Articles tagged as "Asia"

The impact of homophobia and criminalisation on MSM HIV vulnerability worldwide

Sexual stigma, criminalization, investment, and access to HIV services among men who have sex with men worldwide.

Arreola S, Santos GM, Beck J, Sundararaj M, Wilson PA, Hebert P, Makofane K, Do TD, Ayala G. AIDS Behav. 2015 Feb;19(2):227-34. doi: 10.1007/s10461-014-0869-x.

Globally, HIV disproportionately affects men who have sex with men (MSM). This study explored associations between access to HIV services and (1) individual-level perceived sexual stigma; (2) country-level criminalization of homosexuality; and (3) country-level investment in HIV services for MSM. 3340 MSM completed an online survey assessing access to HIV services. MSM from over 115 countries were categorized according to criminalization of homosexuality policy and investment in HIV services targeting MSM. Lower access to condoms, lubricants, and HIV testing were each associated with greater perceived sexual stigma, existence of homosexuality criminalization policies, and less investment in HIV services. Lower access to HIV treatment was associated with greater perceived sexual stigma and criminalization. Criminalization of homosexuality and low investment in HIV services were both associated with greater perceived sexual stigma. Efforts to prevent and treat HIV among MSM should be coupled with structural interventions to reduce stigma, overturn homosexuality criminalization policies, and increase investment in MSM-specific HIV services.

Abstract access 

Editor’s notes: Homosexuality is still illegal in 39% of the 193 UN recognised countries. This criminalisation likely increases HIV vulnerability among gay men and other men who have sex with men. In this study, 3340 gay men and other men who have sex with men from more than 115 countries completed an online survey about their perceptions of homophobia and their ease of accessing basic HIV prevention services. The authors conducted an ecological analysis to examine the relationship between the uptake of HIV services among gay men and other men who have sex with men. The authors looked at structural factors at the individual level which included their perceptions of homophobia within the society in which they live and at the country level including criminalising policies. More than 50% of respondents reported difficulty in accessing HIV services including condoms, lubricants, HIV testing services and antiretroviral therapy (ART). Perceived homophobia, criminalization of homosexual behaviour, and low country investment in HIV services were each associated with reduced access to condoms, lubricants, HIV testing services and ART. Improving access to HIV services for gay men and other men who have sex with men is urgently required as they carry a disproportionate burden of HIV in low and middle income countries. This study adds to a body of evidence which suggests that addressing structural barriers such as the criminalisation of homosexuality and sexual stigma (homophobia) will be necessary to reduce HIV vulnerability among gay men and other men who have sex with men, globally.

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Savings-led microfinance programme leads to lower sexual risk among sex workers in Mongolia

Efficacy of a savings-led microfinance intervention to reduce sexual risk for HIV among women engaged in sex work: a randomized clinical trial.

Witte SS, Aira T, Tsai L, Riedel M, Offringa R, Chang M, El-Bassel N, Ssewamala F. Am J Public Health. 2015 Mar;105(3):e95-e102. doi: 10.2105/AJPH.2014.302291. Epub 2015 Jan 20.

Objectives: We tested whether a structural intervention combining savings-led microfinance and HIV prevention components would achieve enhanced reductions in sexual risk among women engaging in street-based sex work in Ulaanbaatar, Mongolia, compared with an HIV prevention intervention alone.

Methods: Between November 2011 and August 2012, we randomized 107 eligible women who completed baseline assessments to either a 4-session HIV sexual risk reduction intervention (HIVSRR) alone (n = 50) or a 34-session HIVSRR plus a savings-led microfinance intervention (n = 57). At 3- and 6-month follow-up assessments, participants reported unprotected acts of vaginal intercourse with paying partners and number of paying partners with whom they engaged in sexual intercourse in the previous 90 days. Using Poisson and zero-inflated Poisson model regressions, we examined the effects of assignment to treatment versus control condition on outcomes.

Results: At 6-month follow-up, the HIVSRR plus microfinance participants reported significantly fewer paying sexual partners and were more likely to report zero unprotected vaginal sex acts with paying sexual partners.

Conclusions: Findings advance the HIV prevention repertoire for women, demonstrating that risk reduction may be achieved through a structural intervention that relies on asset building, including savings, and alternatives to income from sex work.

Abstract access

Editor’s notes: This study on sexual risk among sex workers in Ulaanbaatar, Mongolia, contributes to evidence that economic empowerment reduces HIV risk. Mongolia has a low prevalence of HIV. But it is considered highly vulnerable to the spread of HIV. This suggests that such programmes should be implemented to prevent concentrated epidemics becoming generalised epidemics. The authors acknowledge that while microfinance might be economically empowering it may represent “saving down”, which can keep women in debt and in a cycle of poverty and a reliance on sex work. The trial tested whether increasing financial literacy, business development knowledge and skills and personal savings would lead to more significant reductions in sexual risk behaviours than a sexual risk reduction programme alone. Groups of sex workers were randomised to receive either a four session HIV sexual risk reduction programme (HIVSRR) or HIVSRR plus a savings-led microfinance programme. The HIVSRR alone involved the delivery of two sessions per week for two weeks and focused on skills to develop self-efficacy for risk reduction. The HIVSRR plus savings-led microfinance programme involved the four sessions on self-efficacy for risk reduction, followed by 12 financial literacy sessions three times a week and then 12 sessions of business development training three times a week. The activities were tested at three months and six months to explore the short time impact on sexual risk. The authors found that women who received the HIVSSRR plus savings-led microfinance programme reported greater reductions in number of paying sexual partners and fewer sexual partners at six months follow up. These women were also more likely to report no unprotected vaginal sex acts at six months follow up. This study is important in illustrating that as a structural programme, the provision of microfinance is more effective if women are provided with skills to manage finances and to save money instead of ending up in a cycle of debt repayment. This has important implications for other microfinance programmes, such as programmes to reduce gender-based violence.

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Late antiretroviral therapy start persists for children under two years of age in low- and middle-income countries

Immunodeficiency in children starting antiretroviral therapy in low-, middle-, and high-income countries.

Koller M, Patel K, Chi BH, Wools-Kaloustian K, Dicko F, Chokephaibulkit K, Chimbetete C, Avila D, Hazra R, Ayaya S, Leroy V, Truong HK, Egger M, Davies MA, IeDEA, NISDI, PHACS and IMPAACT 219C studies.  J Acquir Immune Defic Syndr. 2015 Jan 1;68(1):62-72. doi: 10.1097/QAI.0000000000000380.

Background: The CD4 cell count or percent (CD4%) at the start of combination antiretroviral therapy (cART) is an important prognostic factor in children starting therapy and an important indicator of program performance. We describe trends and determinants of CD4 measures at cART initiation in children from low-, middle-, and high-income countries.

Methods: We included children aged <16 years from clinics participating in a collaborative study spanning sub-Saharan Africa, Asia, Latin America, and the United States. Missing CD4 values at cART start were estimated through multiple imputation. Severe immunodeficiency was defined according to World Health Organization criteria. Analyses used generalized additive mixed models adjusted for age, country, and calendar year.

Results: A total of 34 706 children from 9 low-income, 6 lower middle-income, 4 upper middle-income countries, and 1 high-income country (United States) were included; 20 624 children (59%) had severe immunodeficiency. In low-income countries, the estimated prevalence of children starting cART with severe immunodeficiency declined from 76% in 2004 to 63% in 2010. Corresponding figures for lower middle-income countries were from 77% to 66% and for upper middle-income countries from 75% to 58%. In the United States, the percentage decreased from 42% to 19% during the period 1996 to 2006. In low- and middle-income countries, infants and children aged 12-15 years had the highest prevalence of severe immunodeficiency at cART initiation.

Conclusions: Despite progress in most low- and middle-income countries, many children continue to start cART with severe immunodeficiency. Early diagnosis and treatment of HIV-infected children to prevent morbidity and mortality associated with immunodeficiency must remain a global public health priority.

Abstract access 

Editor’s notes: This article describes trends and determinants of CD4 cell measures at antiretroviral therapy (ART) initiation in about 35 000 children in low, middle, and high-income countries. Temporal trends in CD4 measures at ART initiation are a useful indicator of the health system’s ability to identify and treat eligible children in a timely fashion. They are also a useful measure of responsiveness to guideline changes.

Previous WHO guidelines recommended early ART initiation, regardless of immunologic or clinical thresholds. But the authors found that in 2010, approximately two-thirds of children below two years of age, in low- and middle-income countries were still starting ART with severe immunodeficiency.

Delayed country-level implementation of WHO guidelines, poor access to early infant diagnosis, slow turn-around time of test results, and limited ART availability for infants and young children are all contributing factors to this delayed ART initiation. The authors point out that timely diagnosis of paediatric HIV does not necessarily result in timely ART. The main reasons for this diagnosis to treatment gap include HIV diagnostic tests and paediatric ART being located at separate sites without robust referral mechanisms between services. There are challenges with CD4 measurement to determine eligibility. These include access to tests, turn-around time and interpretation of results and health care worker discomfort with treating children.

Currently, only 22% of children living with HIV in sub-Saharan Africa are receiving ART. To decrease the treatment gap among children, WHO 2013 guidelines recommend universal ART for all children living with HIV, aged below five years of age, irrespective of CD4 count or clinical stage. Removing the requirement for a CD4 measurement also removes the time lag while waiting for CD4 results. Thus the guidelines aim both to increase treatment accessibility and to accelerate treatment initiation for all children. 

HIV Treatment
Africa, Asia, Northern America
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Sexual health of the partners of people who inject drugs

'Women at risk': the health and social vulnerabilities of the regular female partners of men who inject drugs in Delhi, India.

Sharma V, Sarna A, Luchters S, Sebastian M, Degomme O, Saraswati LR, Madan I, Thior I, Tun W. Cult Health Sex. 2014 Dec 2:1-15. [Epub ahead of print]

Needle and syringe sharing is common among people who inject drugs and so is unprotected sex, which consequently puts their sex partners at risk of sexually transmitted infections (STIs) including HIV and other blood-borne infections, like hepatitis. We undertook a nested study with the regular female partners of men who inject drugs participating in a longitudinal HIV incidence study in Delhi, India. In-depth interviews were conducted with female partners of 32 men. The interviews aimed to gather focused and contextual knowledge of determinants of safe sex and reproductive health needs of these women. Information obtained through interviews was triangulated and linked to the baseline behavioural data of their partner (index men who injected drugs). The study findings illustrate that women in monogamous relationships have a low perception of STI- and HIV-related risk. Additionally, lack of awareness about hepatitis B and C is a cause of concern. Findings also suggest impact of male drug use on the fertility of the female partner. It is critical to empower regular female partners to build their self-risk assessment skills and self-efficacy to negotiate condom use. Future work must explore the role of drug abuse among men who inject drugs in predicting fertility and reproductive morbidity among their female partners.

Abstract access 

Editor’s notes: This is an interesting study describing the HIV and sexual health needs of female partners of people who inject drugs (PWID). The study’s strengths lie in the innovative way in which female partners of PWID were reached and recruited into the study. Female partners of PWID are a highly hidden group and there has been little research conducted among them, with research focussing mostly on PWID and their HIV risk. Therefore the approach to identifying female partners through an existing cohort of male PWID is highly innovative and provides new information on a hidden population. Findings have important implications for HIV programmes for this population. These include the need to increase uptake of HIV testing, teach the importance of condoms as a contraceptive method and for HIV prevention, as well as dispelling myths that assumed monogamy is a sufficient prevention tool. The paper clearly illustrates that addressing sexual and reproductive health needs of this population is paramount, including addressing problems with infertility and the need for contraceptives. The paper usefully highlights the impact of a male partner’s drug use on the daily lives of their female partner, including increased poverty and high levels of violence.

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Increasing transmitted resistance to antiretroviral therapy in low/middle-income countries - highest prevalence in MSM

Global burden of transmitted HIV drug resistance and HIV-exposure categories: a systematic review and meta-analysis.

Pham QD, Wilson DP, Law MG, Kelleher AD, Zhang L. AIDS. 2014 Nov 28;28(18):2751-62. doi: 10.1097/QAD.0000000000000494.

Objectives: Our aim was to review the global disparities of transmitted HIV drug resistance (TDR) in antiretroviral-naive MSM, people who inject drugs (PWID) and heterosexual populations in both high-income and low/middle-income countries.

Design/methods: We undertook a systematic review of the peer-reviewed English literature on TDR (1999-2013). Random-effects meta-analyses were performed to pool TDR prevalence and compare the odds of TDR across at-risk groups.

Results: A total of 212 studies were included in this review. Areas with greatest TDR prevalence were North America (MSM: 13.7%, PWID: 9.1%, heterosexuals: 10.5%); followed by western Europe (MSM: 11.0%, PWID: 5.7%, heterosexuals: 6.9%) and South America (MSM: 8.3%, PWID: 13.5%, heterosexuals: 7.5%). Our data indicated disproportionately high TDR burdens in MSM in Oceania (Australia 15.5%), eastern Europe/central Asia (10.2%) and east Asia (7.8%). TDR epidemics have stabilized in high-income countries, with a higher prevalence (range 10.9-12.6%) in MSM than in PWID (5.2-8.3%) and heterosexuals (6.4-9.0%) over 1999-2013. In low/middle-income countries, TDR prevalence in all at-risk groups in 2009-2013 almost doubled than that in 2004-2008 (MSM: 7.8 vs. 4.2%, P = 0.011; heterosexuals: 4.1 vs. 2.6%, P < 0.001; PWID: 4.8 vs. 2.4%, P = 0.265, respectively). The risk of TDR infection was significantly greater in MSM than that in heterosexuals and PWID. We observed increasing trends of resistance to non-nucleoside reverse transcriptase and protease inhibitors among MSM.

Conclusion: TDR prevalence is stabilizing in high-income countries, but increasing in low/middle-income countries. This is likely due to the low, but increasing, coverage of antiretroviral therapy in these settings. Transmission of TDR is most prevalent among MSM worldwide.

Abstract access 

Editor’s notes: HIV mutates very rapidly, and many early antiretroviral agents had a low genetic barrier to the development of resistance. Thus the emergence of virus resistant to antiretroviral agents, particularly to early drug classes, was inevitable. Surveillance for drug-resistant virus among people with no prior history of taking antiretroviral drugs (transmitted drug resistance) is essential to monitor the spread of drug resistance at population level.

This systematic review aimed to compare transmitted drug resistance in different geographical regions and between subpopulations of HIV-positive people by likely route of transmission. Transmitted resistance was most prevalent in high income settings. This is not surprising given wide use of suboptimal drug regimens before effective triple therapy was available. Reassuringly, the prevalence of transmitted resistance seems to have stabilised in high-income settings. The increase in transmitted resistance in low and middle income countries is of more concern. It is not surprising, given that first-line regimens comprising two nucleoside reverse transcriptase inhibitors and a non-nucleoside reverse transcriptase inhibitor are vulnerable to the development of resistance if the drug supply is interrupted or adherence is suboptimal. In addition, if viral load monitoring is not available, people remain on failing drug regimens for longer, and thus have more risk of transmitting resistant virus.

Within the subpopulations examined in this review, transmitted resistance was consistently higher in men who have sex with men, suggesting that resistance testing prior to treatment is particularly valuable for this population.

Limitations of the review include exclusion of studies that did not compare transmitted resistance between the specified subpopulations, and small sample size in many subgroups.

Continued surveillance for transmitted drug resistance is critical. This is most important in settings where individualised resistance testing is not available. This will ensure that people starting antiretroviral therapy receive treatment that will suppress their viral load effectively. Wider use of viral load monitoring, combined with access to effective second and third line regimens, will also help limit spread of drug resistance.

HIV Treatment
Angola, Argentina, Australia, Austria, Belgium, Benin, Botswana, Brazil, Burkina Faso, Cambodia, Cameroon, Canada, Central African Republic, Chad, China, Côte d'Ivoire, Croatia, Cuba, Cyprus, Denmark, Dominican Republic, El Salvador, Estonia, Ethiopia, France, Gabon, Georgia, Germany, Greece, Guatemala, Honduras, Hong Kong Special Administrative Region of China, Hungary, India, Indonesia, Ireland, Israel, Italy, Japan, Kazakhstan, Kenya, Latvia, Malawi, Malaysia, Moldova, Mozambique, Netherlands, Peru, Philippines, Poland, Portugal, Republic of Korea, Romania, Russia, Rwanda, Slovenia, South Africa, Spain, Swaziland, Sweden, Switzerland, Taiwan, Thailand, Uganda, United Kingdom of Great Britain and Northern Ireland, United Republic of Tanzania, United States of America, Viet Nam, Zambia, Zimbabwe
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TB pre- and post- antiretroviral therapy initiation in India

Incidence and mortality of tuberculosis before and after initiation of antiretroviral therapy: an HIV cohort study in India.

Alvarez-Uria G, Pakam R, Midde M, Naik PK. J Int AIDS Soc. 2014 Dec 9;17:19251. doi: 10.7448/IAS.17.1.19251. eCollection 2014.

Introduction: India has the highest burden of tuberculosis (TB) in the world, but the epidemiology of HIV-associated TB is not well known.

Methods: We describe the incidence and the mortality of TB from HIV diagnosis to antiretroviral therapy (ART) initiation (pre-ART group) and after ART initiation (on-ART group) in an HIV cohort study in Anantapur, India. Multivariable analysis of factors associated with TB was performed using competing risk regression and restricted cubic spline methods.

Results: A total of 4590 patients and 3133 person-years (py) of follow-up were included in the pre-ART group, and 3784 patients and 4756 py were included in the on-ART group. In the pre-ART group, the incidence of TB was high during the first month after HIV diagnosis and dropped nearly four times soon after. In the on-ART group, the incidence of TB increased after ART initiation reaching a peak in the third month. The probability of having TB within 30 months was 22.3% (95% confidence interval [CI], 21.1-23.6) in the pre-ART group and 17.8% (95% CI, 16.3-19.3) in the on-ART group. In a multivariable analysis, women had a lower risk of TB in both groups. Poor socio-economic conditions were associated with an increased risk of TB in the pre-ART group, but not in the group on-ART. While the association between low CD4 counts and TB was strong in the pre-ART group, this association was weaker in the on-ART group, and the highest risk of TB was seen in those patients with CD4 counts around 110 cells/mm3. The cumulative incidence of mortality at 12 months in patients with TB was 29.6% (95% CI, 26.9-32.6) in pre-ART TB and 34.9% (95% CI, 31-39.1) in on-ART TB. Half deaths before ART initiation and two thirds of deaths after ART initiation occurred in patients with TB.

Conclusions: The high incidence and mortality of TB seen in this study underscore the urgent need to improve the prevention and diagnosis of HIV-associated TB in India. We found substantial differences between TB before and after ART initiation.

Abstract  Full-text [free] access

Editor’s notes: Although India has a huge burden of TB, there are relatively few published data regarding the epidemiology of HIV-associated TB, which this retrospective analysis begins to address. This study describes the incidence of TB and mortality among people with TB. The study looked at a cohort of people living with HIV, attending a rural hospital funded by a non-governmental organisation where medical care, including antiretroviral therapy and TB treatment, were provided free of charge. The authors report extremely high incidence of TB shortly after both HIV diagnosis and antiretroviral therapy initiation. They also report high mortality among individuals with TB, all of which are far greater than described in antiretroviral therapy programmes in South Africa. As the authors note, this likely reflects multiple issues. These include the fact that people often first present for HIV care due to symptoms of TB, unsatisfactory screening for TB, and inadequate investigation of individuals with TB symptoms, which relies on sputum microscopy and radiology. Furthermore, isoniazid preventive therapy is not yet implemented in India and the authors report that buildings designated as antiretroviral therapy centres are often inadequate in terms of infection control. This study highlights the urgency of comprehensive implementation of WHO’s three I’s (intensified case finding, isoniazid preventive therapy, infection control) for tuberculosis strategy in this setting and access to better, affordable and rapid diagnostic tests for TB.

Avoid TB deaths
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Disease-specific Global Fund grants may be preventing the realisation of system-wide synergies for increased human resources for health

Global Fund investments in human resources for health: innovation and missed opportunities for health systems strengthening.

Bowser D, Sparkes SP, Mitchell A, Bossert TJ, Bärnighausen T, Gedik G, Atun R. Health Policy Plan. 2014 Dec;29(8):986-97. doi: 10.1093/heapol/czt080. Epub 2013 Nov 6.

Background: Since the early 2000s, there have been large increases in donor financing of human resources for health (HRH), yet few studies have examined their effects on health systems.

Objective: To determine the scope and impact of investments in HRH by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), the largest investor in HRH outside national governments.

Methods: We used mixed research methodology to analyse budget allocations and expenditures for HRH, including training, for 138 countries receiving money from the Global Fund during funding rounds 1-7. From these aggregate figures, we then identified 27 countries with the largest funding for human resources and training and examined all HRH-related performance indicators tracked in Global Fund grant reports. We used the results of these quantitative analyses to select six countries with substantial funding and varied characteristics-representing different regions and income levels for further in-depth study: Bangladesh (South and West Asia, low income), Ethiopia (Eastern Africa, low income), Honduras (Latin America, lower-middle income), Indonesia (South and West Asia, lower-middle income), Malawi (Southern Africa, low income) and Ukraine (Eastern Europe and Central Asia, upper-middle income). We used qualitative methods to gather information in each of the six countries through 159 interviews with key informants from 83 organizations. Using comparative case-study analysis, we examined Global Fund's interactions with other donors, as well as its HRH support and co-ordination within national health systems.

Results: Around US$1.4 billion (23% of total US$5.1 billion) of grant funding was allocated to HRH by the 138 Global Fund recipient countries. In funding rounds 1-7, the six countries we studied in detail were awarded a total of 47 grants amounting to US$1.2 billion and HRH budgets of US$276 million, of which approximately half were invested in disease-focused in-service and short-term training activities. Countries employed a variety of mechanisms including salary top-ups, performance incentives, extra compensation and contracting of workers for part-time work, to pay health workers using Global Fund financing. Global Fund support for training and salary support was not co-ordinated with national strategic plans and there were major deficiencies in the data collected by the Global Fund to track HRH financing and to provide meaningful assessments of health system performance.

Conclusion: The narrow disease focus and lack of co-ordination with national governments call into question the efficiency of funding and sustainability of Global Fund investments in HRH and their effectiveness in strengthening recipient countries' health systems. The lessons that emerge from this analysis can be used by both the Global Fund and other donors to improve co-ordination of investments and the effectiveness of programmes in recipient countries.

Abstract access 

Editor’s notes: This study describes Global Fund’s budget allocations, expenditures and specific activities on human resources for health (HRH) from 2002 to 2010. The authors were particularly interested in exploring whether and how these investments contributed to health system strengthening through a more detailed qualitative analysis of six geographically and programmatically different countries.  

They find that the 27 countries with the largest budgeted HRH expenditures allocated some 29.6% to HRH, and had a ratio of 1.35 health workers trained in comparison to the total national health workforce, suggesting duplication of training activities and programme inefficiency. This reflects the confirmed lack of coordination with national HRH training programmes that the authors documented, particularly in Ethiopia, Bangladesh and Malawi. In terms of coordinating HRH salary support and financing plans, only Honduras and Malawi had developed plans for absorbing some of the health workers that were being covered by Global Fund grants. In other countries, the top-ups and monetary compensation/ incentives funded through Global Fund grants to increase retention and motivation, were considered short-term and would not be sustained. Of the six country case studies, it is only in Malawi that the Global Fund coordinated its efforts with the national HRH strategy and other donor programmes.

The study highlights the need for a paradigm shift away from disease-focused grants to co-investments in HIV, tuberculosis and malaria that would allow the realisation of remarkable synergies and efficiency gains.

Africa, Asia, Europe, Latin America
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Antiretroviral therapy alone not enough to reduce TB incidence where HIV- and TB- prevalence is high

Incidence of HIV-associated tuberculosis among individuals taking combination antiretroviral therapy: a systematic review and meta-analysis.

Kufa T, Mabuto T, Muchiri E, Charalambous S, Rosillon D, Churchyard G, Harris RC. PLoS One. 2014 Nov 13;9(11):e111209. doi: 10.1371/journal.pone.0111209. eCollection 2014.

Background: Knowledge of tuberculosis incidence and associated factors is required for the development and evaluation of strategies to reduce the burden of HIV-associated tuberculosis.

Methods: Systematic literature review and meta-analysis of tuberculosis incidence rates among HIV-infected individuals taking combination antiretroviral therapy.

Results: From PubMed, EMBASE and Global Index Medicus databases, 42 papers describing 43 cohorts (32 from high/intermediate and 11 from low tuberculosis burden settings) were included in the qualitative review and 33 in the quantitative review. Cohorts from high/intermediate burden settings were smaller in size, had lower median CD4 cell counts at study entry and fewer person-years of follow up. Tuberculosis incidence rates were higher in studies from sub-Saharan Africa and from World Bank low/middle income countries. Tuberculosis incidence rates decreased with increasing CD4 count at study entry and duration on combination antiretroviral therapy. Summary estimates of tuberculosis incidence among individuals on combination antiretroviral therapy were higher for cohorts from high/intermediate burden settings compared to those from the low tuberculosis burden settings (4.17 per 100 person-years [95% Confidence Interval (CI) 3.39-5.14 per 100 person-years] vs. 0.4 per 100 person-years [95% CI 0.23-0.69 per 100 person-years]) with significant heterogeneity observed between the studies.

Conclusions: Tuberculosis incidence rates were high among individuals on combination antiretroviral therapy in high/intermediate burden settings. Interventions to prevent tuberculosis in this population should address geographical, socioeconomic and individual factors such as low CD4 counts and prior history of tuberculosis.

Abstract Full-text [free] access

Editor’s notes: This systematic review and meta-analysis looks at tuberculosis (TB) incidence rates among adults living with HIV on antiretroviral treatment (ART). The review reinforces and quantifies what we already know about the disparities between low-burden and high-burden settings. TB incidence rates in high and intermediate burden settings are ten times higher than those in low burden settings.

The authors draw attention to the need for implementation of programmes that address the social determinants of TB. Low socio-economic conditions are associated with higher TB incidence rates in individuals on ART. Interestingly, the meta-analysis found that TB incidence rates were higher among individuals on ART who had a previous history of TB, than individuals who did not have a history of previous TB. The epidemiological association between previous TB treatment and active TB was one of the foundations for the emphasis on case retention and cure rates with the Directly Observed Treatment, Short-Course (DOTS) strategy. Yet prevalence surveys conducted in Zimbabwe, South Africa and Zambia in the pre-ART and early ART era did not find an association between a history of previous TB and prevalent active undiagnosed TB in individuals living with HIV. The finding from this meta-analysis suggests that individuals on ART are now surviving long enough to develop recurrent TB disease.

The overall message of the study is that ART alone is not sufficient to reduce TB incidence in high HIV prevalence settings. Additional strategies are required to prevent TB focussing on individuals with low CD4 counts, a history of previous TB disease and people who have recently initiated ART.

Avoid TB deaths
Africa, Asia, Europe, Northern America
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Why pregnant women and mothers living with HIV do not access, or do not stay in care

A systematic review of individual and contextual factors affecting ART initiation, adherence, and retention for HIV-infected pregnant and postpartum women.

Hodgson I, Plummer ML, Konopka SN, Colvin CJ, Jonas E, Albertini J, Amzel A, Fogg KP. PLoS One. 2014 Nov 5;9(11):e111421. doi: 10.1371/journal.pone.0111421. eCollection 2014.

Background: Despite progress reducing maternal mortality, HIV-related maternal deaths remain high, accounting, for example, for up to 24 percent of all pregnancy-related deaths in sub-Saharan Africa. Antiretroviral therapy (ART) is effective in improving outcomes among HIV-infected pregnant and postpartum women, yet rates of initiation, adherence, and retention remain low. This systematic literature review synthesized evidence about individual and contextual factors affecting ART use among HIV-infected pregnant and postpartum women.

Methods: Searches were conducted for studies addressing the population (HIV-infected pregnant and postpartum women), intervention (ART), and outcomes of interest (initiation, adherence, and retention). Quantitative and qualitative studies published in English since January 2008 were included. Individual and contextual enablers and barriers to ART use were extracted and organized thematically within a framework of individual, interpersonal, community, and structural categories.

Results: Thirty-four studies were included in the review. Individual-level factors included both those within and outside a woman's awareness and control (e.g., commitment to child's health or age). Individual-level barriers included poor understanding of HIV, ART, and prevention of mother-to-child transmission, and difficulty managing practical demands of ART. At an interpersonal level, disclosure to a spouse and spousal involvement in treatment were associated with improved initiation, adherence, and retention. Fear of negative consequences was a barrier to disclosure. At a community level, stigma was a major barrier. Key structural barriers and enablers were related to health system use and engagement, including access to services and health worker attitudes.

Conclusions: To be successful, programs seeking to expand access to and continued use of ART by integrating maternal health and HIV services must identify and address the relevant barriers and enablers in their own context that are described in this review. Further research on this population, including those who drop out of or never access health services, is needed to inform effective implementation.

Abstract Full-text [free] access

Editor’s notes: This systematic review is one of three by the same team, related to HIV and maternal mortality. The review findings illustrate that the individual and contextual factors which affect antiretroviral therapy (ART) initiation, adherence and retention for pregnant/postpartum women living with HIV are numerous. Fears over disclosure, and consequent stigma and discrimination feature in many of the studies reviewed. Practical barriers might be overcome, by making services more accessible. The lack of knowledge about HIV and treatment among some women may be addressed through information campaigns. However, the fear of negative consequences as a result of disclosure, even to health workers, presents significant barriers to care. This is something that is of particular note as Option B+ is rolled out. An important strength of this review is the combination of qualitative and quantitative studies. The meticulous description of the approach to the review is also welcome. The authors’ call for ‘consistent, standardised and appropriate measures of adherence and retention’ with a ‘longitudinal component’, is a valuable suggestion as the performance of countries in providing Option B+ begins to be compared.

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Diagnosis of syphilis as an entry point for PrEP initiation among men who have sex with men

Syphilis predicts HIV incidence among men and transgender women who have sex with men in a preexposure prophylaxis trial.

Solomon MM, Mayer KH, Glidden DV, Liu AY, McMahan VM, Guanira JV, Chariyalertsak S, Fernandez T, Grant RM, iPrEx Study Team. Clin Infect Dis. 2014 Oct;59(7):1020-6. doi: 10.1093/cid/ciu450. Epub 2014 Jun 13.

Background: Syphilis infection may potentiate transmission of human immunodeficiency virus (HIV). We sought to determine the extent to which HIV acquisition was associated with syphilis infection within an HIV preexposure prophylaxis (PrEP) trial and whether emtricitabine/tenofovir (FTC/TDF) modified that association.

Methods: The Preexposure Prophylaxis Initiative (iPrEx) study randomly assigned 2499 HIV-seronegative men and transgender women who have sex with men (MSM) to receive oral daily FTC/TDF or placebo. Syphilis prevalence at screening and incidence during follow-up were measured. Hazard ratios for the effect of incident syphilis on HIV acquisition were calculated. The effect of FTC/TDF on incident syphilis and HIV acquisition was assessed.

Results: Of 2499 individuals, 360 (14.4%) had a positive rapid plasma reagin test at screening; 333 (92.5%) had a positive confirmatory test, which did not differ between the arms (FTC/TDF vs placebo, P = .81). The overall syphilis incidence during the trial was 7.3 cases per 100 person-years. There was no difference in syphilis incidence between the study arms (7.8 cases per 100 person-years for FTC/TDF vs 6.8 cases per 100 person-years for placebo, P = .304). HIV incidence varied by incident syphilis (2.8 cases per 100 person-years for no syphilis vs 8.0 cases per 100 person-years for incident syphilis), reflecting a hazard ratio of 2.6 (95% confidence interval, 1.6-4.4; P < .001). There was no evidence for interaction between randomization to the FTC/TDF arm and incident syphilis on HIV incidence.

Conclusions: In HIV-seronegative MSM, syphilis infection was associated with HIV acquisition in this PrEP trial; a syphilis diagnosis should prompt providers to offer PrEP unless otherwise contraindicated.

Abstract  Full-text [free] access

Editor’s notes: The Preexposure Prophylaxis Initiative (iPrEx) trial and other recent trials have illustrated clearly that preexposure prophylaxis (PrEP) with emtricitabine/tenofovir (FTC/TDF) dramatically reduces the risk of HIV when used correctly and consistently. There is current discussion about the practical implications of these findings. This paper confirms a strong association between incident syphilis and HIV acquisition among men who have sex with men (MSM), and illustrates that syphilis did not attenuate the protective benefit of FTC/TDF against HIV. Syphilis continues to be prevalent among MSM in many settings, and the screening prevalence of 13% in this study is consistent with global estimates. These results highlight that individuals with syphilis are a key group for HIV acquisition. The results suggest that a new diagnosis of syphilis is an important opportunity for PrEP initiation, unless contraindications are present. This would be in addition to immediate syphilis treatment, and treatment for sexual partners. 

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