Articles tagged as "Asia"

Combination harm reduction may be more effective and cost-effective than partial approaches alone

The cost-effectiveness of harm reduction.

Wilson DP, Donald B, Shattock AJ, Wilson D, Fraser-Hurt N. Int J Drug Policy. 2015 Feb;26 Suppl 1:S5-11. doi: 10.1016/j.drugpo.2014.11.007. Epub 2014 Dec 1.

HIV prevalence worldwide among people who inject drugs (PWID) is around 19%. Harm reduction for PWID includes needle-syringe programs (NSPs) and opioid substitution therapy (OST) but often coupled with antiretroviral therapy (ART) for people living with HIV. Numerous studies have examined the effectiveness of each harm reduction strategy. This commentary discusses the evidence of effectiveness of the packages of harm reduction services and their cost-effectiveness with respect to HIV-related outcomes as well as estimate resources required to meet global and regional coverage targets. NSPs have been shown to be safe and very effective in reducing HIV transmission in diverse settings; there are many historical and very recent examples in diverse settings where the absence of, or reduction in, NSPs have resulted in exploding HIV epidemics compared to controlled epidemics with NSP implementation. NSPs are relatively inexpensive to implement and highly cost-effective according to commonly used willingness-to-pay thresholds. There is strong evidence that substitution therapy is effective, reducing the risk of HIV acquisition by 54% on average among PWID. OST is relatively expensive to implement when only HIV outcomes are considered; other societal benefits substantially improve the cost-effectiveness ratios to be highly favourable. Many studies have shown that ART is cost-effective for keeping people alive but there is only weak supportive, but growing evidence, of the additional effectiveness and cost-effectiveness of ART as prevention among PWID. Packages of combined harm reduction approaches are highly likely to be more effective and cost-effective than partial approaches. The coverage of harm reduction programs remains extremely low across the world. The total annual costs of scaling up each of the harm reduction strategies from current coverage levels, by region, to meet WHO guideline coverage targets are high with ART greatest, followed by OST and then NSPs. But scale-up of all three approaches is essential. These interventions can be cost-effective by most thresholds in the short-term and cost-saving in the long-term.

Abstract   Full-text [free] access

Editor’s notes: The spread of HIV among people who inject drugs has driven epidemics throughout regions of eastern Europe, and central and South-East Asia. In eastern Europe and central Asia, the majority of HIV infections have been attributed to injecting drug use. Some countries in the Middle East and North Africa region have also been experiencing rapidly emerging HIV epidemics among people who inject drugs. Harm reduction refers to methods of reducing health risks when eliminating them may not be possible. This paper provides a comprehensive review of evidence on the effectiveness and cost-effectiveness of different harm reduction approaches. These include needle- syringe programmes, opioid substitution therapy (OST), and antiretroviral therapy (ART), when implemented in different settings. Importantly, alongside considering the potential benefits of each approach separately, it makes the case that combination  prevention strategies are synergistic, and may achieve multiple impacts. Sadly still however, the coverage of harm reduction remains very low across the world. An estimated 90% of people who inject drugs worldwide are not accessing needle-syringe programmes, despite this being a highly effective and cost-effective programme. Along with the need for a greater investment in harm reduction, there are socio-political and legislative reasons for poor coverage of harm reduction. This cannot be improved without first addressing the stigma, discrimination and intolerance that restricts the expansion of harm reduction programmes in many settings. Addressing these barriers remains of paramount importance for facilitating effective harm reduction programmes. Encouragingly however, high OST coverage has been reported in Iran, Czech Republic and western Europe, and several countries in Asia and the Middle East have begun to scale-up their programmes. China has recently had the largest OST scale-up programme in the world. Uptake of ART by people living with HIV who inject drugs illustrates the largest disparities with what is required or deemed to be appropriate access. Only 14% of people living with HIV who inject drugs globally, have access to ART, with the largest gaps in ART provision in eastern Europe and central Asia. The further expansion of harm reduction is urgently needed, both to meet WHO targets, and to achieve the UNAIDS 90-90-90 target.

Asia, Europe, Oceania
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Can a simple risk score predict chronic kidney disease among people living with HIV?

Development and validation of a risk score for chronic kidney disease in HIV infection using prospective cohort data from the D:A:D study.

Mocroft A, Lundgren JD, Ross M, Law M, Reiss P, Kirk O, Smith C, Wentworth D, Neuhaus J, Fux CA, Moranne O, Morlat P, Johnson MA, Ryom L, D:A:D study group, the Royal Free Hospital Clinic Cohort, and the INSIGHT, SMART, and ESPRIT study groups. PLoS Med. 2015 Mar 31;12(3):e1001809. doi: 10.1371/journal.pmed.1001809. eCollection 2015.

Background: Chronic kidney disease (CKD) is a major health issue for HIV-positive individuals, associated with increased morbidity and mortality. Development and implementation of a risk score model for CKD would allow comparison of the risks and benefits of adding potentially nephrotoxic antiretrovirals to a treatment regimen and would identify those at greatest risk of CKD. The aims of this study were to develop a simple, externally validated, and widely applicable long-term risk score model for CKD in HIV-positive individuals that can guide decision making in clinical practice.

Methods and findings: A total of 17 954 HIV-positive individuals from the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) study with ≥3 estimated glomerular filtration rate (eGFR) values after 1 January 2004 were included. Baseline was defined as the first eGFR >60 ml/min/1.73 m2 after 1 January 2004; individuals with exposure to tenofovir, atazanavir, atazanavir/ritonavir, lopinavir/ritonavir, other boosted protease inhibitors before baseline were excluded. CKD was defined as confirmed (>3 mo apart) eGFR ≤60 ml/min/1.73 m2. Poisson regression was used to develop a risk score, externally validated on two independent cohorts. In the D:A:D study, 641 individuals developed CKD during 103 185 person-years of follow-up (PYFU; incidence 6.2/1000 PYFU, 95% CI 5.7-6.7; median follow-up 6.1 y, range 0.3-9.1 y). Older age, intravenous drug use, hepatitis C coinfection, lower baseline eGFR, female gender, lower CD4 count nadir, hypertension, diabetes, and cardiovascular disease (CVD) predicted CKD. The adjusted incidence rate ratios of these nine categorical variables were scaled and summed to create the risk score. The median risk score at baseline was -2 (interquartile range -4 to 2). There was a 1:393 chance of developing CKD in the next 5 y in the low risk group (risk score <0, 33 events), rising to 1:47 and 1:6 in the medium (risk score 0-4, 103 events) and high risk groups (risk score ≥5, 505 events), respectively. Number needed to harm (NNTH) at 5 y when starting unboosted atazanavir or lopinavir/ritonavir among those with a low risk score was 1702 (95% CI 1166-3367); NNTH was 202 (95% CI 159-278) and 21 (95% CI 19-23), respectively, for those with a medium and high risk score. NNTH was 739 (95% CI 506-1462), 88 (95% CI 69-121), and 9 (95% CI 8-10) for those with a low, medium, and high risk score, respectively, starting tenofovir, atazanavir/ritonavir, or another boosted protease inhibitor. The Royal Free Hospital Clinic Cohort included 2548 individuals, of whom 94 individuals developed CKD (3.7%) during 18 376 PYFU (median follow-up 7.4 y, range 0.3-12.7 y). Of 2013 individuals included from the SMART/ESPRIT control arms, 32 individuals developed CKD (1.6%) during 8452 PYFU (median follow-up 4.1 y, range 0.6-8.1 y). External validation showed that the risk score predicted well in these cohorts. Limitations of this study included limited data on race and no information on proteinuria.

Conclusions: Both traditional and HIV-related risk factors were predictive of CKD. These factors were used to develop a risk score for CKD in HIV infection, externally validated, that has direct clinical relevance for patients and clinicians to weigh the benefits of certain antiretrovirals against the risk of CKD and to identify those at greatest risk of CKD.

Abstract  Full-text [free] access

Editor’s notes: The nephrotoxicity of antiretroviral drugs, particularly tenofovir, is of concern, particularly where there is limited access to laboratory monitoring of kidney function. The development of kidney impairment among people with HIV is associated with poor outcomes, and in low resource settings where dialysis is not available this can be catastrophic.

This study, like previous work, attempts to address this problem by developing a risk score for the development of chronic kidney disease (CKD). The strength of this study is the availability of data for over 17 000 men and women living with HIV enrolled in cohort studies for many years, and in over 40 countries globally. The resulting risk score uses nine simple clinical variables which predict CKD both overall, and after starting potentially nephrotoxic antiretrovirals. A short risk score, not including cardiovascular risk factors, which may be more suitable for low resource settings, shows almost as good a prediction of CKD.

So will this risk score become widely used in clinical decision making? For high income countries this tool may be useful to identify people where strategies to prevent cardiovascular and renal disease are best focussed. It may also be useful to identify people at high risk of developing CKD for whom use of tenofovir may be unacceptable, especially when monitoring of kidney function is limited. However, few of the enrolled people were from low and middle income countries, and there was limited information on the race of participants. Therefore, the risk score may need to be validated in low resource settings before it can be widely used. Whether the use of the tool would help to improve clinical outcomes where kidney function is frequently monitored is unclear.

Meanwhile, a new drug formulation, tenofovir alafenamide (TAF), is currently in clinical trials. This appears to be associated with less renal toxicity, and to be safe and well tolerated among adults with decreased kidney function. If future trial results support this evidence, and tenofovir alafenamide becomes widely available, concern about drug nephrotoxicity may become a less pressing clinical issue.

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Out of pocket spending on HIV care in India makes the poor even poorer

Consumption patterns and levels among households with HIV positive members and economic impoverishment due to medical spending in Pune city, India.

Sharma V, Krishnaswamy D, Mulay S. AIDS Care. 2015 Mar 4:1-5. [Epub ahead of print]

HIV infection poses a serious threat to the economy of a household. Out of pocket (OOP) health spending can be prohibitive and can drag households below poverty level. Based on the data collected from a cross-sectional survey of 401 households with HIV+ members in Pune city, India, this paper examines the consumption levels and patterns among households, and comments on the economic impoverishment resulting from OOP medical spending. Analysis reveals that households with HIV positive members spend a major portion of their monthly consumption expenditure on food items. Medical expenditure constitutes a large portion of their total consumption spending. Expenditure on children's education constitutes a minor proportion of total monthly spending. A high proportion of medical expenditure has a bearing on the economic condition of households with HIV positive members. Poverty increases by 20% among the studied HIV households when OOP health spending is adjusted. It increases 18% among male-headed households and 26% among female-headed households. The results reiterate the need of greater support from the government in terms of accessibility and affordability of health care to save households with HIV positive members from economic catastrophe.

Abstract access 

Editor’s notes: This paper describes expenditure patterns for households with one or more people living with HIV. The authors find that medical expenditure within a household with a member living with HIV is relatively high, some 9.6% of total expenditure. Overall, households were economically vulnerable, with health-associated spending often pushing people below the poverty line. This type of research is especially timely in the context of increasing interest in reducing out of pocket expenditure. Further research around the poverty effects of illness is critical to inform policies as universal access to health care becomes a greater international priority.  

Asia
India
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How to reduce attrition among community healthcare workers essential to HIV prevention programmes among female sex-workers

Peer outreach work as economic activity: implications for HIV prevention interventions among female sex workers.

George A, Blankenship KM. PLoS One. 2015 Mar 16;10(3):e0119729. doi: 10.1371/journal.pone.0119729. eCollection 2015.

Female sex workers (FSWs) who work as peer outreach workers in HIV prevention programs are drawn from poor socio-economic groups and consider outreach work, among other things, as an economic activity. Yet, while successful HIV prevention outcomes by such programs are attributed in part to the work of peers who have dense relations with FSW communities, there is scant discussion of the economic implications for FSWs of their work as peers. Using observational data obtained from an HIV prevention intervention for FSWs in south India, we examined the economic benefits and costs to peers of doing outreach work and their implications for sex workers' economic security. We found that peers considered their payment incommensurate with their workload, experienced long delays receiving compensation, and at times had to advance money from their pockets to do their assigned peer outreach work. For the intervention these conditions resulted in peer attrition and difficulties in recruitment of new peer workers. We discuss the implications of these findings for uptake of services, and the possibility of reaching desired HIV outcomes. Inadequate and irregular compensation to peers and inadequate budgetary outlays to perform their community-based outreach work could weaken peers' relationships with FSW community members, undermine the effectiveness of peer-mediated HIV prevention programs and invalidate arguments for the use of peers.

Abstract   Full-text [free] access

Editor’s notes: Many HIV prevention programmes among female sex worker populations recruit female sex workers to act as community health workers. Community health workers act as a bridge between health services and the community, tailoring activities to the local context and encouraging community ownership of programmes. Evidence suggests that female sex workers acting as community health workers can be critical to maximising benefit from HIV prevention programmes. They also provide a network for social and legal advocacy among female sex workers. Yet despite their importance to programmes, attrition among community health workers is often high and little research has been done to investigate why this might be. This paper gathers data from India and finds that an HIV prevention programme paid community health workers much less than they could have earned through sex-work, while the large workload meant they spent far more time on outreach activities than they were paid for. This encouraged attrition of the community health worker workforce, which could have substantially reduced the impact of the HIV prevention programme. The authors suggest that the importance of community health workers to programmes should be reflected by providing sufficient payment for outreach work. Although this study was carried out among a female sex worker population, these findings are relevant anywhere community health workers are used to deliver programmes elsewhere. Furthermore, other research has suggested that an important motivation for community health workers to take on work is to reduce their economic vulnerability. If programmes pay community health workers too little, or unreliably, they can actually increase the economic vulnerability of the very people they are seeking to protect.

Asia
India
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Potential for psychological programmes for mental disorders among people living with HIV: further studies necessary in sub-Saharan Africa

Psychological interventions for common mental disorders for people living with HIV in low- and middle-income countries: systematic review.

Chibanda D, Cowan FM, Healy JL, Abas M, Lund C. Trop Med Int Health. 2015 Mar 7. doi: 10.1111/tmi.12500. [Epub ahead of print]

Objective: To assess the effectiveness of structured psychological interventions against common mental disorders (CMD) in people living with HIV infection (PLWH), in low- and middle-income countries (LMIC).

Methods: Systematic review of psychological interventions for CMD from LMIC for PLWH, with two-stage screening carried out independently by 2 authors.

Results: Of 190 studies, 5 met inclusion criteria. These were randomised-controlled trials based on the principles of cognitive behaviour therapy (CBT) and were effective in reducing CMD symptoms in PLWH. Follow-up of study participants ranged from 6 weeks to 12 months with multiple tools utilised to measure the primary outcome. Four studies showed a high risk of bias, while 1 study from Iran met low risk of bias in all 6 domains of the Cochrane risk of bias tool and all 22 items of the CONSORT instrument.

Conclusion: There is a need for more robust and adequately powered studies to further explore CBT-based interventions in PLWH. Future studies should report on components of the psychological interventions, fidelity measurement and training, including supervision of delivering agents, particularly where lay health workers are the delivering agent.

Abstract   Full-text [free] access

Editor’s notes: Common mental disorders (CMD) including depression and anxiety, are highly prevalent among people living with HIV and contribute to poor HIV outcomes, including treatment failure. However, the lack of mental health professionals in many low- and middle-income countries means that lay health workers can play an important role in treating CMD. This has been well-documented from non-HIV settings, but not among people living with HIV. This systematic review found that few studies have rigorously evaluated the effectiveness of psychological programmes for CMD among people living with HIV (and only one from sub-Saharan Africa), but all of these reported benefits in the activity arm compared to the control arm. This suggests that further, large, well-designed trials are necessary to evaluate such activities especially in countries most severely affected by HIV in southern and eastern Africa. Key points raised by this review include the need for locally validated tools to assess mental health outcomes in future trials. The importance of formative work to develop and finalise the programme for the trial setting, including local stakeholders, systems for assessing the fidelity of the activity, and a referral or supervision plan, is ever more emphasized.  

Africa, Asia
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Barriers and facilitators of safer sexual behaviour for people living with HIV on ART

Intimacy versus isolation: a qualitative study of sexual practices among sexually active HIV-infected patients in HIV care in Brazil, Thailand, and Zambia.

Closson EF, Mimiaga MJ, Sherman SG, Tangmunkongvorakul A, Friedman RK, Limbada M, Moore AT, Srithanaviboonchai K, Alves CA, Roberts S, Oldenburg CE, Elharrar V, Mayer KH, Safren SA, HPTN063 study team. PLoS One. 2015 Mar 20;10(3):e0120957. doi: 10.1371/journal.pone.0120957. eCollection 2015.

The success of global treatment as prevention (TasP) efforts for individuals living with HIV/AIDS (PLWHA) is dependent on successful implementation, and therefore the appropriate contribution of social and behavioral science to these efforts. Understanding the psychosocial context of condomless sex among PLWHA could shed light on effective points of intervention. HPTN 063 was an observational mixed-methods study of sexually active, in-care PLWHA in Thailand, Zambia, and Brazil as a foundation for integrating secondary HIV prevention into HIV treatment. From 2010-2012, 80 qualitative interviews were conducted with PLWHA receiving HIV care and reported recent sexual risk. Thirty men who have sex with women (MSW) and 30 women who have sex with men (WSM) participated in equal numbers across the sites. Thailand and Brazil also enrolled 20 biologically-born men who have sex with men (MSM). Part of the interview focused on the impact of HIV on sexual practices and relationships. Interviews were recorded, transcribed, translated into English and examined using qualitative descriptive analysis. The mean age was 25 (SD = 3.2). There were numerous similarities in experiences and attitudes between MSM, MSW and WSM across the three settings. Participants had a high degree of HIV transmission risk awareness and practiced some protective sexual behaviors such as reduced sexual activity, increased use of condoms, and external ejaculation. Themes related to risk behavior can be categorized according to struggles for intimacy and fears of isolation, including: fear of infecting a sex partner, guilt about sex, sexual communication difficulty, HIV-stigma, and worry about sexual partnerships. Emphasizing sexual health, intimacy and protective practices as components of nonjudgmental sex-positive secondary HIV prevention interventions is recommended. For in-care PLWHA, this approach has the potential to support TasP. The overlap of themes across groups and countries indicates that similar intervention content may be effective for a range of settings.

Abstract   Full-text [free] access

Editor’s notes: Antiretroviral therapy has transformed the lives of many people living with HIV, holding the promise of sustaining health well into older age. Yet, as the authors of this paper remind us, HIV remains a stigmatised condition. Because of the fear and prejudice which continue to surround HIV, living with the infection while on antiretroviral therapy remains challenging not least because of its impact on intimate relationships. Using qualitative data from three very different cultural settings, the authors illustrate the continuing impact of HIV infection on the lives of people taking antiretroviral therapy. Many people in the study were keen to reduce the risk of infecting others through risky sexual behaviour. As a consequence, some struggled to establish and sustain intimate relationships trapped in feelings of shame about their infection and guilt about sexual enjoyment. The findings in this paper are not new. But what is interesting is how similar the experience of women and men living with HIV was across the different settings. As the health of more and more people living with HIV is sustained through antiretroviral therapy, there is a continuing and urgent need for programmes that address the fears and concerns that they may have about sexual behaviour. 

Africa, Asia, Latin America
Brazil, Thailand, Zambia
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Boosted protease inhibitor monotherapy as second-line ART: a strategy for resource-limited settings?

Lopinavir/ritonavir monotherapy as second-line antiretroviral treatment in resource-limited settings - week 104 analysis of ACTG A5230.

Kumarasamy N, Aga E, Ribaudo HJ, Wallis CL, Katzenstein DA, Stevens WS, Norton MR, Klingman KL, Hosseinipour MC, Crump JA, Supparatpinyo K, Badal-Faesen S, Bartlett JA. Clin Infect Dis. 2015 Feb 18. pii: civ109. [Epub ahead of print]

Objective: ACTG A5230 evaluated lopinavir/ritonavir (LPV/r) monotherapy following virologic failure on first-line regimens in Africa and Asia.

Methods: Eligible subjects had received first-line regimens for at least 6 months and had plasma HIV-1 RNA levels 1000-200 000copies/mL. All subjects received LPV/r 400/100mg twice daily. Virologic failure (VF) was defined as failure to suppress to <400 copies/mL by week 24, or confirmed rebound to >400 copies/mL at or after week 16 following confirmed suppression. Subjects with VF added emtricitabine 200mg/tenofovir 300mg (FTC/TDF) once daily. The probability of continued HIV-1 RNA <400 copies/mL on LPV/r-monotherapy through week 104 was estimated with a 95% confidence interval (CI); predictors of treatment success were evaluated with Cox proportional hazards models.

Results: 123 subjects were enrolled. Four subjects died and 2 discontinued prematurely; 117 /123 (95%) completed 104 weeks. Through week 104, 49 subjects met the primary endpoint; 47 had VF, and 2 intensified treatment without VF. Of the 47 subjects with VF, 41 (33%) intensified treatment, and 39/41 subsequently achieved levels <400 copies/mL. The probability of continued suppression <400copies/mL over 104 weeks on LPV/r-monotherapy was 60% [95% CI 50%, 68%]; 80-85% maintained levels <400 copies/mL with FTC/TDF intensification as needed. Ultrasensitive assays on specimens with HIV-1 RNA level<400 copies/mL at weeks 24, 48 and 104 revealed that 61%, 62% and 65% were suppressed to <40 copies/mL, respectively.

Conclusion: LPV/r monotherapy after first-line virologic failure with FTC/TDF intensification when needed provides durable suppression of HIV-1 RNA over 104 weeks.

Abstract access 

Editor’s notes: First-line antiretroviral therapy failure is increasingly encountered in resource-limited settings. However limited access to viral load monitoring means that treatment failure is often not recognised until immunological or clinical failure occurs. Late switching can lead to the accumulation of resistance mutations. Resistance to nucleoside reverse transcriptase inhibitors (NRTI) is of particular concern as this class remains a component of second-line, boosted protease inhibitor (bPI)-based regimens. Several studies have now looked at boosted protease inhibitor monotherapy as an alternative strategy. A strategy which aims to limit the toxicity and additional cost associated with NRTIs. In general boosted protease inhibitor monotherapy has been found to have inferior virologic outcomes when compared to bPI plus two NRTIs or bPI plus raltegravir.

In this study, while short term virologic outcomes were favourable (87% probability of continued virologic suppression over 24 weeks); longer term outcomes with bPI monotherapy were less good. However, with frequent viral load monitoring, 4-12 weekly, early detection of virologic failure and intensification with two NRTIs, outcomes in the bPI monotherapy arm improved substantially. This strategy warrants further investigation. But without markedly increasing access to viral load monitoring and lowering the cost to allow frequent testing, it is difficult to see how this strategy could be implemented in practice in resource-constrained settings. 

HIV Treatment
Africa, Asia
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Adolescent adherence to antiretroviral therapy: what matters?

Factors associated with adherence to antiretroviral therapy among adolescents living with HIV/AIDS in low- and middle-income countries: a systematic review.

Hudelson C, Cluver L. AIDS Care. 2015 Feb 23:1-12. [Epub ahead of print]

Adolescents living in low- and middle-income countries (LMICs) are disproportionately burdened by the global HIV/AIDS pandemic. Maintaining medication adherence is vital to ensuring that adolescents living with HIV/AIDS receive the benefits of antiretroviral therapy (ART), although this group faces unique challenges to adherence. Knowledge of the factors influencing adherence among people during this unique developmental period is needed to develop more targeted and effective adherence-promoting strategies. This systematic review summarizes the literature on quantitative observational studies examining correlates, including risk and resilience-promoting factors, of ART adherence among adolescents living with HIV/AIDS in LMICs. A systematic search of major electronic databases, conference-specific databases, gray literature, and reference lists of relevant reviews and documents was conducted in May 2014. Included studies examined relationships between at least one factor and ART adherence as an outcome and were conducted in primarily an adolescent population (age 10-19) in LMICs. The search identified 7948 unique citations from which 15 studies fit the inclusion criteria. These 15 studies identified 35 factors significantly associated with ART adherence representing a total of 4363 participants across nine different LMICs. Relevant studies revealed few consistent relationships between measured factors and adherence while highlighting potentially important themes for ART adherence including the impact of (1) adolescent factors such as gender and knowledge of serostatus, (2) family structure, (3) the burdensome ART regimens, route of administration, and attitudes about medication, and (4) health care and environmental factors, such as rural versus urban location and missed clinic appointments. Rates of adherence across studies ranged from 16% to 99%. This review identifies unique factors significantly related to ART adherence among adolescents living in LMICs. More research using longitudinal designs and rigorous measures of adherence is required in order to identify the range of factors influencing ART adherence as adolescents living with HIV/AIDS in LMICs grow into adulthood.

Abstract access 

Editor’s notes: Expanded access to antiretroviral therapy (ART) and scale-up of programmes to prevent mother-to-child HIV transmission has resulted in the burden of paediatric HIV infection shifting onto adolescents, in low- and middle-income countries. Adolescents and young adults account for 41% of incident infections globally and are the only age group for which AIDS-associated deaths have risen in the past decade.

As the number of adolescents on ART increases, sustaining optimal adherence has emerged as the key challenge. While there are limited adolescent-specific data available, estimates of ART adherence suggest that adolescents have much poorer adherence than adults. This leads to increased risk of disease progression, transmission to sexual partners and antiretroviral drug resistance.

There is a growing body of literature that has examined factors affecting adherence, but to date the focus has been on adults and young children. Therefore, this systematic review of factors associated with good and suboptimal adherence specifically among adolescents aged 10 to 19 years, is timely.

There were a diverse range of factors associated with adherence across the fifteen studies considered. These include knowledge of serostatus, the influence of family structure, burdensome regimens, route of administration (caregiver giving medication versus adolescent self-medicating), and attitudes about medication and missed appointments. These factors likely interact with the complexities faced during adolescence to increase the risk of suboptimal adherence.   

The studies considered in this review had significant weaknesses. Firstly, most studies were cross-sectional. Therefore the extent to which causality between the considered factors and adherence can be inferred is limited. Secondly, not all studies reported on the strengths of the relationship between the factors and adherence or accounted for confounding. Thirdly, the method of measuring adherence varied between studies. Only one study in the review used a gold standard, objective treatment outcome measure, HIV viral load.

Notwithstanding these limitations, this is the first study to examine correlates of adherence to ART in adolescence. Although there were few consistent relationships between these factors and adherence, the study does suggest potential activities to improve adherence.

Given the central role of adolescents in determining the trajectory of the HIV epidemic, there is a need for more rigorous research to define factors affecting adherence behaviours among adolescents. Programmes addressing important risk- and resilience-promoting factors such as caregiver support and less burdensome regimens have potential to improve adherence. 

Africa, Asia, Europe, Latin America
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Injecting drug use increases risk of TB disease in Indonesians living with HIV

Active and latent tuberculosis among HIV-positive injecting drug users in Indonesia.

Meijerink H, Wisaksana R, Lestari M, Meilana I, Chaidir L, van der Ven AJ, Alisjahbana B, van Crevel R. J Int AIDS Soc. 2015 Feb 16;18(1):19317. doi: 10.7448/IAS.18.1.19317. eCollection 2015.

Introduction: Injecting drug use (IDU) is associated with tuberculosis but few data are available from low-income settings. We examined IDU in relation to active and latent tuberculosis (LTBI) among HIV-positive individuals in Indonesia, which has a high burden of tuberculosis and a rapidly growing HIV epidemic strongly driven by IDU.

Methods: Active tuberculosis was measured prospectively among 1900 consecutive antiretroviral treatment (ART)-naive adult patients entering care in a clinic in West Java. Prevalence of LTBI was determined cross-sectionally in a subset of 518 ART-experienced patients using an interferon-gamma release assay.

Results: Patients with a history of IDU (53.1%) more often reported a history of tuberculosis treatment (34.8% vs. 21.9%, p < 0.001), more often received tuberculosis treatment during follow-up (adjusted HR = 1.71; 95% CI: 1.25-2.35) and more often had bacteriologically confirmed tuberculosis (OR = 1.67; 95% CI: 0.94-2.96). LTBI was equally prevalent among people with and without a history of IDU (29.1 vs. 30.4%, NS). The risk estimates did not change after adjustment for CD4 cell count or ART.

Conclusions: HIV-positive individuals with a history of IDU in Indonesia have more active tuberculosis, with similar rates of LTBI. Within the HIV clinic, LTBI screening and isoniazid preventive therapy may be prioritized to patients with a history of IDU.

Abstract  Full-text [free] access

Editor’s notes: In Europe and northern America, HIV-positive people who inject drugs are at greater risk of TB infection and disease compared with other HIV-positive individuals. In many Asian countries, there is a growing problem of injecting drug use which has contributed to the HIV epidemic. This study explored the association between injecting drug use and TB among people living with HIV in Indonesia. The main analysis included 1900 HIV-positive, ART-naive individuals without TB disease and followed them from enrolment in HIV care to starting TB treatment. Just over half of the study population gave a history of injecting drug use. There was no differentiation between current and historical drug use.

A history of injecting drug use was associated with a 71% increased risk of TB disease during the first year after enrolment in HIV care. This association was maintained after adjusting for age, CD4 cell count and the use of antiretroviral therapy. The association was similar when the analysis was restricted to microbiologically-proven TB disease. The divergence in risk seemed to be early after enrolment, the first six months after entering HIV care. And the majority of TB diagnoses occurred before initiation of ART. This suggests the need for intensified TB diagnostic strategies on enrolment in HIV care. Despite enrolment over almost six years and follow-up for up to six years, the median follow-up was less than a year in the group without a history of injecting drug use. This compares to just under two years for people who inject drugs. This suggests substantial loss to follow-up and may have contributed to the higher observed risk of TB among people who inject drugs. 

This article also reports the prevalence of a positive QuantiFERON Gold In-Tube assay in a separate group of HIV-positive individuals with a median time on ART of over two years. There was no difference in the proportion with a positive QuantiFERON test among individuals with and without a history of injecting drug use. This was a very different study population, however, with a median CD4 cell count >350 cells/µl. Almost half reported previous TB treatment, which makes the QuantiFERON results more difficult to interpret.

These data underline the importance of screening for active TB among people entering HIV care, and of isoniazid preventive therapy for individuals with latent infection.

Avoid TB deaths
Asia
Indonesia
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Don’t ask, don’t tell: concealment as a stigma management strategy in India

'I am doing fine only because I have not told anyone': the necessity of concealment in the lives of people living with HIV in India.

George MS, Lambert H. Cult Health Sex. 2015 Feb 23:1-14. [Epub ahead of print]

In HIV prevention and care programmes, disclosure of status by HIV-positive individuals is generally encouraged to contain the infection and provide adequate support to the person concerned. Lack of disclosure is generally framed as a barrier to preventive behaviours and accessing support. The assumption that disclosure is beneficial is also reflected in studies that aim to identify determinants of disclosure and recommend individual-level measures to promote disclosure. However, in contexts where HIV infection is stigmatised and there is fear of rejection and discrimination among those living with HIV, concealment of status becomes a way to try and regain as much as possible the life that was disrupted by the discovery of HIV infection. In this study of HIV-positive women and children in India, concealment was considered essential by individuals and families of those living with HIV to re-establish and maintain their normal lives in an environment where stigma and discrimination were prevalent. This paper describes why women and care givers of children felt the need to conceal HIV status, the various ways in which people tried to do so and the implications for treatment of people living with HIV. We found that while women were generally willing to disclose their status to their husband or partner, they were very keen to conceal their status from all others, including family members. Parents and carers with an HIV-positive child were not willing to disclose this status to the child or to others. Understanding the different rationales for concealment would help policy makers and programme managers to develop more appropriate care management strategies and train care providers to assist clients in accessing care and support without disrupting their lives.

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Editor’s notes: This paper provides a powerful illustration of the persistence of stigma in the lives of many people living with HIV in India. Using data collected in 2012, the authors illustrate how prejudice and discrimination shape the lives of the women and children included in this study. While access to antiretroviral therapy (ART) provided a way for participants to regain and maintain what is described as ‘normal life’, that same treatment could result in unintended disclosure. Participants spoke of the fear of being seen carrying ART, since illustrations of the pills were widely available at clinics. They described the challenges of disclosing to their children as well as other relatives. Disclosure to wider social networks posed a reputational threat because of the association of HIV with moral laxity. All these are challenges that many people face in other settings too, providing further evidence of the persistence of HIV-associated stigma. The authors also illustrate the unintended consequences of well-meaning policies. One striking illustration came from a participant who was using a free travel pass, available to people living with HIV to collect their treatment. The pass included the word ‘AIDS’ and a ticket collector ridiculed the woman and her husband in front of other passengers because of this evidence of infection. The authors make the point that encouraging disclosure may overlook the importance of concealment as a way to cope with stigma. 

Asia
India
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