Articles tagged as "HIV testing and treatment"

One-stop clinic-based ART initiation strengthens HIV treatment cascade

Initiating antiretroviral therapy for HIV at a patient's first clinic visit: the RapIT randomized controlled trial.

Rosen S, Maskew M, Fox MP, Nyoni C, Mongwenyana C, Malete G, Sanne I, Bokaba D, Sauls C, Rohr J, Long L. PLoS Med. 2016 May 10;13(5):e1002015. doi: 10.1371/journal.pmed.1002015. eCollection 2016.

Background: High rates of patient attrition from care between HIV testing and antiretroviral therapy (ART) initiation have been documented in sub-Saharan Africa, contributing to persistently low CD4 cell counts at treatment initiation. One reason for this is that starting ART in many countries is a lengthy and burdensome process, imposing long waits and multiple clinic visits on patients. We estimated the effect on uptake of ART and viral suppression of an accelerated initiation algorithm that allowed treatment-eligible patients to be dispensed their first supply of antiretroviral medications on the day of their first HIV-related clinic visit.

Methods and findings: RapIT (Rapid Initiation of Treatment) was an unblinded randomized controlled trial of single-visit ART initiation in two public sector clinics in South Africa, a primary health clinic (PHC) and a hospital-based HIV clinic. Adult (≥18 y old), non-pregnant patients receiving a positive HIV test or first treatment-eligible CD4 count were randomized to standard or rapid initiation. Patients in the rapid-initiation arm of the study ("rapid arm") received a point-of-care (POC) CD4 count if needed; those who were ART-eligible received a POC tuberculosis (TB) test if symptomatic, POC blood tests, physical exam, education, counseling, and antiretroviral (ARV) dispensing. Patients in the standard-initiation arm of the study ("standard arm") followed standard clinic procedures (three to five additional clinic visits over 2-4 wk prior to ARV dispensing). Follow up was by record review only. The primary outcome was viral suppression, defined as initiated, retained in care, and suppressed (≤400 copies/ml) within 10 mo of study enrollment. Secondary outcomes included initiation of ART ≤90 d of study enrollment, retention in care, time to ART initiation, patient-level predictors of primary outcomes, prevalence of TB symptoms, and the feasibility and acceptability of the intervention. A survival analysis was conducted comparing attrition from care after ART initiation between the groups among those who initiated within 90 d. Three hundred and seventy-seven patients were enrolled in the study between May 8, 2013 and August 29, 2014 (median CD4 count 210 cells/mm3). In the rapid arm, 119/187 patients (64%) initiated treatment and were virally suppressed at 10 mo, compared to 96/190 (51%) in the standard arm (relative risk [RR] 1.26 [1.05-1.50]). In the rapid arm 182/187 (97%) initiated ART ≤90 d, compared to 136/190 (72%) in the standard arm (RR 1.36, 95% confidence interval [CI], 1.24-1.49). Among 318 patients who did initiate ART within 90 d, the hazard of attrition within the first 10 mo did not differ between the treatment arms (hazard ratio [HR] 1.06; 95% CI 0.61-1.84). The study was limited by the small number of sites and small sample size, and the generalizability of the results to other settings and to non-research conditions is uncertain.

Conclusions: Offering single-visit ART initiation to adult patients in South Africa increased uptake of ART by 36% and viral suppression by 26%. This intervention should be considered for adoption in the public sector in Africa.

Abstract  Full-text [free] access 

Editor’s notes: This randomised controlled trial provides evidence that initiating ART at a single clinic visit limits pre-ART losses and increases the proportion in care with viral suppression within the first year of ART. Almost all people in the rapid arm initiated ART within 90 days. Attrition post-ART initiation remained quite high. One in three participants initiating ART in the rapid arm did not achieve the primary outcome of retention in care with viral suppression. However, this was not enough to offset the clear benefit of reduced pre-ART loss to follow-up.

There are a few things to note about the study. Firstly, the study design allowed for people who were enrolled at various stages in the pre-ART period, from HIV testing to receipt of CD4+ cell count. Fewer than half were enrolled on the day of HIV diagnosis. Secondly, the trial procedures relating to ART initiation were performed by research staff embedded in the health facilities. The one-stop ART initiation strategy was quite intensive, involving point-of-care testing for CD4+ cell count, TB, and routine pre-ART blood tests. This took over two hours for a single person, and more than four hours if TB testing was required. Lastly, the virologic suppression outcome was based on viral load measurement at any point between three and 12 months. It will therefore be particularly interesting to see longer-term data on virologic suppression and retention to see whether the effects were sustained.

The effectiveness and cost-effectiveness of this strategy should now be evaluated. The removal of CD4+ cell count eligibility criteria for ART might help to streamline the pre-initiation procedures, but additional effort might be required to make this process more efficient and suitable for implementation in routine care settings.  

Africa
South Africa
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ART reduces, but does not eliminate, HIV transmission in serodiscordant couples in a real-world setting

Antiretroviral therapy to prevent HIV acquisition in serodiscordant couples in a hyperendemic community in rural South Africa.  

Oldenburg CE, Barnighausen T, Tanser F, Iwuji CC, De Gruttola V, Seage GR, 3rd, Mimiaga MJ, Mayer KH, Pillay D, Harling G. Clin Infect Dis. 2016 May 20. pii: ciw335. [Epub ahead of print]

Background: Antiretroviral therapy (ART) was highly efficacious in preventing HIV transmission in stable serodiscordant couples in the HPTN-052 study, a resource-rich randomized controlled trial. However, minimal evidence exists of the effectiveness of ART in preventing HIV acquisition in stable serodiscordant couples in real-life population-based settings in hyperendemic communities of sub-Saharan Africa, where health systems are typically resource-poor and overburdened, adherence to ART is suboptimal, and HIV status disclosure to sexual partners is inconsistent.

Methods: Data arose from a population-based open cohort in KwaZulu-Natal, South Africa. HIV-uninfected individuals present between January 2005 and December 2013 (n=17 016) were included. Interval-censored time-updated proportional hazards regression was used to assess how the ART status affected HIV transmission risk in stable serodiscordant relationships.

Results: Of 17 016 individuals, 1846 had an HIV-uninfected and 196 had an HIV-infected stable partner over the follow-up period. HIV incidence was 3.8 per 100 person-years (100PY) among individuals with an HIV-infected partner (95% confidence interval [CI] 2.3-5.6), corresponding to 1.4 per 100PY (95% CI 0.4-3.5) among those with HIV-infected partners on ART and 5.6 per 100PY (95% CI 3.5-8.4) among those with partners not on ART. Use of ART was associated with a 77% decrease in HIV acquisition risk amongst serodiscordant couples (aHR=0.23, 95% CI 0.07-0.80).

Conclusions: ART initiation was associated with a very large reduction in HIV acquisition in serodiscordant couples in rural KwaZulu-Natal. However, real-life effectiveness was substantially lower than in the HPTN-052 trial. To eliminate HIV transmission in serodiscordant couples, additional prevention interventions are likely needed.

Abstract access

Editor’s notes: The landmark HPTN-052 multi-country trial among stable serodiscordant couples demonstrated that antiretroviral therapy (ART) substantially lowers the probability of transmission from HIV-positive people to their HIV-negative partners. However, the magnitude of effect of ART on transmission may not be generalisable to population level because in real-life settings, partnerships may not be stable, and there are operational challenges to programmatic delivery of ART at scale.

This study estimated the transmission risk in stable, serodiscordant couples, in a real-life setting in rural KwaZulu-Natal. The study included all stable serodiscordant couples in the community, whereas HPTN-052 enrolled individuals who presented to health services, and restricted recruitment to HIV-positive participants who disclosed their positive status to their partner.

The authors found that ART was associated with a decrease of 77% in transmission risk in this real-world setting, compared to a decrease of about 89% among people who immediately initiated ART in the HPTN-052 study.

The authors attributed this reduced effect size to a higher number of missed visits and lower adherence to ART in a real-life setting compared to the controlled trial. They also found fewer HIV-positive people with virologic suppression (77%, versus about 90% in the HPTN-052 trial) and lower disclosure rates (disclosure of HIV status to their partner was a requirement for inclusion in the trial).

The authors conclude that ART is highly effective in preventing HIV transmission in stable serodiscordant couples, but that to eliminate HIV transmission, additional preventive measures are necessary. 

Epidemiology, treatment
Africa
South Africa
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Partner’s knowledge of HIV suppression among male couples in San Francisco

Relationship dynamics and partner beliefs about viral suppression: a longitudinal study of male couples living with HIV/AIDS (the duo project).

Conroy AA, Gamarel KE, Neilands TB, Dilworth SE, Darbes LA, Johnson MO. AIDS Behav. 2016 May 5. [Epub ahead of print]

Accurate beliefs about partners' viral suppression are important for HIV prevention and care. We fit multilevel mixed effects logistic regression models to examine associations between partners' viral suppression beliefs and objective HIV RNA viral load tests, and whether relationship dynamics were associated with accurate viral suppression beliefs over time. Male couples (N = 266 couples) with at least one HIV-positive partner on antiretroviral therapy completed five assessments over 2 years. Half of the 407 HIV-positive partners were virally suppressed. Of the 40% who had inaccurate viral load beliefs, 80% assumed their partner was suppressed. The odds of having accurate viral load beliefs decreased over time (OR = 0.83; p = 0.042). Within-couple differences in dyadic adjustment (OR = 0.66; p < 0.01) and commitment (OR = 0.82; p = 0.022) were negatively associated with accurate viral load beliefs. Beliefs about a partner's viral load may factor into sexual decision-making and social support. Couple-based approaches are warranted to improve knowledge of partners' viral load.

Abstract access

Editor’s notes: This study with male couples in San Francisco examined how accurate a partner’s knowledge about their partner’s viral load status was, and if this changes over time. The study was the first of its kind. The research team enrolled 266 male couples where at least one of the couple was HIV-positive and on ART for >30 days. Most couples (72%) were seroconcordant (both HIV-positive) and 28% were serodiscordant. Participants were mostly white, middle-aged men with low-income levels. Eighty percent were living with their partner. The couples had been together on average 6.6 years. Thus, this sample may differ substantially from other studies with gay men and other men who have sex with men. Approximately 50% of men living with HIV on ART were virally suppressed at each of three visits. However, between 24% (visit one) and 40% (visit three) of men had inaccurate knowledge about their partner’s viral suppression, with most of these people wrongly believing their partner’s viral load to be suppressed when it was not. Surprisingly, these results were similar among serodiscordant and seroconcordant couples. Results did not differ significantly according to most relationship characteristics (relationship satisfaction; commitment; intimacy; equality; constructive communication).

The results are interesting because inaccuracy in partner’s beliefs about viral load suppression may translate into poor decision making around the safety of condomless anal intercourse. In addition, having accurate knowledge of partner viral suppression is important for the provision of social support associate with HIV care and treatment. Qualitative studies are necessary to understand why many men in this study had an inaccurate knowledge about their partner’s viral suppression. And why this inaccuracy increased over time. Understanding these issues and how they translate to other populations will be useful for developing programmes among male couples to reduce HIV transmission and increase partner’s social support associated with HIV care and treatment. 

Northern America
United States of America
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Using mathematical models to understand the impact of universal therapy for HIV serodiscordant couples

Estimating the impact of universal antiretroviral therapy for HIV serodiscordant couples through home HIV testing: insights from mathematical models.

Roberts ST, Khanna AS, Barnabas RV, Goodreau SM, Baeten JM, Celum C, Cassels S. J Int AIDS Soc. 2016 May 11;19(1):20864. doi: 10.7448/IAS.19.1.20864. eCollection 2016.

Introduction: Antiretroviral therapy (ART) prevents HIV transmission within HIV serodiscordant couples (SDCs), but slow implementation and low uptake has limited its impact on population-level HIV incidence. Home HIV testing and counselling (HTC) campaigns could increase ART uptake among SDCs by incorporating couples' testing and ART referral. We estimated the reduction in adult HIV incidence achieved by incorporating universal ART for SDCs into home HTC campaigns in KwaZulu-Natal (KZN), South Africa, and southwestern (SW) Uganda.

Methods: We constructed dynamic, stochastic, agent-based network models for each region. We compared adult HIV incidence after 10 years under three scenarios: (1) "Current Practice," (2) "Home HTC" with linkage to ART for eligible persons (CD4 <350) and (3) "ART for SDCs" regardless of CD4, delivered alongside home HTC.

Results: ART for SDCs reduced HIV incidence by 38% versus Home HTC: from 1.12 (95% CI: 0.98-1.26) to 0.68 (0.54-0.82) cases per 100 person-years (py) in KZN, and from 0.56 (0.50-0.62) to 0.35 (0.30-0.39) cases per 100 py in SW Uganda. A quarter of incident HIV infections were averted over 10 years, and the proportion of virally suppressed HIV-positive persons increased approximately 15%.

Conclusions: Using home HTC to identify SDCs and deliver universal ART could avert substantially more new HIV infections than home HTC alone, with a smaller number needed to treat to prevent new HIV infections. Scale-up of home HTC will not diminish the effectiveness of targeting SDCs for treatment. Increasing rates of couples' testing, disclosure, and linkage to care is an efficient way to increase the impact of home HTC interventions on HIV incidence.

Abstract  Full-text [free] access 

Editor’s notes: Delivering effective and efficient HIV prevention programmes to serodiscordant couples continues to be a challenge. The study used a dynamic stochastic agent–based network model to estimate the impact of universal antiretroviral therapy for serodiscordant couples. The authors examined the scaling up of antiretroviral therapy through home HIV testing and counselling in KwaZulu-Natal in South Africa and South-western Uganda. Data from South Africa and Uganda were used to compare three HIV programme scenarios. These included routine antiretroviral therapy delivery in the general population, routine antiretroviral therapy  delivery in the general population and home HIV testing and counselling campaigns, and home HIV testing and counselling and delivery of antiretroviral therapy to serodiscordant couples during home HIV testing and counselling campaigns.  The authors found that a combination of HIV prevention programmes that provide universal antiretroviral therapy for serodiscordant couples in the context of home HIV testing and counselling had more impact in reducing HIV incidence. The study demonstrated that home HIV testing and counselling and linkage to care HIV programmes can substantially reduce HIV incidence in South Africa and Uganda. This is a very interesting and well-designed modelling study which incorporates the effects of partnership dynamics in estimating the population level impact of HIV programmes.

HIV modelling
Africa
South Africa, Uganda
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Trial shows improvements to uptake of VMMC and linkage into HIV care but little effect on ART initiation

Uptake of antiretroviral therapy and male circumcision after community-based HIV testing and strategies for linkage to care versus standard clinic referral: a multisite, open-label, randomised controlled trial in South Africa and Uganda.

Barnabas RV, van Rooyen H, Tumwesigye E, Brantley J, Baeten JM, van Heerden A, Turyamureeba B, Joseph P, Krows M, Thomas KK, Schaafsma TT, Hughes JP, Celum C. Lancet HIV. 2016 May;3(5):e212-20. doi: 10.1016/S2352-3018(16)00020-5. Epub 2016 Mar 10.

Background: Male circumcision decreases HIV acquisition by 60%, and antiretroviral therapy (ART) almost eliminates HIV transmission from HIV-positive people who are virally suppressed; however, coverage of these interventions has lagged behind targets. We aimed to assess whether community-based HIV testing with counsellor support and point-of-care CD4 cell count testing would increase uptake of ART and male circumcision.

Methods: We did this multisite, open-label, randomised controlled trial in six research-naive communities in rural South Africa and Uganda. Eligible HIV-positive participants (aged ≥16 years) were randomly assigned (1:1:1) in a factorial design to receive lay counsellor clinic linkage facilitation, lay counsellor follow-up home visits, or standard-of-care clinic referral, and then (1:1) either point-of-care CD4 cell count testing or referral for CD4 testing. HIV-negative uncircumcised men (aged 16-49 years) who could receive secure mobile phone text messages were randomly assigned (1:1:1) to receive text message reminders, lay counsellor visits, or standard clinic referral. The study biostatistician generated the randomisation schedule via a computer-generated random number program with varying block sizes (multiples of six or three) stratified by country. Primary outcomes for HIV-positive people were obtaining a CD4 cell count, linkage to an HIV clinic, ART initiation, and viral suppression at 9 months, and for HIV-negative uncircumcised men were visiting a circumcision facility and uptake of male circumcision at 3 months. We assessed social harms as a safety outcome throughout the study. We did the primary analyses by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT02038582.

Findings: Between June 6, 2013, and March 11, 2015, 15 332 participants were tested. 2339 (15%) participants tested HIV positive, of whom 1325 (57%) were randomly assigned to receive lay counsellor clinic linkage facilitation (n=437), lay counsellor follow-up home visits (n=449), or standard clinic referral (n=439), and then point-of-care CD4 cell testing (n=206, n=220, and n=213, respectively) or referral for CD4 testing (n=231, n=229, and n=226, respectively). 12 993 (85%) participants tested HIV negative, of whom 750 (6%) uncircumcised men were randomly assigned to receive clinic referral (n=230), text message reminders (n=288), or lay counsellor follow-up visits (n=232). 1218 (93%) of 1303 HIV-positive participants were linked to care, but only 488 (37%) participants initiated ART. Overall, 635 (50%) of 1272 HIV-positive individuals achieved viral suppression at 9 months: 219 (52%) of 419 participants in the clinic facilitation group, 202 (47%) of 431 participants in the lay counsellor follow-up group, and 214 (51%) of 422 participants in the clinic referral group, with no significant differences between groups (p=0.668 for clinic facilitation and p=0.273 for lay counsellor follow-up vs clinic referral). 523 (72%) of 734 HIV-negative men visited a circumcision facility, with no difference between groups. 62 (28%) of 224 men were circumcised in the male circumcision clinic referral group compared with 137 (48%) of 284 men in the text message reminder group (relative risk 1.72, 95% CI 1.36-2.17; p<0.0001) and 106 (47%) of 226 men in the lay counsellor follow-up group (1.67, 1.29-2.14; p=0.0001). No cases of study-related social harm were reported, including probing about partnership separation, unintended disclosure, gender-based violence, and stigma.

Interpretation: All the community-based strategies achieved high rates of linkage of HIV-positive people to HIV clinics, roughly a third of whom initiated ART, and of those more than 80% were virally suppressed at 9 months. Uptake of male circumcision was almost two-times higher in men who received text message reminders or lay counsellor visits than in those who received standard-of-care clinic referral. Clinic barriers to ART initiation should be addressed in future strategies to increase the proportion of HIV-positive people accessing treatment and achieving viral suppression.

Abstract access

Editor’s notes: This study described a robust evaluation of approaches to enhance uptake of antiretroviral therapy (ART) and voluntary medical male circumcision (VMMC) following community-based approaches of HIV testing (home-based and mobile HIV testing). For HIV negative men, the close to 50% uptake of VMMC from the text message reminder approach is especially encouraging as it seems a low cost method for wider scale-up. The limitation however is that reliable and private access to a phone would be necessary. Nonetheless, with the increasing availability of mobile phones in Africa, this is a promising approach.

The findings for people living with HIV are more complex. There was remarkably high (93%) linkage into care in the study settings at nine months – even in the referral only arm. Unfortunately, this did not translate into high proportions initiating ART overall, 37%. The benefits from the approaches to enhance uptake of ART were also mixed. ART initiation was increased with lay-counsellor follow-up but not with clinic facilitation, even though the latter did illustrate benefits for linkage to care. Further, viral suppression at nine months was similar across the study arms. Point-of-care CD4-counts did not affect rates of linkage, ART initiation or viral suppression.

The findings from this comprehensive evaluation of approaches to enhance uptake of services remind us of the opportunity not only to actively promote VMMC for HIV-negative men as part of HIV-testing services, but also that both text messages and lay counsellor follow-up can increase uptake. The study also highlights that increasing linkage to care for people living with HIV does not necessarily translate into increasing uptake of treatment. The authors describe possible reasons for this and it seems that addressing health systems challenges within facilities and innovations around treatment delivery should be priorities.

Health care delivery
Africa
South Africa, Uganda
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Silent transfers result in underestimation of retention on ART

Retention in care and patient-reported reasons for undocumented transfer or stopping care among HIV-infected patients on antiretroviral therapy in eastern Africa: application of a sampling-based approach.

Geng EH, Odeny TA, Lyamuya R, Nakiwogga-Muwanga A, Diero L, Bwana M, Braitstein P, Somi G, Kambugu A, Bukusi E, Wenger M, Neilands TB, Glidden DV, Wools-Kaloustian K, Yiannoutsos C, Martin J, East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium. Clin Infect Dis. 2016 Apr 1;62(7):935-44. doi: 10.1093/cid/civ1004. Epub 2015 Dec 17.

Background: Improving the implementation of the global response to human immunodeficiency virus requires understanding retention after starting antiretroviral therapy (ART), but loss to follow-up undermines assessment of the magnitude of and reasons for stopping care.

Methods: We evaluated adults starting ART over 2.5 years in 14 clinics in Uganda, Tanzania, and Kenya. We traced a random sample of patients lost to follow-up and incorporated updated information in weighted competing risks estimates of retention. Reasons for nonreturn were surveyed.

Results: Among 18 081 patients, 3150 (18%) were lost to follow-up and 579 (18%) were traced. Of 497 (86%) with ascertained vital status, 340 (69%) were alive and, in 278 (82%) cases, updated care status was obtained. Among all patients initiating ART, weighted estimates incorporating tracing outcomes found that 2 years after ART, 69% were in care at their original clinic, 14% transferred (4% official and 10% unofficial), 6% were alive but out of care, 6% died in care (<60 days after last visit), and 6% died out of care (≥60 days after last visit). Among lost patients found in care elsewhere, structural barriers (eg, transportation) were most prevalent (65%), followed by clinic-based (eg, waiting times) (33%) and psychosocial (eg, stigma) (27%). Among patients not in care elsewhere, psychosocial barriers were most prevalent (76%), followed by structural (51%) and clinic based (15%).

Conclusions: Accounting for outcomes among those lost to follow-up yields a more informative assessment of retention. Structural barriers contribute most to silent transfers, whereas psychological and social barriers tend to result in longer-term care discontinuation.

Abstract access 

Editor’s notes: The authors explore outcomes by tracing a sample of people who were lost to follow-up from antiretroviral therapy (ART) clinics. They collected data on reasons provided by patients for undocumented transfer out, or stopping ART. The findings are important, both to be able to critically evaluate the success of ART programmes (and individual clinics) in retaining people in care, and to identify barriers to retention which may be amenable to change. Consistent with findings elsewhere, the most common outcome among “lost” ART clinic attendees was “silent” (unofficial) transfer to another clinic, which, in this three-country study, accounted for a 10% underestimation of retention in care over two years. This highlights the pressing need for improved electronic medical record systems with centralised identification, in order to be able to track individuals between facilities so that accurate retention data can be collated.

As ART programmes move towards universal immediate initiation, the rate of stopping care (or transferring) will likely increase. In this study, 22% of people who had stopped care gave “I felt well” as a reason. The need for programmes to respond to the structural, psychological and social barriers identified will become even more important. 

Africa
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Botswana within reach of UNAIDS 90-90-90 treatment target

Botswana's progress toward achieving the 2020 UNAIDS 90-90-90 antiretroviral therapy and virological suppression goals: a population-based survey.

Gaolathe T, Wirth KE, Holme MP, Makhema J, Moyo S, Chakalisa U, Yankinda EK, Lei Q, Mmalane M, Novitsky V, Okui L, van Widenfelt E, Powis KM, Khan N, Bennett K, Bussmann H, Dryden-Peterson S, Lebelonyane R, El-Halabi S, Mills LA, Marukutira T, Wang R, Tchetgen EJ, DeGruttola V, Essex M, Lockman S, Botswana Combination Prevention Project study team. Lancet HIV. 2016 May;3(5):e221-30. doi: 10.1016/S2352-3018(16)00037-0. Epub 2016 Mar 24.

Background: HIV programmes face challenges achieving high rates of HIV testing and treatment needed to optimise health and to reduce transmission. We used data from the Botswana Combination Prevention Project study survey to assess Botswana's progress toward achieving UNAIDS targets for 2020: 90% of all people living with HIV knowing their status, 90% of these receiving sustained antiretroviral therapy (ART), and 90% of those having virological suppression (90-90-90).

Methods: A population-based sample of individuals was recruited and interviewed in 30 rural and periurban communities from Oct 30, 2013, to Nov 24, 2015, as part of a large, ongoing community-randomised trial designed to assess the effect of a combination prevention package on HIV incidence. A random sample of about 20% of households in each community was selected. Consenting household residents aged 16-64 years who were Botswana citizens or spouses of citizens responded to a questionnaire and had blood drawn for HIV testing in the absence of documentation of positive HIV status. Viral load testing was done in all HIV-infected participants, irrespective of treatment status. We used modified Poisson generalised estimating equations to obtain prevalence ratios, corresponding Huber robust SEs, and 95% Wald CIs to examine associations between individual sociodemographic factors and a binary outcome indicating achievement of the three individual and combined overall 90-90-90 targets. The study is registered at ClinicalTrials.gov, number NCT01965470.

Findings: 81% of enumerated eligible household members took part in the survey (10% refused and 9% were absent). Among 12 610 participants surveyed, 3596 (29%) were infected with HIV, and 2995 (83.3%, 95% CI 81.4-85.2) of these individuals already knew their HIV status. Among those who knew their HIV status, 2617 (87.4%, 95% CI 85.8-89.0) were receiving ART (95% of those eligible by national guidelines, and 73% of all infected people). Of the 2609 individuals receiving ART with a viral load measurement, 2517 (96.5%, 95% CI 96.0-97.0) had viral load of 400 copies per mL or less. Overall, 70.2% (95% CI 67.5-73.0) of HIV-infected people had virological suppression, close to the UNAIDS target of 73%.

Interpretation: UNAIDS 90-90-90 targets are achievable even in resource-constrained settings with high HIV burden.

Abstract access    

Editor’s notes: The UNAIDS treatment target set for 2020 aim for at least 90 percent of all people living with HIV to be diagnosed, at least 90 percent of people diagnosed to receive antiretroviral therapy, and for treatment to be effective and consistent enough in at least 90 percent of those people on treatment to suppress the virus. This would result in about 73% of all HIV-positive people being virally suppressed. 

This study estimated coverage of HIV diagnosis, antiretroviral therapy and viral suppression among 30 communities in Botswana, a country with a high HIV prevalence (~ 25%), to assess the country’s progress towards the UNAIDS treatment target. They found that overall, about 70% of people living with HIV had viral suppression (defined in this analysis as having a viral load of less than HIV RNA 400 copies per mL), close to the UNAIDS target of 73%. However, there is still substantial ongoing transmission (demonstrated by an HIV incidence of 1.4% per year in 2013). The authors attribute this mainly to the 30% of people living with HIV that remain unsuppressed (undiagnosed, or not on treatment, or not virally suppressed because of poor adherence or drug resistance). They also acknowledge that other factors such as the complexities of sexual networks, risk behaviour patterns, and biological factors may play a role.

Interestingly the authors found very high proportions of viral suppression. Nearly 97% of people on ART were virally suppressed. The authors also found that younger age was the strongest predictor of not reaching the ultimate target (diagnosed, on treatment and being virally suppressed). People living with HIV aged 20-29 years old were about 50% less likely to be virally suppressed compared with people 60 years and older. Young people living with HIV aged between 16-19 years old were 60% less likely to be virally suppressed. This emphasizes again the need for focussed programmes for adolescents and young people.

Botswana has reached this level of coverage even when the criterion for initiating antiretroviral therapy was a CD4 cell count below 350 cells per μL, even before moving to providing treatment for everyone diagnosed with HIV. The authors conclude that the high proportions of HIV testing, antiretroviral therapy and viral suppression provide good evidence that the UNAIDS treatment target is achievable.

Africa
Botswana
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SMS technology can decrease time to ART initiation in infants, Rwanda

TRACnet Internet and SMS technology improves time to antiretroviral therapy initiation among HIV-infected infants in Rwanda.

Kayumba K, Nsanzimana S, Binagwaho A, Mugwaneza P, Rusine J, Remera E, Koama JB, Ndahindwa V, Johnson P, Riedel DJ, Condo J. Pediatr Infect Dis J. 2016 Mar 30. [Epub ahead of print]

Background: Delays in testing HIV-exposed infants and obtaining results in resource-limited settings contribute to delays for initiating antiretroviral therapy (ART) in infants. To overcome this challenge, Rwanda expanded its national mobile and internet-based HIV/AIDS informatics system, called TRACnet, to include HIV PCR results in 2010. This study was performed to evaluate the impact of TRACnet technology on the time to delivery of test results and the subsequent initiation of ART in HIV-infected infants.

Methods: A retrospective cohort study was conducted on 380 infants who initiated ART in 190 health facilities in Rwanda from March 2010 to June 2013. Program data collected by the TRACnet system was extracted and analyzed.

Results: Since the introduction of TRACnet for processing PCR results, the time to receive results has significantly decreased from a median of 144 days [IQR 121-197] to 23 days [IQR 17-43]. The number of days between PCR sampling and health facility receipt of results decreased substantially from a median of 90 days [IQR 83-158] to 5 days [IQR 2-8]. After receiving PCR results at a health facility, it takes a median of 44 days [IQR 32-77] before ART initiation. Result turnaround time was significantly associated with time to initiating ART (P<0.001). An increased number of staff trained for HIV care and treatment was also significantly associated with decreased time to ART initiation (P=0.004).

Conclusions: The use of mobile technology for communication of HIV PCR results, coupled with well-trained and skilled personnel, can reduce delays in communicating results to providers. Such reductions may improve timely ART initiation in resource-limited settings.

Abstract access

Editor’s notes: Early identification and prompt treatment of infants who have perinatally acquired HIV is critical to decrease HIV-associated mortality in children. Testing of HIV-exposed infants is an integral part of prevention of mother-to-child HIV transmission programmes, and is termed early infant diagnosis (EID). Despite the scale-up of prevention of mother-to-child HIV transmission programmes, delays in obtaining HIV test results and in initiating infants on ART remains a serious programmatic challenge. Delays occur at several stages, including transport of specimens to centralised laboratories, processing of specimens by laboratories, receipt of results by health facilities and delay in initiation of antiretroviral therapy (ART) once positive results are received by health providers. Delays of up to several months between HIV testing and receipt of results have been observed in many high-burden countries.

In this study conducted in Rwanda, a short message service (SMS) was incorporated into the existing national TRACnet system to speed delivery of HIV test results from the central laboratory to health facilities. This interactive system is used for reporting by health facilities, either through a mobile phone or via the internet, depending on availability. Notably, this was complemented by strengthening all the processes between HIV testing and initiation of ART. This included training of nurses at health facilities, and improving the sample transportation process and the laboratory procedures at the central laboratory. The time from sample collection to receipt of results decreased from a median of 144 days to 23 days. Importantly this was also associated with a reducing in time to ART initiation.   

This study illustrates how a relatively simple SMS technology can be used to address structural barriers. Mobile phones are widely used in resource-constrained settings, and can be used to enhance efficiency of delivery of both HIV and other health services, as illustrated by this innovative study. However, success will require investment in improvement of transportation and laboratory systems, and training of health care providers, not only to utilise such systems, but also to respond to results in a timely manner. Further, there are further challenges in getting people to return to clinics to get their results and starting treatment. Strategies for engaging people will also be required if the ultimate outcome of prompt treatment of infants is to be realised. 

Africa
Rwanda
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HIV testing in South Africa: on track to reach the first “90”?

Changes in self-reported HIV testing during South Africa's 2010/2011 national testing campaign: gains and shortfalls.

Maughan-Brown B, Lloyd N, Bor J, Venkataramani AS. J Int AIDS Soc. 2016; 19(1): 20658.

Objectives: HIV counselling and testing is critical to HIV prevention and treatment efforts. Mass campaigns may be an effective strategy to increase HIV testing in countries with generalized HIV epidemics. We assessed the self-reported uptake of HIV testing among individuals who had never previously tested for HIV, particularly those in high-risk populations, during the period of a national, multisector testing campaign in South Africa (April 2010 and June 2011).

Design: This study was a prospective cohort study.

Methods: We analyzed data from two waves (2010/2011, n=16 893; 2012, n=18 707) of the National Income Dynamics Study, a nationally representative cohort that enabled prospective identification of first-time testers. We quantified the number of adults (15 years and older) testing for the first time nationally. To assess whether the campaign reached previously underserved populations, we examined changes in HIV testing coverage by age, gender, race and province sub-groups. We also estimated multivariable logistic regression models to identify socio-economic and demographic predictors of first-time testing.

Results: Overall, the proportion of adults ever tested for HIV increased from 43.7% (95% confidence interval (CI): 41.48, 45.96) to 65.2% (95% CI: 63.28, 67.10) over the study period, with approximately 7.6 million (95% CI: 6,387,910; 8,782,986) first-time testers. Among black South Africans, the country's highest HIV prevalence sub-group, HIV testing coverage improved among poorer and healthier individuals, thus reducing gradients in testing by wealth and health. In contrast, HIV testing coverage remained lower for men, younger individuals and the less educated, indicating persistent if not widening disparities by gender, age and education. Large geographic disparities in coverage also remained as of 2012.

Conclusions: Mass provision of HIV testing services can be effective in increasing population coverage of HIV testing. The geographic and socio-economic disparities in programme impacts can help guide best practices for future efforts. These efforts should focus on hard-to-reach populations, including men and less-educated individuals.

Abstract Full-text [free] access

Editor’s notes: In South Africa, around one in eight people are living with HIV yet around half of these people do not know that they are HIV positive. To meet the 90-90-90 treatment target by 2020, there needs to be considerable expansion of HIV testing coverage. This analysis used independent nationally representative data on self-reported HIV testing to demonstrate that coverage of HIV testing increased substantially following the national multi-sector HIV testing campaign in 2010/11. Despite the expansion in coverage, in the 2012 survey one in three people aged >15 years reported never having received an HIV test. There was marked gender disparity, some 72% of women versus 57% men reported ever having tested in the 2012 survey. There were also prominent gaps among certain socio-economic groups, suggesting persistent inequities in access to HIV testing. 

Although South Africa performs around 10 million HIV tests per year, the number of people tested falls substantially below the target of 30 million tests set for 2016 in the National Strategic Plan. In September, South Africa will implement the “test and treat” approach where all people living with HIV will be offered antiretroviral therapy. In addition, demonstration projects are underway of pre-exposure prophylaxis (PrEP) for HIV prevention. HIV testing services  is the gateway to all treatment and prevention services. The national campaign for HIV testing will clearly need to be revitalised in order to maximise the impact of these public health activities. At the same time, the data reported here would suggest that more innovative and focused approaches may be necessary for difficult to reach population groups.

Africa
South Africa
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Finding out at home: community members’ and healthcare workers’ views on the use of oral HIV self-testing in Kayelitsha, South Africa

'I know that I do have HIV but nobody saw me': oral HIV self-testing in an informal settlement in South Africa.

Martinez Perez G, Cox V, Ellman T, Moore A, Patten G, Shroufi A, Stinson K, Van Cutsem G, Ibeto M. PLoS One. 2016 Apr 4;11(4):e0152653. doi: 10.1371/journal.pone.0152653. eCollection 2016.

Reaching universal HIV-status awareness is crucial to ensure all HIV-infected patients access antiretroviral treatment (ART) and achieve virological suppression. Opportunities for HIV testing could be enhanced by offering self-testing in populations that fear stigma and discrimination when accessing conventional HIV Counselling and Testing (HCT) in health care facilities. This qualitative research aims to examine the feasibility and acceptability of unsupervised oral self-testing for home use in an informal settlement of South Africa. Eleven in-depth interviews, two couple interviews, and two focus group discussions were conducted with seven healthcare workers and thirteen community members. Thematic analysis was done concurrently with data collection. Acceptability to offer home self-testing was demonstrated in this research. Home self-testing might help this population overcome barriers to accepting HCT; this was particularly expressed in the male and youth groups. Nevertheless, pilot interventions must provide evidence of potential harm related to home self-testing, intensify efforts to offer quality counselling, and ensure linkage to HIV/ART-care following a positive self-test result.

 Abstract Full-text [free] access

Editor’s notes: This is a qualitative study with services users and healthcare workers from an HIV testing service ran by Médecins Sans Frontières (MSF) in Kayelitsha, South Africa. Couple and individual interviews and focus group discussions were conducted with 20 people. The participants discussed preferences of types of HIV testing and acceptability of HIV home-testing. The aim was to inform the pilot of an activity for the use of an oral HIV self-testing device (OraQuick). OraQuick is self-administered as an oral swab and gives results straightaway. The study sample included people who had previously refused an HIV test in the clinic, people who had received an HIV test in the clinic and agreed to a couple interview with their partners. Key reasons for refusing an HIV test in the clinic included: fear of finding out one’s status, fear of HIV-treated discrimination and concerns about confidentiality in testing services. Clinics were seen by male participants as ‘women’s places’.  Men thought visiting a service for an HIV test could harm one’s reputation. Home-testing was seen as preferable because it afforded more privacy. However, not wanting to know one’s status remains a barrier even with home-testing. There were concerns that partners (of both sexes) could pressure one another to test with OraQuick and tensions could arise in case of serodiscordant results. There were concerns that some users could get confused by a test that detects the presence of HIV in the mouth. This would contradict current awareness that HIV cannot be passed through kissing. False-negative tests could encourage unsafe sex. Participants worried that some people may not link into care and treatment after finding out they are HIV positive with a home-test. The study concludes that home-testing could reach populations (especially male partners of women living with HIV and young people) that do not come forward for testing through other services, including clinic-based and voluntary community testing. Many of the disadvantages of home-testing could be mitigated with appropriate education and pre-test counselling. The pilot study continues.  It is expected that the study will be able to address questions of linkage to care for people who test HIV-positive. 

Africa
South Africa
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