Articles tagged as "Europe"

People who inject drugs and the effects of stigma on HIV treatment

A tale of two cities: Stigma and health outcomes among people with HIV who inject drugs in St. Petersburg, Russia and Kohtla-Jarve, Estonia.

Burke SE, Calabrese SK, Dovidio JF, Levina OS, Uuskula A, Niccolai LM, Abel-Ollo K, Heimer R. Soc Sci Med. 2015 Feb 16;130C:154-161. doi: 10.1016/j.socscimed.2015.02.018. [Epub ahead of print]

Experiences of stigma are often associated with negative mental and physical health outcomes. The present work tested the associations between stigma and health-related outcomes among people with HIV who inject drugs in Kohtla-Jarve, Estonia and St. Petersburg, Russia. These two cities share some of the highest rates of HIV outside of sub-Saharan Africa, largely driven by injection drug use, but Estonia has implemented harm reduction services more comprehensively. People who inject drugs were recruited using respondent-driven sampling; those who indicated being HIV-positive were included in the present sample (n = 381 in St. Petersburg; n = 288 in Kohtla-Jarve). Participants reported their health information and completed measures of internalized HIV stigma, anticipated HIV stigma, internalized drug stigma, and anticipated drug stigma. Participants in both locations indicated similarly high levels of all four forms of stigma. However, stigma variables were more strongly associated with health outcomes in Russia than in Estonia. The St. Petersburg results were consistent with prior work linking stigma and health. Lower barriers to care in Kohtla-Jarve may help explain why social stigma was not closely tied to negative health outcomes there. Implications for interventions and health policy are discussed.

Abstract access 

Editor’s notes: This study provides extremely important evidence on the impact of anticipated and felt stigma in relation to HIV and drug use on health outcomes among people who inject drugs in the context of high prevalence of HIV. People who inject drugs in both Russia and Estonia are highly marginalised. Previous studies indicate prevalence to be as high as 90% in Kohtla-Järve and incidence of five per 100 person-years in St Petersburg. Despite their close geographical proximity the two cities are framed by very different social and structural policies that enable and disable the provision of HIV prevention programmes to people who inject drugs. In Estonia, the provision of needle–syringe programmes and opioid substitution therapy is widespread and supported by the government. In Russia the limited harm reduction programmes are provided by non-governmental organisations with little or no support from government. Ambiguous drug policies often prohibit the use of needle –syringe programmes on the grounds they promote drug use. Opioid substitution therapy (OST) is not prescribed and people who inject drugs are viewed as potential criminals by police. People who inject drugs are frequently put under surveillance through a mandatory registration system by police and drug treatment (narcology) clinics. High levels of both internalised and anticipated stigma in relation to HIV and drug use were found in both sites. In Estonia this was not associated with poorer HIV outcomes including access to HIV care, CD4 count or self-reported HIV symptoms. Conversely in St Petersburg, internalised stigma associated with drug use was associated with lower CD4 count, reduced access to HIV care and increased HIV symptoms. This underscores the effectiveness of low-threshold HIV prevention and treatment services for people who inject drugs in the treatment of HIV, despite the existence of other social and cultural norms that stigmatise HIV and drug use. This study demonstrates the effect of stigma on HIV outcomes. However, further research is needed to understand the mechanisms through which stigma interplays with other social and structural factors, such as migration, poverty and criminalisation, to impact on health outcomes among people who inject drugs.

The study has clear policy implications. They include the need for structural interventions such as increased government support for harm reduction. These are necessary to prevent the reproduction of HIV and drug-use related stigma and its harmful impacts. Shorter-term programmes are required in Russia, including the urgent scale up of harm reduction activities and HIV treatment and care for people who inject drugs as well as the provision of inter-personal support to assist people who inject drugs in facing stigma within health services. 

Estonia, Russian Federation
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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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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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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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Feelings of regret after HIV status disclosure: prevalence, trends, and determinants

Was it a mistake to tell others that you are infected with HIV?: factors associated with regret following HIV disclosure among people living with HIV in five countries (Mali, Morocco, Democratic Republic of the Congo, Ecuador and Romania). Results from a community-based research.

Henry E, Bernier A, Lazar F, Matamba G, Loukid M, Bonifaz C, Diop S, Otis J, Préau M; The Partages study group. AIDS Behav. 2014 Dec 23. [Epub ahead of print]

This study examined regret following HIV serostatus disclosure and associated factors in under-investigated contexts (Mali, Morocco, Democratic Republic of the Congo, Ecuador and Romania). A community-based cross-sectional study was implemented by a mixed consortium [researchers/community-based organizations (CBO)]. Trained CBO members interviewed 1500 PLHIV in contact with CBOs using a 125-item questionnaire. A weighted multivariate logistic regression was performed. Among the 1212 participants included in the analysis, 290 (23.9 %) declared that disclosure was a mistake. Female gender, percentage of PLHIV's network knowing about one's seropositivity from a third party, having suffered rejection after disclosure, having suffered HIV-based discrimination at work, perceived seriousness of infection score, daily loneliness, property index and self-esteem score were independently associated with regret. Discrimination, as well as individual characteristics and skills may affect the disclosure experience. Interventions aiming at improving PLHIV skills and reducing their social isolation may facilitate the disclosure process and avoid negative consequences.

Abstract access 

Editor’s notes: Anticipated and perceived consequences of disclosing one’s HIV status are recognized as important drivers for HIV disclosure. This community-based study looked at the experience of disclosing one’s HIV status, and the emotions that were associated with disclosure. The study was nested within a larger cross-sectional research project. 1500 people living with HIV (PLHIV) from Ecuador, the Democratic Republic of the Congo (DRC), Mali, Romania, and Morocco were included in the study. Respondents were asked ‘Was it a mistake to tell others that you are infected with HIV?’ and to answer either ‘yes’ or ‘no.' Participants also responded to questions about the process of disclosure. Among people that had disclosed their status, some 23.9% said that it was a mistake to do so. Almost 40% of participants said that a person in their network learned about their status from a third party. More than 17% of participants responded that they faced rejection and eight percent of participants suffered discrimination at work following disclosure. But this varied greatly across countries. Factors associated with feeling regret after disclosing one’s status included being a female, perceived seriousness of HIV infection, and feeling lonely every day. This study highlights the fact that status disclosure can be emotional and stressful for people living with HIV. This suggests that people living with HIV must weigh the costs and benefits of disclosure before doing so and programmes that empower them to make informed decisions about disclosure may be beneficial. 

Africa, 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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Does pregnancy accelerate HIV progression?

Pregnancy and HIV disease progression: a systematic review and meta-analysis.

Calvert C, Ronsmans C. Trop Med Int Health. 2014 Oct 31. doi: 10.1111/tmi.12412. [Epub ahead of print]

Objective: To assess whether pregnancy accelerates HIV disease progression.

Methods: Studies comparing progression to HIV-related illness, low CD4 count, AIDS-defining illness, HIV-related death, or any death in HIV-infected pregnant and non-pregnant women were included. Relative risks (RR) for each outcome were combined using random effects meta-analysis and were stratified by antiretroviral therapy (ART) availability.

Results: 15 studies met the inclusion criteria. Pregnancy was not associated with progression to HIV-related illness [summary RR: 1.32, 95% confidence interval (CI): 0.66-2.61], AIDS-defining illness (summary RR: 0.97, 95%CI: 0.74-1.25) or mortality (summary RR: 0.97, 95%CI: 0.62-1.53), but there was an association with low CD4 counts (summary RR: 1.41, 95%CI: 0.99-2.02) and HIV-related death (summary RR: 1.65, 95%CI: 1.06-2.57). In settings where ART was available, there was no evidence that pregnancy accelerated progress to HIV/AIDS-defining illnesses, death and drop in CD4 count. In settings without ART availability, effect estimates were consistent with pregnancy increasing the risk of progression to HIV/AIDS-defining illnesses and HIV-related or all-cause mortality, but there were too few studies to draw meaningful conclusions.

Conclusions: In the absence of ART, pregnancy is associated with small but appreciable increases in the risk of several negative HIV outcomes, but the evidence is too weak to draw firm conclusions. When ART is available, the effects of pregnancy on HIV disease progression are attenuated and there is little reason to discourage healthy HIV-infected women who desire to become pregnant from doing so.

Abstract access 

Editor’s notes: The suppression of cell-mediated immunity during pregnancy is associated with increased susceptibility to and/or severity of many infections. Therefore the question of whether pregnancy accelerates HIV disease progression in HIV-positive women is pertinent. A previous systematic review published in the late 1990s found weak evidence that the odds of acquiring an AIDS-defining illness or death were higher among HIV-positive pregnant women than HIV-positive non-pregnant women. The findings from this meta-analysis also suggest that in the absence of antiretroviral therapy (ART), pregnancy is associated with an increase in the risk of several negative HIV outcomes. Fortunately ART appears to diminish the effects of pregnancy on HIV progression.  The authors also draw attention to the methodological weaknesses of the studies included and highlight the need for better quality data, examining whether pregnancy aggravates HIV progression.

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Socioeconomic inequalities in access to HIV care in European countries with universal healthcare systems

Delayed HIV diagnosis and initiation of antiretroviral therapy: inequalities by educational level, COHERE in EuroCoord.

Socio-economic Inequalities and HIV Writing Group for Collaboration of Observational HIV Epidemiological Research in Europe (COHERE) in EuroCoord. AIDS. 2014 Sep 24;28(15):2297-306. doi: 10.1097/QAD.0000000000000410.

Objectives: In Europe and elsewhere, health inequalities among HIV-positive individuals are of concern. We investigated late HIV diagnosis and late initiation of combination antiretroviral therapy (cART) by educational level, a proxy of socioeconomic position.

Design and Methods: We used data from nine HIV cohorts within COHERE in Austria, France, Greece, Italy, Spain and Switzerland, collecting data on level of education in categories of the UNESCO/International Standard Classification of Education standard classification: non-completed basic, basic, secondary and tertiary education. We included individuals diagnosed with HIV between 1996 and 2011, aged at least 16 years, with known educational level and at least one CD4 cell count within 6 months of HIV diagnosis. We examined trends by education level in presentation with advanced HIV disease (AHD) (CD4 <200 cells/µl or AIDS within 6 months) using logistic regression, and distribution of CD4 cell count at cART initiation overall and among presenters without AHD using median regression.

Results: Among 15 414 individuals, 52, 45, 37, and 31% with uncompleted basic, basic, secondary and tertiary education, respectively, presented with AHD (P trend <0.001). Compared to patients with tertiary education, adjusted odds ratios of AHD were 1.72 (95% confidence interval 1.48-2.00) for uncompleted basic, 1.39 (1.24-1.56) for basic and 1.20 (1.08-1.34) for secondary education (P < 0.001). In unadjusted and adjusted analyses, median CD4 cell count at cART initiation was lower with poorer educational level.

Conclusions: Socioeconomic inequalities in delayed HIV diagnosis and initiation of cART are present in European countries with universal healthcare systems and individuals with lower educational level do not equally benefit from timely cART initiation.

Abstract access 

Editor’s notes: COHERE in EuroCoord is a collaboration of 35 observational cohorts covering 32 European countries. The present study uses data from nine cohorts in six countries which collected data on educational achievement. Health inequalities are a growing concern in resource rich settings and this study confirms that even in Europe in the era of wide antiretroviral therapy (ART) use, individuals with lower educational attainment were more likely to present with advanced HIV disease. The association was stronger in men. This is possibly due to earlier diagnosis in women attending antenatal services who benefit from universal offer of HIV testing for prevention of mother-to-child transmission. People who were less educated were also more likely to initiate ART at a lower CD4 count. Interestingly, this latter association was seen even when analyses were restricted to individuals who were diagnosed early. This suggests lower education and by proxy socioeconomic status, is a further and specific barrier to ART initiation, even amongst individuals diagnosed in a timely fashion. The authors conclude that their findings suggest policies and activities that target socioeconomic determinants leading to delays in HIV diagnosis and combination antiretroviral therapy (cART) initiation are needed.

Health care delivery
Austria, France, Greece, Italy, Spain, Switzerland
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What happens to people living with HIV who inject drugs in prison?

Within-prison drug injection among HIV-infected Ukrainian prisoners: prevalence and correlates of an extremely high-risk behaviour.

Izenberg JM, Bachireddy C, Wickersham JA, Soule M, Kiriazova T, Dvoriak S, Altice FL. Int J Drug Policy. 2014 Sep;25(5):845-52. doi: 10.1016/j.drugpo.2014.02.010. Epub 2014 Feb 28.

Background: In Ukraine, HIV-infection, injection drug use, and incarceration are syndemic; however, few services are available to incarcerated people who inject drugs (PWIDs). While data are limited internationally, within-prison drug injection (WP-DI) appears widespread and may pose significant challenges in countries like Ukraine, where PWIDs contribute heavily to HIV incidence. To date, WP-DI has not been specifically examined among HIV-infected prisoners, the only persons that can transmit HIV.

Methods: A convenience sample of 97 HIV-infected adults recently released from prison within 1-12 months was recruited in two major Ukrainian cities. Post-release surveys inquired about WP-DI and injection equipment sharing, as well as current and prior drug use and injection, mental health, and access to within-prison treatment for HIV and other comorbidities. Logistic regression identified independent correlates of WP-DI.

Results: Complete data for WP-DI were available for 95 (97.9%) respondents. Overall, 54 (56.8%) reported WP-DI, among whom 40 (74.1%) shared injecting equipment with a mean of 4.4 (range 0-30) other injectors per needle/syringe. Independent correlates of WP-DI were recruitment in Kyiv (AOR 7.46, p=0.003), male gender (AOR 22.07, p=0.006), and active pre-incarceration opioid use (AOR 8.66, p=0.005).

Conclusions: Among these recently released HIV-infected prisoners, WP-DI and injection equipment sharing were frequent and involved many injecting partners per needle/syringe. The overwhelming majority of respondents reporting WP-DI used opioids both before and after incarceration, suggesting that implementation of evidence-based harm reduction practices, such as opioid substitution therapy and/or needle/syringe exchange programmes within prison, is crucial to addressing continuing HIV transmission among PWIDs within prison settings. The positive correlation between Kyiv site and WP-DI suggests that additional structural interventions may be useful.

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Editor’s notes: This is a powerful article contributing to the evidence base on the vulnerability of the health of people living in prisons. It highlights a particularly vulnerable sub-population of people living in prisons who are HIV positive. The study uses an innovative approach in recruiting a sample of people living with HIV recently released from prison, reporting a history of injecting drug use (n=95) on the basis that outside of prison people will be able to talk more freely about their drug use. The rationale for this study is simple: to document the existence of HIV risk associated with injecting drug use among people living in prisons. It is important since Ukraine and other countries of the former Soviet Union, have underplayed the need for HIV programmes including needle syringe programmes by denying that injecting drug use takes place in prison. This provides empirical evidence that it does, and among HIV positive people living in prisons, so the risk of HIV transmission to people who inject is high. It provides further evidence for the urgent need for HIV programmes among people who inject drugs  in prison. This is of particular relevance in the context of Ukraine, which has one of the fastest growing HIV epidemics globally, with infection driven by injecting drug use. The punitive approach to drug use in Ukraine is well highlighted through the study, by the fact that 76% of the sample were in prison on a drug-related charge. This paper confirms that injecting or other injecting risk behaviours occurred in prison, as has been evidenced elsewhere, and the majority of the sample injected prior to incarceration. It also shows that there is a lack of HIV programmes in place, particularly considering half the sample was aware of their diagnosis prior to imprisonment and the remainder found out while in prison. The study also shows a high prevalence of TB or history of TB (69%) but low levels of treatment while in prison. These illustrate a clear disregard for the health of people living in prisons, which is a breach of human rights, as well as being a poor public health strategy. Unlike other countries in the region, Ukraine does provide opiate substitution therapy to people who inject drugs, as part of an HIV prevention and treatment strategy. This paper provides further evidence for the need to extend this package of programmes to prison populations

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