimens for drug-resistant TB. This provides a solid platform on which to develop public health programmes to stop the spread of drug-resistant TB.

Comorbidity, Epidemiology
Africa
South Africa
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Are the pills going to make you live long Mum? Questions children ask once they learn their mother is living with HIV

Communication about HIV and death: maternal reports of primary school-aged children's questions after maternal HIV disclosure in rural South Africa.

Rochat TJ, Mitchell J, Lubbe AM, Stein A, Tomlinson M, Bland RM. Soc Sci Med. 2017 Jan;172:124-134. doi: 10.1016/j.socscimed.2016.10.031. Epub 2016 Nov 21.

Introduction: Children's understanding of HIV and death in epidemic regions is under-researched. We investigated children's death-related questions post maternal HIV-disclosure. Secondary aims examined characteristics associated with death-related questions and consequences for children's mental health.

Methods: HIV-infected mothers (N = 281) were supported to disclose their HIV status to their children (6-10 years) in an uncontrolled pre-post intervention evaluation. Children's questions post-disclosure were collected by maternal report, 1-2 weeks post-disclosure. 61/281 children asked 88 death-related questions, which were analysed qualitatively. Logistic regression analyses examined characteristics associated with death-related questions. Using the parent-report Child Behaviour Checklist (CBCL), linear regression analysis examined differences in total CBCL problems by group, controlling for baseline.

Results: Children's questions were grouped into three themes: 'threats'; 'implications' and 'clarifications'. Children were most concerned about the threat of death, mother's survival, and prior family deaths. In multivariate analysis variables significantly associated with asking death-related questions included an absence of regular remittance to the mother (AOR 0.25 [CI 0.10, 0.59] p = 0.002), mother reporting the child's initial reaction to disclosure being "frightened" (AOR 6.57 [CI 2.75, 15.70] p≤0.001) and level of disclosure (full/partial) to the child (AOR 2.55 [CI 1.28, 5.06] p = 0.008). Controlling for significant variables and baseline, all children showed improvements on the CBCL post-intervention; with no significant differences on total problems scores post-intervention (β   -0.096 SE1.366  t = -0.07 p = 0.944).

Discussion: The content of questions children asked following disclosure indicate some understanding of HIV and, for almost a third of children, its potential consequence for parental death. Level of maternal disclosure and stability of financial support to the family may facilitate or inhibit discussions about death post-disclosure. Communication about death did not have immediate negative consequences on child behaviour according to maternal report.

Conclusion: In sub-Saharan Africa, given exposure to death at young ages, meeting children's informational needs could increase their resilience.

Abstract  Full-text [free] access 

Editor’s notes: This is an unusual study examining the experience of the disclosure conversation between mother and child about the mother’s HIV positive status in Kwazulu-Natal. The paper examines the death-associated questions that mothers reported children (aged 6-10 years old, HIV exposed but uninfected) asked up to one week after the ‘disclosure event’. The findings indicate that although the treatability and chronic nature of HIV is complex, children’s questions suggest that they are attempting understand the implications of their mother’s HIV positive status for them, their mother’s and their care. Much research has illustrated that disclosure of both the parents or the child’s own HIV positive status is commonly delayed. This delay may exacerbate the challenges a young person has in adapting to this knowledge. We also know that parents, like a large proportion of people living with HIV, are daunted and feel ill equipped to manage disclosure to others, especially children. However little evidence is currently available evaluating the impact of programmes that are designed to support parents to disclose their own HIV status to their children. Therefore, this programme and study is very welcome.

The focus on death-questions is particularly interesting. This provides some illustration of how children are reportedly processing the information that they have been given. Many questions indicate a prior knowledge of HIV, illness and/ or death. It also suggests that children are managing this new knowledge within this broader context. Within this high HIV-prevalence context, a discursive emphasis on the efficacy of HIV treatment to reduce the risk of HIV-associated mortality within the delivery of timely, age-appropriate education information may be critical.  This can reduce fears around maternal death and supporting children to manage and adapt to their situations. A clear direction for further enquiry would be to follow up these families to assess the impact of full/ partial disclosure over time on the children and the mothers.     

Africa
South Africa
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Xpert® for active TB case finding in high prevalence communities

Effect of new tuberculosis diagnostic technologies on community-based intensified case finding: a multicentre randomised controlled trial.

Calligaro GL, Zijenah LS, Peter JG, Theron G, Buser V, McNerney R, Bara W, Bandason T, Govender U, Tomasicchio M, Smith L, Mayosi BM, Dheda K. Lancet Infect Dis. 2017 Jan 4. pii: S1473-3099(16)30384-X. doi: 10.1016/S1473-3099(16)30384-X. [Epub ahead of print]

Background: Inadequate case detection results in high levels of undiagnosed tuberculosis in sub-Saharan Africa. Data for the effect of new diagnostic tools when used for community-based intensified case finding are not available, so we investigated whether the use of sputum Xpert®-MTB/RIF and the Determine™ TB LAM urine test in two African communities could be effective.

Methods: In a pragmatic, randomised, parallel-group trial with individual randomisation stratified by country, we compared sputum Xpert®-MTB/RIF, and if HIV-infected, the Determine™ TB LAM urine test (novel diagnostic group), with laboratory-based sputum smear microscopy (routine diagnostic group) for intensified case finding in communities with high tuberculosis and HIV prevalence in Cape Town, South Africa, and Harare, Zimbabwe. Participants were randomly assigned (1:1) to these groups with computer-generated allocation lists, using culture as the reference standard. In Cape Town, participants were randomised and tested at an Xpert®-equipped mobile van, while in Harare, participants were driven to a local clinic where the same diagnostic tests were done. The primary endpoint was the proportion of culture-positive tuberculosis cases initiating tuberculosis treatment in each study group at 60 days. This trial is registered at ClinicalTrials.gov, number NCT01990274.

Findings: Between Oct 18, 2013, and March 31, 2015, 2261 individuals were screened and 875 (39%) of these met the criteria for diagnostic testing. 439 participants were randomly assigned to the novel group and 436 to the routine group. 74 (9%) of 875 participants had confirmed tuberculosis. If late culture-based treatment initiation was excluded, more patients with culture-positive tuberculosis were initiated on treatment in the novel group at 60 days (36 [86%] of 42 in the novel group vs 18 [56%] of 32 in the routine group). Thus the difference in the proportion initiating treatment between groups was 29% (95% CI 9-50, p=0.0047) and 53% more patients initiated therapy in the novel diagnostic group than in the routine diagnostic group. One culture-positive patient was treated based only on a positive LAM test.

Interpretation: Compared with traditional tools, Xpert®-MTB/RIF for community-based intensified case finding in HIV and tuberculosis-endemic settings increased the proportion of patients initiating treatment. By contrast, urine LAM testing was not found to be useful for intensive case finding in this setting.

Abstract access   

Editor’s notes: Undiagnosed tuberculosis (TB) is the main source of ongoing transmission of Mycobacterium tuberculosis in the community.  Community-based intensified TB case finding strategies in high prevalence settings aim to reduce the prevalence of undiagnosed tuberculosis (TB) and thereby to reduce TB transmission. This is the first randomised trial to date comparing a point of contact diagnostic tool, Xpert® MTB/RIF, with a traditional tool, smear microscopy, for community-based intensive case-finding in sub-Saharan Africa.

The key finding was that a community-based intensified strategy using Xpert® MTB/RIF reduced time-to-treatment and increased the proportion of culture-positive people started on treatment in the first 60 days (when culture-based treatment initiation was not included).  Additional findings included a reduction in the number of people with TB treated empirically and a 50% increase in 60-day detection rate compared with smear microscopy. However, there was no difference by study arm in the proportion of culture-positive people who were retained on TB treatment at six months, and this was suboptimal (69% versus 71% for routine versus novel). The study also demonstrated that it was feasible to undertake community-based screening by minimally trained health-care workers using Xpert® in a mobile van with a generator or on site within a community-based clinic. 

It is interesting to note that there were major differences between study sites. In multivariable analysis, study site was the strongest risk factor for a shorter time-to-treatment initiation among culture-positive cases (Harare versus Cape Town - adjusted hazard ratio 7.18, 95% confidence interval 3.69 – 13.96) with screening method (novel versus routine diagnostics) found to have an adjusted hazard ratio of 2.32 (95% confidence interval 1.35 – 3.97). This finding likely reflects differences in the clinical management of Xpert®-negative and smear-negative people with presumed TB between study sites. In Harare, almost all people with a negative test result (in either arm) were referred for chest radiography, and probably because of this, a much larger proportion of study participants were started on anti-tuberculosis treatment in Harare compared to Cape Town (49% versus 9%). There was also a major difference in retention on treatment at six months among culture-positive people (81% in Harare versus 59% in Cape Town). These results highlight the importance of context, including heterogeneity in patient characteristics and differences in quality of health-care, access and practices between settings, in interpreting study findings associated with TB case-finding strategies.

Whether implementation of community-based intensive case finding using Xpert® in high-prevalence areas actually translates into reduced community TB transmission or improved clinical outcomes remains to be determined. 

Africa
South Africa, Zimbabwe
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Anal high-risk HPV and high-grade lesions: screening is required for women living with HIV

Prevalence of anal HPV and anal dysplasia in HIV-infected women from Johannesburg, South Africa.

Goeieman BJ, Firnhaber CS, Jong E, Michelow P, Swarts A, Williamson AL, Allan B, Smith JS, Kegorilwe P, Wilkin TJ. J Acquir Immune Defic Syndr. 2017 Jan 30. doi: 10.1097/QAI.0000000000001300. [Epub ahead of print]

Background: Anal cancer is a relatively common cancer among HIV-infected populations. There are limited data on the prevalence of anal high-risk human papillomavirus (HR-HPV) infection and anal dysplasia in HIV-infected women from resource-constrained settings.

Methods: A cross-sectional study of HIV-infected women age 25-65 recruited from an HIV clinic in Johannesburg, South Africa. Cervical and anal swabs were taken for conventional cytology and HR-HPV testing. Women with abnormal anal cytology and 20% of women with negative cytology were seen for high resolution anoscopy (HRA) with biopsy of visible lesions.

Results: Two hundred women were enrolled. Anal HR-HPV was found in 43%. The anal cytology results were negative in 51 (26%); 97 (49%) had low-grade squamous intraepithelial lesions (SIL), 32 (16%) had atypical squamous cells of unknown significance and 19 (9.5%) had high-grade SIL or atypical squamous cells suggestive of high-grade SIL. On HRA, 71 (36%) had atypia or low-grade SIL on anal histology and 17 (8.5%) had high-grade SIL. Overall 31 (17.5%) had high-grade SIL present on anal cytology or histology. Abnormal cervical cytology was found in 70% and cervical HR-HPV in 41%.

Conclusion: We found a significant burden of anal HR-HPV infection, abnormal anal cytology and high-grade SIL in our cohort. This is the first study of the prevalence of anal dysplasia in HIV-infected women from sub-Saharan Africa. Additional studies are needed to define the epidemiology of these conditions, as well as the incidence of anal cancer, in this population.

Abstract access

Editor’s notes: Women living with HIV have a higher incidence of anogenital cancers compared to HIV-negative women, even in the ART era. Previous studies have illustrated that women living with HIV in South Africa have a high risk of cervical high-risk (HR)-HPV, and high rates of high-grade cervical intraepithelial neoplasia. This is the first study to report the prevalence of anal HR-HPV and anal high-grade squamous intraepithelial lesions (HSIL+) among women living with HIV in Africa.

This cross-sectional study among 200 women living with HIV attending a HIV treatment centre in Johannesburg, South Africa, the majority (97%) of whom were on ART, reported a high  prevalence of anal HR-HPV and anal HSIL+ by high-resolution anoscopy (43% and 8.5%, respectively). Women with low current CD4+ cell count and with shorter duration of ART use had marginally higher prevalence of anal HR-HPV and HSIL+.

It remains unclear whether high-grade anal lesions among women living with HIV have the same propensity to progress to anal cancer as is known to occur for high-grade cervical lesions to cervical cancer. Studies among HIV-positive and HIV-negative men report frequent spontaneous regression of anal intraepithelial lesions (AIN) and high rates of recurrence following treatment, but longitudinal data are limited among women living with HIV. Prolonged ART use may have contributed to a reduction in HPV-associated cervical lesions, and the same could be true for anal lesions. Larger prospective studies are necessary to define the rates of high-grade lesion incidence and progression and associated risk factors among women living with HIV in order to guide screening and management decisions.  

Comorbidity, Epidemiology
Africa
South Africa
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Assisted partner services a safe, effective strategy to identify undiagnosed HIV cases in sub-Saharan Africa

Assisted partner services for HIV in Kenya: a cluster randomised controlled trial.

Cherutich P, Golden MR, Wamuti B, Richardson BA, Asbjornsdottir KH, Otieno FA, Ng'ang'a A, Mutiti PM, Macharia P, Sambai B, Dunbar M, Bukusi D, Farquhar C. Lancet HIV. 2016 Nov 29. pii: S2352-3018(16)30214-4. doi: 10.1016/S2352-3018(16)30214-4. [Epub ahead of print]

Background: Assisted partner services for index patients with HIV infections involves elicitation of information about sex partners and contacting them to ensure that they test for HIV and link to care. Assisted partner services are not widely available in Africa. We aimed to establish whether or not assisted partner services increase HIV testing, diagnoses, and linkage to care among sex partners of people with HIV infections in Kenya.

Methods: In this cluster randomised controlled trial, we recruited non-pregnant adults aged at least 18 years with newly or recently diagnosed HIV without a recent history of intimate partner violence who had not yet or had only recently linked to HIV care from 18 HIV testing services clinics in Kenya. Consenting sites in Kenya were randomly assigned (1:1) by the study statistician (restricted randomisation; balanced distribution in terms of county and proximity to a city) to immediate versus delayed assisted partner services. Primary outcomes were the number of partners tested for HIV, the number who tested HIV positive, and the number enrolled in HIV care, in those who were interviewed at 6 week follow-up. Participants within each cluster were masked to treatment allocation because participants within each cluster received the same intervention. This trial is registered with ClinicalTrials.gov, number NCT01616420.

Findings: Between Aug 12, 2013, and Aug 31, 2015, we randomly allocated 18 clusters to immediate and delayed HIV assisted partner services (nine in each group), enrolling 1305 participants: 625 (48%) in the immediate group and 680 (52%) in the delayed group. 6 weeks after enrolment of index patients, 392 (67%) of 586 partners had tested for HIV in the immediate group and 85 (13%) of 680 had tested in the delayed group (incidence rate ratio 4.8, 95% CI 3.7-6.4). 136 (23%) partners had new HIV diagnoses in the immediate group compared with 28 (4%) in the delayed group (5.0, 3.2-7.9) and 88 (15%) versus 19 (3%) were newly enrolled in care (4.4, 2.6-7.4). Assisted partner services did not increase intimate partner violence (one intimate partner violence event related to partner notification or study procedures occurred in each group).

Interpretation: Assisted partner services are safe and increase HIV testing and case-finding; implementation at the population level could enhance linkage to care and antiretroviral therapy initiation and substantially decrease HIV transmission.

Abstract access  

Editor’s notes: One of the greatest challenges to achieving goals such as the UNAIDS 90:90:90 treatment target is the development of more effective strategies to enable people undiagnosed living with HIV to be tested and engaged with care. One strategy for achieving this in high-income settings, albeit with a very limited evidence base, is assisted partner services. In this approach, health-care workers identify and attempt to contact the sexual partners of people recently diagnosed with HIV. These partners are then encouraged to be tested and engaged with care. This pragmatic cluster randomised study, conducted in Kenya, aimed to assess whether assisted partner services were feasible in a sub-Saharan African setting and if so, to measure the effectiveness in terms of additional individuals testing for HIV, receiving new HIV diagnoses and engaging with care as a result of the programme.

The results were striking, in that six weeks after enrolment almost five times as many partners of index cases in the immediate group (partners contacted  at enrolment) had been tested for HIV compared to the delayed group (partners contacted  six weeks after enrolment). There were five times as many new HIV diagnoses in the immediate group compared to the delayed group. There were also four times as many partners newly engaged with care in the immediate arm compared to the delayed arm. There was also no evidence that the tracing of sexual partners led to an increase in intimate partner violence.

These results illustrate that assisted partner services can make an important contribution to identifying people living with HIV who are undiagnosed, enabling people to get tested and engaged with care in a low-income setting. A major challenge, identified by the study authors, is whether the human resources would be available in already highly stretched settings to implement this strategy. They suggest that task shifting from professional healthcare providers to a less highly educated cadre of workers would be feasible and point to other areas of care such as safe male circumcision and ART delivery, where this has been successfully achieved. 

Africa
Kenya
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Peer support: not a panacea for poor adherence

Use of peers to improve adherence to antiretroviral therapy: a global network meta-analysis.

Kanters S, Park JJ, Chan K, Ford N, Forrest J, Thorlund K, Nachega JB, Mills EJ. J Int AIDS Soc. 2016 Nov 30;19(1):21141. doi: 10.7448/IAS.19.1.21141. eCollection 2016.

Introduction: It is unclear whether using peers can improve adherence to antiretroviral therapy (ART). To construct the World Health Organization's global guidance on adherence interventions, we conducted a systematic review and network meta-analysis to determine the effectiveness of using peers for achieving adequate adherence and viral suppression.

Methods: We searched for randomized clinical trials of peer-based interventions to promote adherence to ART in HIV populations. We searched six electronic databases from inception to July 2015 and major conference abstracts within the last three years. We examined the outcomes of adherence and viral suppression among trials done worldwide and those specific to low- and middle-income countries (LMIC) using pairwise and network meta-analyses.

Results and discussion: Twenty-two trials met the inclusion criteria. We found similar results between pairwise and network meta-analyses, and between the global and LMIC settings. Peer supporter+Telephone was superior in improving adherence than standard-of-care in both the global network (odds-ratio [OR]=4.79, 95% credible intervals [CrI]: 1.02, 23.57) and the LMIC settings (OR=4.83, 95% CrI: 1.88, 13.55). Peer support alone, however, did not lead to improvement in ART adherence in both settings. For viral suppression, we found no difference of effects among interventions due to limited trials.

Conclusions: Our analysis showed that peer support leads to modest improvement in adherence. These modest effects may be due to the fact that in many settings, particularly in LMICs, programmes already include peer supporters, adherence clubs and family disclosures for treatment support. Rather than introducing new interventions, a focus on improving the quality in the delivery of existing services may be a more practical and effective way to improve adherence to ART.

Abstract  Full-text [free] access 

Editor’s notes: Sustained adherence to antiretroviral therapy (ART) is critical to ensure successful treatment outcomes and prevent drug resistance, AIDS-associated illness, death and onward transmission of HIV infection. In recent years, there has been much enthusiasm for use of peer support as a programme to improve adherence. Most high HIV prevalence settings have limited resources. Stigma influences adherence to treatment, and peer-based support may be a practical solution both in terms of being low cost and a mechanism for addressing stigma.

In this systematic review, the authors evaluated the effectiveness of peer-supporter programmes alone or in combination with other activities, namely telephone calls, device reminders or cognitive behavioural therapy (CBT), globally and in low and middle-income countries (LMIC). The systematic review findings were used to inform the 2015 World Health Organization HIV treatment guidelines.

The study demonstrates that peer support alone did not have any impact on adherence or on viral suppression. It did demonstrate modest improvements on adherence when combined with telephone activities. Several factors need to be considered in interpreting these findings. Firstly, adherence was assessed using a variety of methods including pill counts and the Medication Event Monitoring System (MEMS), which may have introduced heterogeneity. Secondly, few trials (particularly in LMICs) used HIV viral load as an outcome and therefore there may not have been adequate statistical power to detect an effect. Thirdly, populations included in the review were heterogeneous e.g. ART-naïve and experienced, people who inject drugs, non-adherent individuals. Notably, only one trial included children and adolescents among whom adherence is typically poorer. 

Importantly, in many settings particularly in LMICs, programmes already include treatment supporters and adherence clubs and therefore additional peer support would likely not add additional impact. The findings of this study suggest that programmes should focus on improving the quality of existing services rather than introduce new programmes. The review also highlights the need to standardise adherence measures and the need for robust research on adherence, particularly among children.         

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Thymidine analogue mutations associated with extensive resistance in African people failing on tenofovir

Occult HIV-1 drug resistance to thymidine analogues following failure of first-line tenofovir combined with a cytosine analogue and nevirapine or efavirenz in sub-Saharan Africa: a retrospective multi-centre cohort study.

Gregson J, Kaleebu P, Marconi VC, van Vuuren C, Ndembi N, Hamers RL, Kanki P, Hoffmann CJ, Lockman S, Pillay D, de Oliveira T, Clumeck N, Hunt G, Kerschberger B, Shafer RW, Yang C, Raizes E, Kantor R, Gupta RK. Lancet Infect Dis. 2016 Nov 30. pii: S1473-3099(16)30469-8. doi: 10.1016/S1473-3099(16)30469-8. [Epub ahead of print]

Background: HIV-1 drug resistance to older thymidine analogue nucleoside reverse transcriptase inhibitor drugs has been identified in sub-Saharan Africa in patients with virological failure of first-line combination antiretroviral therapy (ART) containing the modern nucleoside reverse transcriptase inhibitor tenofovir. We aimed to investigate the prevalence and correlates of thymidine analogue mutations (TAM) in patients with virological failure of first-line tenofovir-containing ART.

Methods: We retrospectively analysed patients from 20 studies within the TenoRes collaboration who had locally defined viral failure on first-line therapy with tenofovir plus a cytosine analogue (lamivudine or emtricitabine) plus a non-nucleoside reverse transcriptase inhibitor (NNRTI; nevirapine or efavirenz) in sub-Saharan Africa. Baseline visits in these studies occurred between 2005 and 2013. To assess between-study and within-study associations, we used meta-regression and meta-analyses to compare patients with and without TAMs for the presence of resistance to tenofovir, cytosine analogue, or NNRTIs.

Findings: Of 712 individuals with failure of first-line tenofovir-containing regimens, 115 (16%) had at least one TAM. In crude comparisons, patients with TAMs had lower CD4 counts at treatment initiation than did patients without TAMs (60.5 cells per µL [IQR 21.0-128.0] in patients with TAMS vs 95.0 cells per µL [37.0-177.0] in patients without TAMs; p=0.007) and were more likely to have tenofovir resistance (93 [81%] of 115 patients with TAMs vs 352 [59%] of 597 patients without TAMs; p<0.0001), NNRTI resistance (107 [93%] vs 462 [77%]; p<0.0001), and cytosine analogue resistance (100 [87%] vs 378 [63%]; p=0.0002). We detected associations between TAMs and drug resistance mutations both between and within studies; the correlation between the study-level proportion of patients with tenofovir resistance and TAMs was 0.64 (p<0.0001), and the odds ratio for tenofovir resistance comparing patients with and without TAMs was 1.29 (1.13-1.47; p<0.0001)

Interpretation: TAMs are common in patients who have failure of first-line tenofovir-containing regimens in sub-Saharan Africa, and are associated with multidrug resistant HIV-1. Effective viral load monitoring and point-of-care resistance tests could help to mitigate the emergence and spread of such strains.

Abstract  Full-text [free] access 

Editor’s notes: Since 2012, WHO has recommended that tenofovir should be included in first-line antiretroviral therapy, in place of the thymidine analogues, zidovudine and stavudine, which have more significant adverse effects. When therapy fails to maintain virologic control, tenofovir is associated with characteristic resistance mutations that are different from the thymidine analogue mutations (TAMs) associated with the older drugs. This study looked at the resistance patterns of people in Africa with virologic failure after starting on WHO recommended first-line combination including tenofovir and a non-nucleoside reverse transcriptase inhibitor (NNRTI).  TAMs were surprisingly common (16%) for a group who were not known to have received thymidine analogues. This is not what would be expected from this drug combination. The implication is that TAMs may have been present before tenofovir-containing treatment was started, possibly because of undeclared previous therapy. It is well known that TAMs make subsequent therapy with an NNRTI and nucleoside analogues very much more likely to fail. The presence of TAMs was associated with more extensive resistance to other drugs including lamivudine and NNRTIs, some of which may also have been present before the tenofovir based treatment.

Only people with treatment failure were studied. The total number entering into treatment is not recorded. However, based on other reports in Africa the authors speculate a failure rate of 15 to 35% and that they may therefore have found TAMs in two to six percent of people who started treatment. That seems a realistic figure for undeclared prior treatment and gives some perspective to the scale of this problem.

There is continuing concern about drug resistance in low- and middle-income countries.  As the thymidine analogues are phased out, people receiving them may be switched to tenofovir. In situations where there is no access to viral load monitoring, some people will have unrecognised virologic failure and may have developed resistance including TAMs. They are then likely to fail on tenofovir with additional resistance. Realistic strategies are necessary for the prompt detection of treatment failure.

Africa
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