Articles tagged as "Africa"

Comparing different methods to measure HIV incidence in a sub-Saharan African population

Estimating HIV incidence using a cross-sectional survey: comparison of three approaches in a hyperendemic setting, Ndhiwa sub-county, Kenya, 2012.

Blaizot S, Kim AA, Zeh C, Riche B, Maman D, DeCock K, Etard JF, Ecochard R. AIDS Res Hum Retroviruses. 2016 Dec 13. [Epub ahead of print]

Objectives: Estimating HIV incidence is critical for identifying groups at risk for HIV infection, planning and targeting interventions, and evaluating these interventions over time. The use of reliable estimation methods for HIV incidence is thus of high importance. The aim of this study was to compare methods for estimating HIV incidence in a population-based cross-sectional survey.

Design/methods: The incidence estimation methods evaluated included assay-derived methods, a testing history-derived method, and a probability-based method applied to data from the Ndhiwa HIV Impact in Population Survey (NHIPS). Incidence rates by sex and age and cumulative incidence as a function of age were presented.

Results: HIV incidence ranged from 1.38 [95% confidence interval (CI) 0.67-2.09] to 3.30 [95% CI 2.78-3.82] per 100 persons-years overall; 0.59 [95% CI 0.00-1.34] to 2.89 [95% CI 0.11-5.68] in men; and 1.62 [95% CI 0.16-6.04] to 4.03 [95% CI 3.30-4.77] per 100 persons-years in women. Women had higher incidence rates than men for all methods. Incidence rates were highest among women aged 15-24 and 25-34 years and highest among men aged 25-34 years.

Conclusion: Comparison of different methods showed variations in incidence estimates, but they were in agreement to identify most-at-risk groups. The use and comparison of several distinct approaches for estimating incidence are important to provide the best-supported estimate of HIV incidence in the population.

Abstract access

Editor’s notes: The estimation of HIV incidence is important both for planning effective HIV prevention strategies, and also to provide a proximal measure of changes in HIV epidemics both in general populations and in higher risk sub-groups. Further development of methods for accurately measuring HIV incidence that can be applied in routine monitoring settings is necessary.

This study compares three assay-based incidence estimation methods with approaches using self-reported testing history and a probabilistic technique on age and sex stratified sero-prevalence data. Two of the assays, BioRad and Lag, use antibody markers and a recent infection testing algorithm (RITA). The BioRad assay allowed for a longer time window for detection post-infection than the Lag. Recent infections were reclassified using results from HIV viral load tests and self-reported ART use, as appropriate. The other assay detected trace levels of HIV RNA in HIV seronegative individuals. The results for the two RITA assays were very similar at 1.38 [95% CI 0.67 – 2.09] infections per 100 person years (PY) for the BioRad and 1.46 [95% CI 0.71 – 2.22] per 100 PY for Lag. Combining these with HIV-RNA results led to small increases in each incidence estimate. The results for the probability-based incidence assays were very close to those derived from the combination of the RITA and HIV-RNA assays. However, the testing history-derived approach estimated incidence as almost double that from the other methods and this is likely to be in large part due to reporting/recall bias.

Despite the limitations of the methods, it was possible to identify population sub-groups defined by age and sex at higher risk of HIV infection. 

Africa
Kenya
  • share
0 comments.

Antiretroviral therapy in pregnancy is not associated with an increased risk of preterm delivery

PMTCT Option B+ does not increase preterm birth risk and may prevent extreme prematurity: A retrospective cohort study in Malawi.

Chagomerana MB, Miller WC, Pence BW, Hosseinipour MC, Hoffman IF, Flick RJ, Tweya H, Mumba S, Chibwandira F, Powers KA. J Acquir Immune Defic Syndr. 2016 Nov 21. [Epub ahead of print]

Objective: To estimate preterm birth risk among infants of HIV-infected women in Lilongwe, Malawi according to maternal antiretroviral therapy (ART) status and initiation time under Option B+.

Design: Retrospective cohort study of HIV-infected women delivering at ≥27 weeks of gestation, April 2012- November 2015. Among women on ART at delivery, we restricted our analysis to those who initiated ART before 27 weeks of gestation.

Methods: We defined preterm birth as a singleton live birth at ≥27 and <37 weeks of gestation, with births at <32 weeks classified as extremely to very preterm. We used log-binomial models to estimate risk ratios (RR) and 95% confidence intervals (CIs) for the association between ART and preterm birth.

Results: Among 3074 women included in our analyses, 731 preterm deliveries were observed (24%). Overall preterm birth risk was similar in women who had initiated ART at any point before 27 weeks and those who never initiated ART (RR = 1.14; 95% CI: 0.84 - 1.55), but risk of extremely to very preterm birth was 2.33 (1.39 - 3.92) times as great in those who never initiated ART compared to those who did at any point before 27 weeks. Among women on ART before delivery, ART initiation before conception was associated with the lowest preterm birth risk.

Conclusions: ART during pregnancy was not associated with preterm birth, and it may in fact be protective against severe adverse outcomes accompanying extremely to very preterm birth. As pre-conception ART initiation appears especially protective, long-term retention on ART should be a priority to minimize preterm birth in subsequent pregnancies.

Abstract access  

Editor’s notes: Effectively delivered antiretroviral therapy (ART) in pregnancy virtually eliminates the risk of mother-to-child HIV transmission and has been widely adopted. Option B+ is a strategy to start all HIV-positive pregnant women on ART regardless of their CD4 count or other HIV parameters and to continue it indefinitely after delivery to further protect the mother’s health. Balanced against the substantial health gains from the use of ART in pregnancy have been concerns that they may make some adverse pregnancy outcomes more common. Concerns about teratogenicity and birth defects with commonly-used drugs have largely gone as more data has accumulated but prematurity has remained an issue. There has been conflicting evidence from previous studies. Some have suggested an increased risk of preterm birth but others, including meta-analysis, have not. Many earlier studies were predominantly of women with advanced HIV disease, a group with an already-increased risk of preterm birth, and included single- or dual-drug regimens that are no longer recommended. Thus, the results of earlier studies may not be generalizable to women with early stage HIV disease who are being offered newer ART regimens in the context of Option B+.

This study has shown no increase in preterm birth associated with ART in pregnancy, and in fact a statistically and clinically significant protective effect for very early birth (before 32 weeks gestational age). It is a large, thorough and impressive piece of work but has the limitations of any observational study. The risk of unmeasured confounders can never be eliminated; in this case perhaps economic status or level of education. No precise data are presented on the ARV combinations used but it is implied that the great majority of women received efavirenz-based treatment, in accordance with national guidelines in Malawi. Previous studies have suggested that protease inhibitors may be responsible for increased preterm birth. The present study cannot address this question.

This large study of pregnancy outcomes from Option B+ should reassure HIV-positive women and their clinicians that no significant harms were found to be associated with this strategy.  

Africa
Malawi
  • share
0 comments.

Poor adherence during the first three months post-delivery among women on Option B+

Adherence to antiretroviral therapy during and after pregnancy: cohort study on women receiving care in Malawi's Option B+ program.

Haas AD, Msukwa MT, Egger M, Tenthani L, Tweya H, Jahn A, Gadabu OJ, Tal K, Salazar-Vizcaya L, Estill J, Spoerri A, Phiri N, Chimbwandira F, van Oosterhout JJ, Keiser O. Clin Infect Dis. 2016 Nov 1;63(9):1227-1235. Epub 2016 Jul 26.

Background: Adherence to antiretroviral therapy (ART) is crucial to preventing mother-to-child transmission of human immunodeficiency virus (HIV) and ensuring the long-term effectiveness of ART, yet data are sparse from African routine care programs on maternal adherence to triple ART.

Methods: We analyzed data from women who started ART at 13 large health facilities in Malawi between September 2011 and October 2013. We defined adherence as the percentage of days "covered" by pharmacy claims. Adherence of ≥90% was deemed adequate. We calculated inverse probability of censoring weights to adjust adherence estimates for informative censoring. We used descriptive statistics, survival analysis, and pooled logistic regression to compare adherence between pregnant and breastfeeding women eligible for ART under Option B+, and nonpregnant and nonbreastfeeding women who started ART with low CD4 cell counts or World Health Organization clinical stage 3/4 disease.

Results: Adherence was adequate for 73% of the women during pregnancy, for 66% in the first 3 months post partum, and for about 75% during months 4-21 post partum. About 70% of women who started ART during pregnancy and breastfeeding adhered adequately during the first 2 years of ART, but only about 30% of them had maintained adequate adherence at every visit. Risk factors for inadequate adherence included starting ART with an Option B+ indication, at a younger age, or at a district hospital or health center.

Conclusions: One-third of women retained in the Option B+ program adhered inadequately during pregnancy and breastfeeding, especially soon after delivery. Effective interventions to improve adherence among women in this program should be implemented.

Abstract  Full-text [free] access

Editor’s notes: To maximize the impact of antiretroviral therapy (ART), people living with HIV should be diagnosed early, enrolled and retained in pre-ART care, initiated on ART and retained in ART care.  Long-term adherence to achieve and maintain viral load suppression is the last step in the continuum of HIV care.

“Option B+” is the programmatic option for preventing mother-to-child HIV transmission, pioneered by Malawi, in which combination ART is started during pregnancy and continued life-long. This manuscript describes adherence to ART among pregnant women in the Option B+ programme in Malawi. The authors had access to prospectively-collected pharmacy data, and created an adherence measure that estimates the percentage of days ARVs were actually available to women during a time period. Therefore, this indicator measures the maximum number of days that ART could have been taken, but does not measure how much of the treatment was actually consumed. In this study, about a quarter of women started on ART with an Option B+ indication were lost to follow-up during the first year of ART. Among women retained, 30% adhered inadequately during pregnancy and breastfeeding, especially during the first three months after delivery. Unreported transfers of care to other clinics after delivery, postnatal depression, or difficulties with travelling to the facilities may be explanations for this temporary decline in adherence.

The authors validated their pharmacy-based adherence measure against viral load data in a subsample of about 500 people. They found that their adherence measure correlated well with the viral load measurement, and suggest that if access to viral load testing is limited, pharmacy-based adherence measures might be useful to identify people with adherence problems for targeted viral load testing.

These data are consistent with other studies reporting suboptimal retention particularly among women starting ART during pregnancy. Suboptimal adherence to ART during breastfeeding increases the risk of post-natal transmission, and the risk of the emergence of resistant virus in both mother and infant, as well as compromising the mother’s treatment outcome. Programmes need to address these issues in order to support adherence and retention in the early post-natal period. 

Africa
Malawi
  • share
0 comments.

Rape and ARV uptake/adherence

Impact of sexual trauma on HIV care engagement: perspectives of female patients with trauma histories in Cape Town, South Africa.

Watt MH, Dennis AC, Choi KW, Ciya N, Joska JA, Robertson C, Sikkema KJ. AIDS Behav. 2016 Nov 19. [Epub ahead of print]

South African women have disproportionately high rates of both sexual trauma and HIV. To understand how sexual trauma impacts HIV care engagement, we conducted in-depth qualitative interviews with 15 HIV-infected women with sexual trauma histories, recruited from a public clinic in Cape Town. Interviews explored trauma narratives, coping behaviors and care engagement, and transcripts were analyzed using a constant comparison method. Participants reported multiple and complex traumas across their lifetimes. Sexual trauma hindered HIV care engagement, especially immediately following HIV diagnosis, and there were indications that sexual trauma may interfere with future care engagement, via traumatic stress symptoms including avoidance. Disclosure of sexual trauma was limited; no woman had disclosed to an HIV provider. Routine screening for sexual trauma in HIV care settings may help to identify individuals at risk of poor care engagement. Efficacious treatments are needed to address the psychological and behavioral sequelae of trauma.

Abstract access  

Editor’s notes: Few studies have examined the impact of violence exposure on ART uptake and adherence. There is also a paucity of studies from low- and middle-income countries. South African women face a dual burden of HIV and violence risk, especially in areas characterized by extreme poverty, substance abuse and gender inequality. This study used qualitative interviews with 15 women living with HIV with histories of sexual trauma and attending an HIV-treatment clinic. The authors explore the intersections between sexual trauma experience, HIV infection and engagement with HIV care services.

Women reported complex sexual trauma histories, with repeated abuse from childhood into adulthood. This abuse was usually from family members or ‘lovers’. Sexual violence was usually accompanied by physical and emotional abuse. Women described symptoms of post-traumatic stress disorder and depression. Many associated their HIV infection with their sexual trauma / abusive relationship(s). For some, the HIV diagnosis and taking treatment reminded them of their rape and triggered feelings of shame. Women described their sexual violence experience as more stressful and shameful than their HIV status. None had disclosed their trauma history to their HIV care provider. The findings from this study suggest that women with a sexual trauma history may have poorer uptake and adherence to ARVs than women without. Additional research is necessary in low- and middle-income countries to explore this further. There is insufficient support and counselling services for women who have experienced sexual trauma and other abuse. Implementing such services may relieve symptoms of post-traumatic stress disorder and depression and support ART uptake and adherence. 

Africa
South Africa
  • share
0 comments.

Conditional cash transfers had no effect on HIV in high school attendance setting

The effect of a conditional cash transfer on HIV incidence in young women in rural South Africa (HPTN 068): a phase 3, randomised controlled trial.

Pettifor A, MacPhail C, Hughes JP, Selin A, Wang J, Gomez-Olive FX, Eshleman SH, Wagner RG, Mabuza W, Khoza N, Suchindran C, Mokoena I, Twine R, Andrew P, Townley E, Laeyendecker O, Agyei Y, Tollman S, Kahn K. Lancet Glob Health. 2016 Dec;4(12):e978-e988. doi: 10.1016/S2214-109X(16)30253-4. Epub 2016 Nov 1.

Background: Cash transfers have been proposed as an intervention to reduce HIV-infection risk for young women in sub-Saharan Africa. However, scarce evidence is available about their effect on reducing HIV acquisition. We aimed to assess the effect of a conditional cash transfer on HIV incidence among young women in rural South Africa.

Methods: We did a phase 3, randomised controlled trial (HPTN 068) in the rural Bushbuckridge subdistrict in Mpumalanga province, South Africa. We included girls aged 13-20 years if they were enrolled in school grades 8-11, not married or pregnant, able to read, they and their parent or guardian both had the necessary documentation necessary to open a bank account, and were residing in the study area and intending to remain until trial completion. Young women (and their parents or guardians) were randomly assigned (1:1), by use of numbered sealed envelopes containing a randomisation assignment card which were numerically ordered with block randomisation, to receive a monthly cash transfer conditional on school attendance (≥80% of school days per month) versus no cash transfer. Participants completed an Audio Computer-Assisted Self-Interview (ACASI), before test HIV counselling, HIV and herpes simplex virus (HSV)-2 testing, and post-test counselling at baseline, then at annual follow-up visits at 12, 24, and 36 months. Parents or guardians completed a Computer-Assisted Personal Interview at baseline and each follow-up visit. A stratified proportional hazards model was used in an intention-to-treat analysis of the primary outcome, HIV incidence, to compare the intervention and control groups. This study is registered at ClinicalTrials.gov (NCT01233531).

Findings: Between March 5, 2011, and Dec 17, 2012, we recruited 10 134 young women and enrolled 2537 and their parents or guardians to receive a cash transfer programme (n=1225) or not (control group; n=1223). At baseline, the median age of girls was 15 years (IQR 14-17) and 672 (27%) had reported to have ever had sex. 107 incident HIV infections were recorded during the study: 59 cases in 3048 person-years in the intervention group and 48 cases in 2830 person-years in the control group. HIV incidence was not significantly different between those who received a cash transfer (1.94% per person-years) and those who did not (1.70% per person-years; hazard ratio 1.17, 95% CI 0.80-1.72, p=0.42).

Interpretation: Cash transfers conditional on school attendance did not reduce HIV incidence in young women. School attendance significantly reduced risk of HIV acquisition, irrespective of study group. Keeping girls in school is important to reduce their HIV-infection risk. 

Abstract  Full-text [free] access 

Editor’s notes: Cash transfers to vulnerable household and/or individuals have been used successfully in a variety of settings as a means to reduce poverty, improve health and achieve other development-associated outcomes. Cash transfers can help address structural drivers of HIV, such as economic and gender inequalities and low levels of education, and have been proposed as a potentially important addition to HIV prevention efforts. However, the evidence of their effectiveness in the context of HIV prevention is mixed. This study is the first randomized controlled trial to examine the effect of cash transfers conditional on school attendance with HIV incidence in adolescent girls and young women in sub-Saharan Africa. The trial found no evidence that receipt of the conditional cash transfer reduced HIV or HSV-2 incidence.

Staying in education has been highlighted as a key factor for reducing the risk of HIV infection in girls and young women. In this setting, school attendance based on attendance registers was high in both trial arms (95%). This is much higher than in South Africa overall, and higher than in Mpumalanga Province (the study area). Eligibility for the trial was restricted to girls and young women who were currently enrolled in school, so the trial participants may have been more motivated to attend school than those who were not eligible. Interestingly, 75% of individuals who were screened for the trial were found to be ineligible, although the reasons for their exclusion are not given, and it is difficult to know how generalizable the results are. South Africa has a strong social protection system for poor families, and 80% of the study participants were from households that were receiving child support grants. The benefits of additional cash transfers in areas with high coverage of social protection may be minimal. Cash transfers to girls and young women for HIV prevention are likely to have a greater effect in settings with low school attendance and more limited social protection coverage.

Consistent with other studies, the trial found that staying in school was associated with a reduced risk of HIV, irrespective of trial arm. The cash transfer was also associated with a strongly reduced risk of intimate partner violence, and a small effect on reducing some sexual risk behaviours. Cash transfers may work both directly and indirectly, through a variety of different pathways that are likely to vary between settings and between populations. The high-recorded school attendance in both trial arms will have limited the ability to examine education as a pathway through which the cash transfer may have influenced HIV risk. A better understanding of these pathways and how they are affected by the setting may help inform the conditions under which cash transfers may be an effective component of an HIV prevention programme.

Africa
South Africa
  • share
0 comments.

How to keep HIV prevalence low in refugee populations

Predictors of HIV infection: a prospective HIV screening study in a Ugandan refugee settlement.

O'Laughlin KN, Rabideau DJ, Kasozi J, Parker RA, Bustamante ND, Faustin ZM, Greenwald KE, Walensky RP, Bassett IV. BMC Infect Dis. 2016 Nov 23;16(1):695.

Background: The instability faced by refugees may place them at increased risk of exposure to HIV infection. Nakivale Refugee Settlement in southwestern Uganda hosts  68 000 refugees from 11 countries, many with high HIV prevalence. We implemented an HIV screening program in Nakivale and examined factors associated with new HIV diagnosis.

Methods: From March 2013-November 2014, we offered free HIV screening to all clients in the Nakivale Health Center while they waited for their outpatient clinic visit. Clients included refugees and Ugandan nationals accessing services in the settlement. Prior to receiving the HIV test result, participants were surveyed to obtain demographic information including gender, marital status, travel time to reach clinic, refugee status, and history of prior HIV testing. We compared variables for HIV-infected and non-infected clients using Pearson's chi-square test, and used multivariable binomial regression models to identify predictors of HIV infection.

Results: During the HIV screening intervention period, 330 (4%) of 7766 individuals tested were identified as HIV-infected. Refugees were one quarter as likely as Ugandan nationals to be HIV-infected (aRR 0.27 [0.21, 0.34], p < 0.0001). Additionally, being female (aRR 1.43 [1.14, 1.80], p = 0.002) and traveling more than 1 h to the clinic (aRR 1.39 [1.11, 1.74], p = 0.003) increased the likelihood of being HIV-infected. Compared to individuals who were married or in a stable relationship, being divorced/separated/widowed increased the risk of being HIV-infected (aRR 2.41 [1.88, 3.08], p < 0.0001), while being single reduced the risk (aRR 0.60 [0.41, 0.86], p < 0.0001). Having been previously tested for HIV (aRR 0.59 [0.47, 0.74], p < 0.0001) also lowered the likelihood of being HIV-infected.

Conclusions: In an HIV screening program in a refugee settlement in Uganda, Ugandan nationals are at higher risk of having HIV than refugees. The high HIV prevalence among clients seeking outpatient care, including Ugandan nationals and refugees, warrants enhanced HIV screening services in Nakivale and in the surrounding region. Findings from this research may be relevant for other refugee settlements in sub-Saharan Africa hosting populations with similar demographics, including the 9 other refugee settlements in Uganda.

Abstract  Full-text [free] access 

Editor’s notes: The 4% prevalence seen among refugees in this study warrants the introduction of a routine offer of HIV testing and counselling, provider-initiated testing and counselling (PITC), in the outpatient services provided at this refugee settlement in Uganda. Although 7766 people accepted the offer of HIV testing and counselling (HTC), the real extent of the acceptability of this service is unclear because routine service delivery records document simply encounters (23 016 during the study period) rather than unique individuals. There may be challenges in defining and using unique identifiers in refugee settlement health care services but this is one example of their potential utility in helping understand the true burden of disease in these settings. HIV prevalence in refugees accepting testing was not significantly different from that in the general population in their countries of origin. For example, Rwanda 2.3% versus 2.9% and Burundi 1.4% versus 1.0%. The exception was the Democratic Republic of Congo (DRC) with 1.9% of Congolese refugees being HIV-positive compared to 0.8% in the DRC general population, warranting further study to understand this increased HIV risk.

This study reveals lower HIV prevalence among refugees (2%) than among Ugandan nationals availing themselves of the settlement health services (9%). The Ugandans included both refugees and people living in surrounding communities. Ugandans freely come and go from the settlement for job-associated or personal reasons. People testing positive for HIV were more likely to live outside the settlement. The extent of sexual mixing between local Ugandans and refugees from other countries in Nakivale is unknown but providing prevention and treatment services to both populations could help reduce the risk of HIV transmission within the settlement. This study was conducted when the 2010 WHO guidelines of 350 cells/mm3 or WHO stage III/IV for treatment initiation were in effect and antiretroviral therapy was free of charge. However, data are not presented in this paper on the important question of the extent of linkage to care and antiretroviral therapy. These data are now being used worldwide to track progress towards the UNAIDS 90-90-90 treatment target. Refugee settlements in sub-Saharan Africa provide fertile settings for a routine offer of HIV testing and immediate offer of antiretroviral therapy to people found to be HIV-positive, as per current WHO guidelines. This would benefit not only these individuals clinically but would help keep HIV transmission as low as possible in refugee settlements.

Africa
Uganda
  • share
0 comments.

Disbelief, stigma, ‘strong blood’ and inevitability affect seroconversion among HIV serodiscordant couples in Uganda

'People say that we are already dead much as we can still walk': a qualitative investigation of community and couples' understanding of HIV serodiscordance in rural Uganda.

Kim J, Nanfuka M, Moore D, Shafic M, Nyonyitono M, Birungi J, Galenda F, King R. BMC Infect Dis. 2016 Nov 10;16(1):665.

Background: Stable, co-habiting HIV serodiscordant couples are a key population in terms of heterosexual transmission in sub-Saharan Africa. Despite the wide availability of antiretroviral treatment and HIV educational programs, heterosexual transmission continues to drive the HIV epidemic in Africa. To investigate some of the factors involved in transmission or maintenance of serodiscordant status, we designed a study to examine participants' understanding of HIV serodiscordance and the implications this posed for their HIV prevention practices.

Methods: In-depth interviews were conducted with 28 serodiscordant couples enrolled in a treatment-as-prevention study in Jinja, Uganda. Participants were asked questions regarding sexual behaviour, beliefs in treatment and prevention, participants' and communities' understanding and context around HIV serodiscordance. Qualitative framework analysis capturing several main themes was carried out by a team of four members, and was cross-checked for consistency.

Results: It was found that most couples had difficulty explaining the phenomenon of serodiscordance and tended to be confused regarding prevention. Many individuals still held beliefs in pseudoscientific explanations for HIV susceptibility such as blood type and blood "strength". The participants' trust of treatment and medical services were well established. However, the communities' views of both serodiscordance and treatment were more pessimistic and wrought with mistrust. Stigmatization of serodiscordance and HIV-positive status were reported frequently.

Conclusions: The results indicate that despite years of treatment and prevention methods being available, stigmatization and mistrust persist in the communities of HIV-affected individuals and may directly contribute to new cases and seroconversion. We suggest that to optimize the effects of HIV treatment and prevention, clear education and support of such methods are sorely needed in sub-Saharan African communities.

Abstract  Full-text [free] access 

Editor’s notes: Expanded access to antiretroviral treatment has significantly reduced HIV-associated mortality. It has also contributed to reduced HIV incidence including in the most highly affected region of sub-Saharan Africa. Most new infections in this region are due to heterosexual transmission, with transmission within HIV serodiscordant couples in marriage or cohabitation thought to account for most new infections. This qualitative study explores the perceptions of members of HIV serodiscordant couples in terms of their understanding of serodiscordance or eventual seroconversion. The authors also explore how this understanding affects their sexual behaviour and adherence to antiretroviral therapy (for people living with HIV).

This sub-study was part of the Highly Active Antiretroviral therapy as Prevention (HAARP) study of treatment as prevention (TasP) among serodiscordant couples. In-depth interviews were conducted between June 2013 and August 2014.  All couples were initially serodiscordant upon recruitment into treatment. Over the course of the study, 14 HIV seronegative participants seroconverted. These individuals and their partners were selected for the sub-study and gender-matched to control subjects who were HIV seropositive participants whose partners did not seroconvert during the study.

The results of the HPTN 052 trial demonstrated a 96% reduction in HIV transmission within serodisordant couples associated with early use of antiretroviral therapy.  In this rural Ugandan setting, the phenomenon of serodiscordance remains poorly understood by people affected by it and the communities surrounding them. Despite extensive education campaigns and communication about HIV prevention various factors affect understanding of serodiscordance. Medication, confusion, mistrust, stigma, and a resulting sense of inevitability may negatively affect couples’ understanding and belief in the phenomenon of serodiscordance. For a variety of reasons, some serodisordant couples also report lack of consistent condom use. This is of particular concern where abstinence has proved to be an unachievable option for many couples. Improved education regarding serodiscordance and ART treatment will be required to address heterosexual transmission and ensure the maintenance of serodiscordance in affected couples.

Africa
Uganda
  • share
0 comments.

Using HIV testing infrastructure for other diseases can be very low cost

Implementation and operational research: cost and efficiency of a hybrid mobile multidisease testing approach with high HIV testing coverage in east Africa.

Chang W, Chamie G, Mwai D, Clark TD, Thirumurthy H, Charlebois ED, Petersen M, Kabami J, Ssemmondo E, Kadede K, Kwarisiima D, Sang N, Bukusi EA, Cohen CR, Kamya M, Havlir DV, Kahn JG. J Acquir Immune Defic Syndr. 2016 Nov 1;73(3):e39-e45.

Background: In 2013-2014, we achieved 89% adult HIV testing coverage using a hybrid testing approach in 32 communities in Uganda and Kenya (SEARCH: NCT01864603). To inform scalability, we sought to determine: (1) overall cost and efficiency of this approach; and (2) costs associated with point-of-care (POC) CD4 testing, multidisease services, and community mobilization.

Methods: We applied microcosting methods to estimate costs of population-wide HIV testing in 12 SEARCH trial communities. Main intervention components of the hybrid approach are census, multidisease community health campaigns (CHC), and home-based testing for CHC nonattendees. POC CD4 tests were provided for all HIV-infected participants. Data were extracted from expenditure records, activity registers, staff interviews, and time and motion logs.

Results: The mean cost per adult tested for HIV was $20.5 (range: $17.1-$32.1) (2014 US$), including a POC CD4 test at $16 per HIV+ person identified. Cost per adult tested for HIV was $13.8 at CHC vs. $31.7 by home-based testing. The cost per HIV+ adult identified was $231 ($87-$1245), with variability due mainly to HIV prevalence among persons tested (ie, HIV positivity rate). The marginal costs of multidisease testing at CHCs were $1.16/person for hypertension and diabetes, and $0.90 for malaria. Community mobilization constituted 15.3% of total costs.

Conclusions: The hybrid testing approach achieved very high HIV testing coverage, with POC CD4, at costs similar to previously reported mobile, home-based, or venue-based HIV testing approaches in sub-Saharan Africa. By leveraging HIV infrastructure, multidisease services were offered at low marginal costs.

Abstract access  

Editor’s notes: The scale up of HIV testing services over recent years has meant that infrastructure for HIV testing is, in many places, much stronger than that of other diseases. This study assessed the costs and cost-effectiveness of both HIV testing services and additional multi disease testing in 32 communities of Uganda and Kenya. As has been found in other studies, testing people through community health campaigns cost less than home-based testing. However, the cost per HIV positive person identified varied widely according to the underlying HIV prevalence. The costs of including additional disease testing services – for hypertension, diabetes and malaria – were low. A more holistic approach to health testing could lead to substantial health benefits for relatively low cost.

Africa
Kenya, Uganda
  • share
0 comments.

Invasive cervical cancers preventable by HPV vaccines: a comparison of HIV-positive and negative women

Effect of HIV infection on human papillomavirus types causing invasive cervical cancer in Africa.

Clifford GM, de Vuyst H, Tenet V, Plummer M, Tully S, Franceschi S. J Acquir Immune Defic Syndr. 2016 Nov 1;73(3):332-339.

Objectives: HIV infection is known to worsen the outcome of cervical human papillomavirus (HPV) infection and may do so differentially by HPV type.

Design: Twenty-one studies were included in a meta-analysis of invasive cervical cancers (ICC) among women infected with HIV in Africa.

Method: Type-specific HPV DNA prevalence was compared with data from a similar meta-analysis of HIV-negative ICC using prevalence ratios (PR).

Results: HPV detection was similar in 770 HIV-positive (91.2%) and 3846 HIV-negative (89.6%) ICC, but HIV-positive ICC harbored significantly more multiple HPV infections (PR = 1.75, 95% confidence intervals: 1.18 to 2.58), which were significantly more prevalent in ICC tested from cells than from biopsies. HPV16 was the most frequently detected type in HIV-positive ICC (42.5%), followed by HPV18 (22.2%), HPV45 (14.4%), and HPV35 (7.1%). Nevertheless, HIV-positive ICC were significantly less frequently infected with HPV16 than HIV-negative ICC (PR = 0.88, 95% confidence intervals: 0.79 to 0.99). Other high-risk types were significantly more prevalent in HIV-positive ICC, but only for HPV18 was there a significantly higher prevalence of both single and multiple infections in HIV-positive ICC. Increases for other high-risk types were primarily accounted for by multiple infections. The proportion of HPV-positive ICC estimated attributable to HPV16/18 (71.8% in HIV positive, 73.4% in HIV negative) or HPV16/18/31/33/45/52/58 (88.8%, 89.5%) was not affected by HIV.

Conclusions: HIV alters the relative carcinogenicity of HPV types, but prophylactic HPV16/18 vaccines may nevertheless prevent a similar proportion of ICC, irrespective of HIV infection.

Abstract access  

Editor’s notes: Invasive cervical cancer (ICC) is one of the most common cancers in low and middle income countries. In the African region the prevalence of both ICC and HIV are high. Compared to HIV-negative women, HIV-positive women are at increased risk of oncogenic high-risk (HR) human papillomavirus (HPV) incidence and persistence, and cervical lesion incidence and progression. Current HPV vaccines offer potential for cervical cancer prevention by targeting the HR-HPV types associated with ICC. Although there is no data yet available on HPV vaccine efficacy among HIV-positive persons, HPV vaccines have been reported to be safe and immunogenic in HIV-positive children, female adolescents and adults. 

This systematic review compared the HPV type distribution and the HPV vaccine type distribution in ICC biopsy and cervical cell specimens of 770 HIV-positive and 3846 HIV-negative women from 21 studies in 12 African countries.

The authors report that the fraction of ICC attributable to the HPV types included in the current bivalent (HPV16/18) and nonavalent (HPV16/18/31/33/45/52/58) vaccines was similar among HIV-positive and HIV-negative women (bivalent: 61.7% and 67.3%; nonavalent: 88.9% and 89.5%, respectively). However, a non-negligible proportion of ICC from both HIV-positive and HIV-negative women were infected with non-vaccine types in the absence of any of the vaccine types (7.0% and 7.9% of ICC from HIV-positive and HIV-negative women, respectively), and this was highest for HPV35.

These findings confirm that the currently available HPV vaccines could prevent a similar proportion of ICC cases in HIV-positive as in HIV-negative women. ICC remains an important co-morbidity among HIV-positive women even in the antiretroviral era. Given that HIV-positive women are at greater risk of HR-HPV persistence and cervical lesion incidence and faster progression to high-grade cervical lesions, primary prevention of HPV infection through vaccination could reduce HPV infection and HPV-associated disease in Africa. However, cervical cancer screening will continue to remain important for both HIV-positive and HIV-negative women as there remain a proportion of ICC cases that may not be preventable by currently available vaccines. 

Comorbidity, Epidemiology
Africa
  • share
0 comments.

School-based HIV prevention programmes appear ineffective

School-based interventions for preventing HIV, sexually transmitted infections, and pregnancy in adolescents.

Mason-Jones AJ, Sinclair D, Mathews C, Kagee A, Hillman A, Lombard C. Cochrane Database Syst Rev. 2016 Nov 8;11:CD006417.

Background: School-based sexual and reproductive health programmes are widely accepted as an approach to reducing high-risk sexual behaviour among adolescents. Many studies and systematic reviews have concentrated on measuring effects on knowledge or self-reported behaviour rather than biological outcomes, such as pregnancy or prevalence of sexually transmitted infections (STIs).

Objectives: To evaluate the effects of school-based sexual and reproductive health programmes on sexually transmitted infections (such as HIV, herpes simplex virus, and syphilis), and pregnancy among adolescents.

Search methods: We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) for published peer-reviewed journal articles; and ClinicalTrials.gov and the World Health Organization's (WHO) International Clinical Trials Registry Platform for prospective trials; AIDS Education and Global Information System (AEGIS) and National Library of Medicine (NLM) gateway for conference presentations; and the Centers for Disease Control and Prevention (CDC), UNAIDS, the WHO and the National Health Service (NHS) centre for Reviews and Dissemination (CRD) websites from 1990 to 7 April 2016. We hand searched the reference lists of all relevant papers.

Selection criteria: We included randomized controlled trials (RCTs), both individually randomized and cluster-randomized, that evaluated school-based programmes aimed at improving the sexual and reproductive health of adolescents.

Data collection and analysis: Two review authors independently assessed trials for inclusion, evaluated risk of bias, and extracted data. When appropriate, we obtained summary measures of treatment effect through a random-effects meta-analysis and we reported them using risk ratios (RR) with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach.

Main results: We included eight cluster-RCTs that enrolled 55,157 participants. Five trials were conducted in sub-Saharan Africa (Malawi, South Africa, Tanzania, Zimbabwe, and Kenya), one in Latin America (Chile), and two in Europe (England and Scotland). Sexual and reproductive health educational programmes. Six trials evaluated school-based educational interventions. In these trials, the educational programmes evaluated had no demonstrable effect on the prevalence of HIV (RR 1.03, 95% CI 0.80 to 1.32, three trials; 14 163 participants; low certainty evidence), or other STIs (herpes simplex virus prevalence: RR 1.04, 95% CI 0.94 to 1.15; three trials, 17 445 participants; moderate certainty evidence; syphilis prevalence: RR 0.81, 95% CI 0.47 to 1.39; one trial, 6977 participants; low certainty evidence). There was also no apparent effect on the number of young women who were pregnant at the end of the trial (RR 0.99, 95% CI 0.84 to 1.16; three trials, 8280 participants; moderate certainty evidence). Material or monetary incentive-based programmes to promote school attendance. Two trials evaluated incentive-based programmes to promote school attendance. In these two trials, the incentives used had no demonstrable effect on HIV prevalence (RR 1.23, 95% CI 0.51 to 2.96; two trials, 3805 participants; low certainty evidence). Compared to controls, the prevalence of herpes simplex virus infection was lower in young women receiving a monthly cash incentive to stay in school (RR 0.30, 95% CI 0.11 to 0.85), but not in young people given free school uniforms (data not pooled, two trials, 7229 participants; very low certainty evidence). One trial evaluated the effects on syphilis and the prevalence was too low to detect or exclude effects confidently (RR 0.41, 95% CI 0.05 to 3.27; one trial, 1291 participants; very low certainty evidence). However, the number of young women who were pregnant at the end of the trial was lower among those who received incentives (RR 0.76, 95% CI 0.58 to 0.99; two trials, 4200 participants; low certainty evidence). Combined educational and incentive-based programmes. The single trial that evaluated free school uniforms also included a trial arm in which participants received both uniforms and a programme of sexual and reproductive education. In this trial arm herpes simplex virus infection was reduced (RR 0.82, 95% CI 0.68 to 0.99; one trial, 5899 participants; low certainty evidence), predominantly in young women, but no effect was detected for HIV or pregnancy (low certainty evidence).

Authors' conclusions: There is a continued need to provide health services to adolescents that include contraceptive choices and condoms and that involve them in the design of services. Schools may be a good place in which to provide these services. There is little evidence that educational curriculum-based programmes alone are effective in improving sexual and reproductive health outcomes for adolescents. Incentive-based interventions that focus on keeping young people in secondary school may reduce adolescent pregnancy but further trials are needed to confirm this.

Abstract  Full-text [free] access 

Editor’s notes: School-based HIV prevention programmes are widespread worldwide. These programmes use educational institutions as a venue to reach a population that is entering sexual maturity. Several systematic reviews have found beneficial effects of these programmes on HIV-associated knowledge and behaviours, though a subsequent effect of reduced HIV incidence remains unconfirmed. In this systematic review and meta-analysis, the authors included eight randomized controlled trials from sub-Saharan Africa, Europe, and Latin America. Whether using a curriculum- or incentive-based programme, the trials did not provide evidence of an effect of school-based programmes on reducing HIV infection. Nor was there compelling evidence of an effect of these programmes on reducing sexually transmitted infection or pregnancy. This paper highlights the difficulty of translating knowledge and reported behaviors into reductions in HIV infection and other biological outcomes. Further thought is necessary to deliver effective sexual and reproductive health programmes in schools – possibly including incentives, which show some promise but need further evidence on effectiveness. 

Africa, Europe, Latin America
  • share
0 comments.