Articles tagged as "Health systems and services"

Person-to-person spread driving XDR-TB epidemic in KwaZulu-Natal

Transmission of extensively drug-resistant tuberculosis in South Africa.

Shah NS, Auld SC, Brust JC, Mathema B, Ismail N, Moodley P, Mlisana K, Allana S, Campbell A, Mthiyane T, Morris N, Mpangase P, van der Meulen H, Omar SV, Brown TS, Narechania A, Shaskina E, Kapwata T, Kreiswirth B, Gandhi NR. N Engl J Med. 2017 Jan 19;376(3):243-253. doi: 10.1056/NEJMoa1604544.

Background: Drug-resistant tuberculosis threatens recent gains in the treatment of tuberculosis and human immunodeficiency virus (HIV) infection worldwide. A widespread epidemic of extensively drug-resistant (XDR) tuberculosis is occurring in South Africa, where cases have increased substantially since 2002. The factors driving this rapid increase have not been fully elucidated, but such knowledge is needed to guide public health interventions.

Methods: We conducted a prospective study involving 404 participants in KwaZulu-Natal Province, South Africa, with a diagnosis of XDR tuberculosis between 2011 and 2014. Interviews and medical-record reviews were used to elicit information on the participants' history of tuberculosis and HIV infection, hospitalizations, and social networks. Mycobacterium tuberculosis isolates underwent insertion sequence (IS)6110 restriction-fragment-length polymorphism analysis, targeted gene sequencing, and whole-genome sequencing. We used clinical and genotypic case definitions to calculate the proportion of cases of XDR tuberculosis that were due to inadequate treatment of multidrug-resistant (MDR) tuberculosis (i.e., acquired resistance) versus those that were due to transmission (i.e., transmitted resistance). We used social-network analysis to identify community and hospital locations of transmission.

Results: Of the 404 participants, 311 (77%) had HIV infection; the median CD4+ count was 340 cells per cubic millimeter (interquartile range, 117 to 431). A total of 280 participants (69%) had never received treatment for MDR tuberculosis. Genotypic analysis in 386 participants revealed that 323 (84%) belonged to 1 of 31 clusters. Clusters ranged from 2 to 14 participants, except for 1 large cluster of 212 participants (55%) with a LAM4/KZN strain. Person-to-person or hospital-based epidemiologic links were identified in 123 of 404 participants (30%).

Conclusions: The majority of cases of XDR tuberculosis in KwaZulu-Natal, South Africa, an area with a high tuberculosis burden, were probably due to transmission rather than to inadequate treatment of MDR tuberculosis. These data suggest that control of the epidemic of drug-resistant tuberculosis requires an increased focus on interrupting transmission.

Abstract   Full-text [free] access

Editor’s notes: This paper provides further evidence to support person-to-person transmission being the main driver of the XDR-TB epidemic in KwaZulu-Natal, the most populous province of South Africa. The study combined classical and molecular epidemiology: detailed characterisation of people’s clinical history and social networks alongside genotypic methods to characterise their TB strains. With the most conservative estimate, almost seven in ten XDR-TB cases resulted from transmission. However, combining the clinical and genotypic information, as many as nine in ten cases may have been attributable to transmission.

So where was transmission happening? This unfortunately was more difficult to answer. Although epidemiological links (mainly at home or at hospitals) could be defined for around one in three cases, many did not share the same TB strain. More detailed understanding of transmission may have been affected by the relatively low coverage of XDR-TB cases by this study. Full information was available for just over one in three laboratory-confirmed XDR-TB cases in the province over the study period. Also, although there was some genetic diversity in the TB strains, there was one dominant strain (LAM4/KZN). This is the strain responsible for the well-characterised clonal outbreak of XDR-TB involving Tugela Ferry.

Most people with XDR-TB in this study were HIV positive. Interestingly, three-quarters of people living with HIV were on ART at the time of their XDR-TB diagnosis, and two-thirds of people had undetectable viral load. This flags up two things. Firstly, it is a reminder that ART alone is unlikely to control the TB (or drug-resistant TB) epidemic in South Africa. Secondly, it raises further questions that could not be definitively answered here as to whether some of these people might have been infected with XDR-TB while accessing HIV treatment and care in the public health system. 

So what do we do with this new information? These findings should encourage us to focus on developing strategies to interrupt drug-resistant TB transmission. We need better evidence of what works in community settings and health care settings. We need better evidence of how to deliver proven programmes. We still do not know whether we might need different activities to interrupt MDR- and XDR-TB transmission, or whether this should just be encompassed within broader strategies to interrupt all TB transmission. South Africa is leading the way in implementing molecular diagnostics to help with earlier detection of drug-resistant TB, and is at the forefront of developing and testing new drug regimens for drug-resistant TB. This provides a solid platform on which to develop public health programmes to stop the spread of drug-resistant TB.

Comorbidity, Epidemiology
Africa
South Africa
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Are the pills going to make you live long Mum? Questions children ask once they learn their mother is living with HIV

Communication about HIV and death: maternal reports of primary school-aged children's questions after maternal HIV disclosure in rural South Africa.

Rochat TJ, Mitchell J, Lubbe AM, Stein A, Tomlinson M, Bland RM. Soc Sci Med. 2017 Jan;172:124-134. doi: 10.1016/j.socscimed.2016.10.031. Epub 2016 Nov 21.

Introduction: Children's understanding of HIV and death in epidemic regions is under-researched. We investigated children's death-related questions post maternal HIV-disclosure. Secondary aims examined characteristics associated with death-related questions and consequences for children's mental health.

Methods: HIV-infected mothers (N = 281) were supported to disclose their HIV status to their children (6-10 years) in an uncontrolled pre-post intervention evaluation. Children's questions post-disclosure were collected by maternal report, 1-2 weeks post-disclosure. 61/281 children asked 88 death-related questions, which were analysed qualitatively. Logistic regression analyses examined characteristics associated with death-related questions. Using the parent-report Child Behaviour Checklist (CBCL), linear regression analysis examined differences in total CBCL problems by group, controlling for baseline.

Results: Children's questions were grouped into three themes: 'threats'; 'implications' and 'clarifications'. Children were most concerned about the threat of death, mother's survival, and prior family deaths. In multivariate analysis variables significantly associated with asking death-related questions included an absence of regular remittance to the mother (AOR 0.25 [CI 0.10, 0.59] p = 0.002), mother reporting the child's initial reaction to disclosure being "frightened" (AOR 6.57 [CI 2.75, 15.70] p≤0.001) and level of disclosure (full/partial) to the child (AOR 2.55 [CI 1.28, 5.06] p = 0.008). Controlling for significant variables and baseline, all children showed improvements on the CBCL post-intervention; with no significant differences on total problems scores post-intervention (β   -0.096 SE1.366  t = -0.07 p = 0.944).

Discussion: The content of questions children asked following disclosure indicate some understanding of HIV and, for almost a third of children, its potential consequence for parental death. Level of maternal disclosure and stability of financial support to the family may facilitate or inhibit discussions about death post-disclosure. Communication about death did not have immediate negative consequences on child behaviour according to maternal report.

Conclusion: In sub-Saharan Africa, given exposure to death at young ages, meeting children's informational needs could increase their resilience.

Abstract  Full-text [free] access 

Editor’s notes: This is an unusual study examining the experience of the disclosure conversation between mother and child about the mother’s HIV positive status in Kwazulu-Natal. The paper examines the death-associated questions that mothers reported children (aged 6-10 years old, HIV exposed but uninfected) asked up to one week after the ‘disclosure event’. The findings indicate that although the treatability and chronic nature of HIV is complex, children’s questions suggest that they are attempting understand the implications of their mother’s HIV positive status for them, their mother’s and their care. Much research has illustrated that disclosure of both the parents or the child’s own HIV positive status is commonly delayed. This delay may exacerbate the challenges a young person has in adapting to this knowledge. We also know that parents, like a large proportion of people living with HIV, are daunted and feel ill equipped to manage disclosure to others, especially children. However little evidence is currently available evaluating the impact of programmes that are designed to support parents to disclose their own HIV status to their children. Therefore, this programme and study is very welcome.

The focus on death-questions is particularly interesting. This provides some illustration of how children are reportedly processing the information that they have been given. Many questions indicate a prior knowledge of HIV, illness and/ or death. It also suggests that children are managing this new knowledge within this broader context. Within this high HIV-prevalence context, a discursive emphasis on the efficacy of HIV treatment to reduce the risk of HIV-associated mortality within the delivery of timely, age-appropriate education information may be critical.  This can reduce fears around maternal death and supporting children to manage and adapt to their situations. A clear direction for further enquiry would be to follow up these families to assess the impact of full/ partial disclosure over time on the children and the mothers.     

Africa
South Africa
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Xpert® for active TB case finding in high prevalence communities

Effect of new tuberculosis diagnostic technologies on community-based intensified case finding: a multicentre randomised controlled trial.

Calligaro GL, Zijenah LS, Peter JG, Theron G, Buser V, McNerney R, Bara W, Bandason T, Govender U, Tomasicchio M, Smith L, Mayosi BM, Dheda K. Lancet Infect Dis. 2017 Jan 4. pii: S1473-3099(16)30384-X. doi: 10.1016/S1473-3099(16)30384-X. [Epub ahead of print]

Background: Inadequate case detection results in high levels of undiagnosed tuberculosis in sub-Saharan Africa. Data for the effect of new diagnostic tools when used for community-based intensified case finding are not available, so we investigated whether the use of sputum Xpert®-MTB/RIF and the Determine™ TB LAM urine test in two African communities could be effective.

Methods: In a pragmatic, randomised, parallel-group trial with individual randomisation stratified by country, we compared sputum Xpert®-MTB/RIF, and if HIV-infected, the Determine™ TB LAM urine test (novel diagnostic group), with laboratory-based sputum smear microscopy (routine diagnostic group) for intensified case finding in communities with high tuberculosis and HIV prevalence in Cape Town, South Africa, and Harare, Zimbabwe. Participants were randomly assigned (1:1) to these groups with computer-generated allocation lists, using culture as the reference standard. In Cape Town, participants were randomised and tested at an Xpert®-equipped mobile van, while in Harare, participants were driven to a local clinic where the same diagnostic tests were done. The primary endpoint was the proportion of culture-positive tuberculosis cases initiating tuberculosis treatment in each study group at 60 days. This trial is registered at ClinicalTrials.gov, number NCT01990274.

Findings: Between Oct 18, 2013, and March 31, 2015, 2261 individuals were screened and 875 (39%) of these met the criteria for diagnostic testing. 439 participants were randomly assigned to the novel group and 436 to the routine group. 74 (9%) of 875 participants had confirmed tuberculosis. If late culture-based treatment initiation was excluded, more patients with culture-positive tuberculosis were initiated on treatment in the novel group at 60 days (36 [86%] of 42 in the novel group vs 18 [56%] of 32 in the routine group). Thus the difference in the proportion initiating treatment between groups was 29% (95% CI 9-50, p=0.0047) and 53% more patients initiated therapy in the novel diagnostic group than in the routine diagnostic group. One culture-positive patient was treated based only on a positive LAM test.

Interpretation: Compared with traditional tools, Xpert®-MTB/RIF for community-based intensified case finding in HIV and tuberculosis-endemic settings increased the proportion of patients initiating treatment. By contrast, urine LAM testing was not found to be useful for intensive case finding in this setting.

Abstract access   

Editor’s notes: Undiagnosed tuberculosis (TB) is the main source of ongoing transmission of Mycobacterium tuberculosis in the community.  Community-based intensified TB case finding strategies in high prevalence settings aim to reduce the prevalence of undiagnosed tuberculosis (TB) and thereby to reduce TB transmission. This is the first randomised trial to date comparing a point of contact diagnostic tool, Xpert® MTB/RIF, with a traditional tool, smear microscopy, for community-based intensive case-finding in sub-Saharan Africa.

The key finding was that a community-based intensified strategy using Xpert® MTB/RIF reduced time-to-treatment and increased the proportion of culture-positive people started on treatment in the first 60 days (when culture-based treatment initiation was not included).  Additional findings included a reduction in the number of people with TB treated empirically and a 50% increase in 60-day detection rate compared with smear microscopy. However, there was no difference by study arm in the proportion of culture-positive people who were retained on TB treatment at six months, and this was suboptimal (69% versus 71% for routine versus novel). The study also demonstrated that it was feasible to undertake community-based screening by minimally trained health-care workers using Xpert® in a mobile van with a generator or on site within a community-based clinic. 

It is interesting to note that there were major differences between study sites. In multivariable analysis, study site was the strongest risk factor for a shorter time-to-treatment initiation among culture-positive cases (Harare versus Cape Town - adjusted hazard ratio 7.18, 95% confidence interval 3.69 – 13.96) with screening method (novel versus routine diagnostics) found to have an adjusted hazard ratio of 2.32 (95% confidence interval 1.35 – 3.97). This finding likely reflects differences in the clinical management of Xpert®-negative and smear-negative people with presumed TB between study sites. In Harare, almost all people with a negative test result (in either arm) were referred for chest radiography, and probably because of this, a much larger proportion of study participants were started on anti-tuberculosis treatment in Harare compared to Cape Town (49% versus 9%). There was also a major difference in retention on treatment at six months among culture-positive people (81% in Harare versus 59% in Cape Town). These results highlight the importance of context, including heterogeneity in patient characteristics and differences in quality of health-care, access and practices between settings, in interpreting study findings associated with TB case-finding strategies.

Whether implementation of community-based intensive case finding using Xpert® in high-prevalence areas actually translates into reduced community TB transmission or improved clinical outcomes remains to be determined. 

Africa
South Africa, Zimbabwe
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Anal high-risk HPV and high-grade lesions: screening is required for women living with HIV

Prevalence of anal HPV and anal dysplasia in HIV-infected women from Johannesburg, South Africa.

Goeieman BJ, Firnhaber CS, Jong E, Michelow P, Swarts A, Williamson AL, Allan B, Smith JS, Kegorilwe P, Wilkin TJ. J Acquir Immune Defic Syndr. 2017 Jan 30. doi: 10.1097/QAI.0000000000001300. [Epub ahead of print]

Background: Anal cancer is a relatively common cancer among HIV-infected populations. There are limited data on the prevalence of anal high-risk human papillomavirus (HR-HPV) infection and anal dysplasia in HIV-infected women from resource-constrained settings.

Methods: A cross-sectional study of HIV-infected women age 25-65 recruited from an HIV clinic in Johannesburg, South Africa. Cervical and anal swabs were taken for conventional cytology and HR-HPV testing. Women with abnormal anal cytology and 20% of women with negative cytology were seen for high resolution anoscopy (HRA) with biopsy of visible lesions.

Results: Two hundred women were enrolled. Anal HR-HPV was found in 43%. The anal cytology results were negative in 51 (26%); 97 (49%) had low-grade squamous intraepithelial lesions (SIL), 32 (16%) had atypical squamous cells of unknown significance and 19 (9.5%) had high-grade SIL or atypical squamous cells suggestive of high-grade SIL. On HRA, 71 (36%) had atypia or low-grade SIL on anal histology and 17 (8.5%) had high-grade SIL. Overall 31 (17.5%) had high-grade SIL present on anal cytology or histology. Abnormal cervical cytology was found in 70% and cervical HR-HPV in 41%.

Conclusion: We found a significant burden of anal HR-HPV infection, abnormal anal cytology and high-grade SIL in our cohort. This is the first study of the prevalence of anal dysplasia in HIV-infected women from sub-Saharan Africa. Additional studies are needed to define the epidemiology of these conditions, as well as the incidence of anal cancer, in this population.

Abstract access

Editor’s notes: Women living with HIV have a higher incidence of anogenital cancers compared to HIV-negative women, even in the ART era. Previous studies have illustrated that women living with HIV in South Africa have a high risk of cervical high-risk (HR)-HPV, and high rates of high-grade cervical intraepithelial neoplasia. This is the first study to report the prevalence of anal HR-HPV and anal high-grade squamous intraepithelial lesions (HSIL+) among women living with HIV in Africa.

This cross-sectional study among 200 women living with HIV attending a HIV treatment centre in Johannesburg, South Africa, the majority (97%) of whom were on ART, reported a high  prevalence of anal HR-HPV and anal HSIL+ by high-resolution anoscopy (43% and 8.5%, respectively). Women with low current CD4+ cell count and with shorter duration of ART use had marginally higher prevalence of anal HR-HPV and HSIL+.

It remains unclear whether high-grade anal lesions among women living with HIV have the same propensity to progress to anal cancer as is known to occur for high-grade cervical lesions to cervical cancer. Studies among HIV-positive and HIV-negative men report frequent spontaneous regression of anal intraepithelial lesions (AIN) and high rates of recurrence following treatment, but longitudinal data are limited among women living with HIV. Prolonged ART use may have contributed to a reduction in HPV-associated cervical lesions, and the same could be true for anal lesions. Larger prospective studies are necessary to define the rates of high-grade lesion incidence and progression and associated risk factors among women living with HIV in order to guide screening and management decisions.  

Comorbidity, Epidemiology
Africa
South Africa
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Adolescents’ concerns: psychosocial needs of young people living with HIV in Thailand

Psychosocial needs of perinatally HIV-infected youths in Thailand: lessons learnt from instructive counseling.

Manaboriboon B, Lolekha R, Chokephaibulkit K, Leowsrisook P, Naiwatanakul T, Tarugsa J, Durier Y, Aunjit N, Punpanich Vandepitte W, Boon-Yasidhi V. AIDS Care. 2016 Dec;28(12):1615-1622. Epub 2016 Jun 26.

Identifying psychosocial needs of perinatally HIV-infected (pHIV) youth is a key step in ensuring good mental health care. We report psychosocial needs of pHIV youth identified using the "Youth Counseling Needs Survey" (YCS) and during individual counseling (IC) sessions. pHIV youth receiving care at two tertiary-care hospitals in Bangkok or at an orphanage in Lopburi province were invited to participate IC sessions. The youths' psychosocial needs were assessed using instructive IC sessions in four main areas: general health, reproductive health, mood, and psychosocial concerns. Prior to the IC session youth were asked to complete the YCS in which their concerns in the four areas were investigated. Issues identified from the YCS and the IC sessions were compared. During October 2010-July 2011, 150 (68.2%) of 220 eligible youths participated in the IC sessions and completed the YCS. Median age was 14 (range 11-18) years and 92 (61.3%) were female. Mean duration of the IC sessions was 36.5 minutes. One-hundred and thirty (86.7%) youths reported having at least one psychosocial problem discovered by either the IC session or the YCS. The most common problems identified during the IC session were poor health attitude and self-care (48.0%), lack of life skills (44.0%), lack of communication skills (40.0%), poor antiretroviral (ARV) adherence (38.7%), and low self-value (34.7%). The most common problems identified by the YCS were lack of communication skills (21.3%), poor health attitude and self-care (14.0%), and poor ARV adherence (12.7%). Youth were less likely to report psychosocial problems in the YCS than in the IC session. Common psychosocial needs among HIV-infected youth were issues about life skills, communication skills, knowledge on self-care, ARV adherence, and self-value. YCS can identify pHIV youths' psychosocial needs but might underestimate issues. Regular IC sessions are useful to detect problems and provide opportunities for counseling.

Abstract access  

Editor’s notes: The study reports on the psychological needs of young people who acquired HIV in the perinatal period.  The needs were highlighted during counselling sessions and in a survey conducted as part of the Happy-Teen Programme in Thailand. Young people (age 11-18) who have perinatally acquired HIV were recruited in two hospitals and from a service run by an orphanage linked to one of the hospitals. Young people took part in two individual ‘instructive counselling’ sessions, and two survey sessions for a needs-assessment questionnaire. Participants reported higher levels of needs in the counselling sessions compared to the questionnaire. Key areas of need identified included: health attitudes and self-care (e.g., diet, sleep, drug use); issues with sexual risk and difficulties communicating with sexual partners; HIV treatment adherence problems; concerns about HIV-associated stigma; and concerns about peer pressure. The study illustrates the difference in the quality of findings obtained from data collected via the questionnaire in comparison with data collected via sessions with counsellors. The counsellors were people that the young people knew for some time and trusted. The study highlights the importance of counselling with young people to improve self-esteem and health-associated behaviours.  Counsellors are also important to provide referrals for more severe mental health issues. 

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

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

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

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

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

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

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

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

Abstract access  

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

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

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

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

Comorbidity, Epidemiology
Africa
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School-based HIV prevention programmes appear ineffective

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

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

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

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

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

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

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

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

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

Abstract  Full-text [free] access 

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

Africa, Europe, Latin America
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‘I wish I could have a life like others’: mental health challenges for young people living with HIV in Tanzania

A qualitative exploration of the mental health and psychosocial contexts of HIV-positive adolescents in Tanzania.

Ramaiya MK, Sullivan KA, K OD, Cunningham CK, Shayo AM, Mmbaga BT, Dow DE. PLoS One. 2016 Nov 16;11(11):e0165936. doi: 10.1371/journal.pone.0165936. eCollection 2016.

Although 85% of HIV-positive adolescents reside in sub-Saharan Africa, little is known about the psychosocial and mental health factors affecting their daily well-being. Identifying these contextual variables is key to development of culturally appropriate and effective interventions for this understudied and high-risk population. The purpose of this study was to identify salient psychosocial and mental health challenges confronted by HIV-positive youth in a resource-poor Tanzanian setting. A total of 24 qualitative interviews were conducted with a convenience sample of adolescents aged 12-24 receiving outpatient HIV care at a medical center in Moshi, Tanzania. All interviews were audio-recorded, transcribed, and coded using thematic analysis. Psychosocial challenges identified included loss of one or more parents, chronic domestic abuse, financial stressors restricting access to medical care and education, and high levels of internalized and community stigma among peers and other social contacts. Over half of youth (56%) reported difficulties coming to terms with their HIV diagnosis and espoused related feelings of self-blame. These findings highlight the urgent need to develop culturally proficient programs aimed at helping adolescents cope with these manifold challenges. Results from this study guided the development of Sauti ya Vijana (The Voice of Youth), a 10-session group mental health intervention designed to address the psychosocial and mental health needs of HIV-positive Tanzanian youth.

Abstract  Full-text [free] access 

Editor’s notes: This article presents the findings of a mixed-methods study with young people living with HIV and accessing care in Moshi, Tanzania. The study was conducted as part of a larger study assessing mental health needs in this population. The article reports on themes from individual qualitative interviews with 24 young people (aged 13-23) who had mental health difficulties that were previously assessed with the scales used in the larger project. Young people reported a wide range of psychosocial issues leading to ongoing mental health challenges.  These were challenges for which they had received little or no psychological support. Issues included internalized, feared and experienced HIV stigma, loss and bereavement from being orphaned.  Additional challenges were stress from poverty and insecurity in the household, isolation and difficulties with disclosure of their HIV status, and direct and vicarious experiences of violence and abuse. Young people also discussed finding strength in spirituality, friendships and especially peer-support from other young people living with HIV. Findings from the overall study are being used to inform the development of a mental health activity model that, if effective, could be scaled up in other low-income settings. 

Africa
United Republic of Tanzania
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A one-stop shop for HIV and non-communicable disease care in Kibera, Kenya

They just come, pick and go. The acceptability of integrated medication adherence clubs for HIV and non-communicable disease (NCD) patients in Kibera, Kenya.

Venables E, Edwards JK, Baert S, Etienne W, Khabala K, Bygrave H. AIDS Behav. 2016 Oct;20(10):2464-76. doi: 10.1007/s10461-016-1331-z.

Introduction: The number of people on antiretroviral therapy (ART) for the long-term management of HIV in low- and middle-income countries (LMICs) is continuing to increase, along with the prevalence of non-communicable diseases (NCDs). The need to provide large volumes of HIV patients with ART has led to significant adaptations in how medication is delivered, but access to NCD care remains limited in many contexts. Medication Adherence Clubs (MACs) were established in Kibera, Kenya to address the large numbers of patients requiring chronic HIV and/or NCD care. Stable NCD and HIV patients can now collect their chronic medication every three months through a club, rather than through individual clinic appointments.

Methodology: We conducted a qualitative research study to assess patient and health-care worker perceptions and experiences of MACs in the urban informal settlement of Kibera, Kenya. A total of 106 patients (with HIV and/or other NCDs) and health-care workers were purposively sampled and included in the study. Ten focus groups and 19 in-depth interviews were conducted and 15 sessions of participant observation were carried out at the clinic where the MACs took place. Thematic data analysis was conducted using NVivo software, and coding focussed on people's experiences of MACs, the challenges they faced and their perceptions about models of care for chronic conditions.

Results: MACs were considered acceptable to patients and health-care workers because they saved time, prevented unnecessary queues in the clinic and provided people with health education and group support whilst they collected their medication. Some patients and health-care workers felt that MACs reduced stigma for HIV positive patients by treating HIV as any other chronic condition. Staff and patients reported challenges recruiting patients into MACs, including patients not fully understanding the eligibility criteria for the clubs. There were also some practical challenges during the implementation of the clubs, but MACs have shown that it is possible to learn from ART provision and enable stable HIV and NCD patients to collect chronic medication together in a group.

Conclusions: Extending models of care previously only offered to HIV-positive cohorts to NCD patients can help to de-stigmatise HIV, allow for the efficient clinical management of co-morbidities and enable patients to benefit from peer support. Through MACs, we have demonstrated that an integrated approach to providing medication for chronic diseases including HIV can be implemented in resource-poor settings and could thus be rolled out in other similar contexts.

Abstract  Full-text [free] access 

Editor’s notes: As people living with HIV grow older, the chances of multi-morbidities increase. The number of non-communicable disease diagnosis is increasing generally in sub-Saharan Africa. This is not only because of changing lifestyles but also because of better diagnostic skills and ageing populations. The authors of this paper provide valuable information on how HIV and non-communicable disease care can be combined through the provision of ‘adherence clubs’. The clubs in Kibera, Kenya, have practical benefits for people living with more than one condition. The clubs also, as the authors state, provide a way to counter stigma around HIV, because the ‘medication adherence club’ is not disease specific. That said, a very useful and interesting finding from this research was the difference in views between health care workers and patients. The health care workers were often more positive in their views about the impact on stigma, for example, than the patients. It is apparent that sustained promotion of the purpose of the clubs is required. This publicity is necessary not only to spread information about the purpose of the club, but also to ensure people understand who is eligible to attend. If that publicity is successful, and the clubs can be sustained, the provision of an integrated service is an important step forward in chronic disease care models.

Africa
Kenya
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Health care navigators do not improve early outcomes on ART in South Africa

Sizanani: a randomized trial of health system navigators to improve linkage to HIV and TB care in South Africa.

Bassett IV, Coleman SM, Giddy J, Bogart LM, Chaisson CE, Ross D, Jacobsen MM, Robine M, Govender T, Freedberg KA, Katz JN, Walensky RP, Losina E. J Acquir Immune Defic Syndr. 2016 Oct 1;73(2):154-60. doi: 10.1097/QAI.0000000000001025.

Background: A fraction of HIV-diagnosed individuals promptly initiate antiretroviral therapy (ART). We evaluated the efficacy of health system navigators for improving linkage to HIV and tuberculosis (TB) care among newly diagnosed HIV-infected outpatients in Durban, South Africa.

Methods: We conducted a randomized controlled trial (Sizanani Trial, NCT01188941) among adults (≥18 years) at 4 sites. Participants underwent TB screening and randomization into a health system navigator intervention or usual care. Intervention participants had an in-person interview at enrollment and received phone calls and text messages over 4 months. We assessed 9-month outcomes via medical records and the National Population Registry. Primary outcome was completion of at least 3 months of ART or 6 months of TB treatment for coinfected participants.

Results: Four thousand nine hundred three participants were enrolled and randomized; 1899 (39%) were HIV-infected, with 1146 (60%) ART-eligible and 523 (28%) TB coinfected at baseline. In the intervention, 212 (39% of outcome-eligible) reached primary outcome compared to 197 (42%) in usual care (RR 0.93, 95% CI: 0.80 to 1.08). One hundred thirty-one (14%) HIV-infected intervention participants died compared to 119 (13%) in usual care; death rates did not differ between arms (RR 1.06, 95% CI: 0.84 to 1.34). In the as-treated analysis, participants reached for ≥5 navigator calls were more likely to achieve study outcome.

Conclusions: approximately 40% of ART-eligible participants in both study arms reached the primary outcome 9 months after HIV diagnosis. Low rates of engagement in care, high death rates, and lack of navigator efficacy highlight the urgency of identifying more effective strategies for improving HIV and TB care outcomes.

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Editor’s notes: Early mortality remains high among people starting antiretroviral therapy (ART) in low- and middle-income countries, and tuberculosis is consistently identified as a leading cause. In KwaZulu-Natal province, South Africa, where this study was conducted, tuberculosis incidence is very high, and around two-thirds of people starting tuberculosis treatment are HIV-positive. Previous studies have illustrated gaps between positive test results and linkage to HIV and tuberculosis care. For HIV-positive people with tuberculosis, accessing treatment for both HIV and tuberculosis is made more difficult by a lack of integrated care in many settings. Health care navigators have helped people with HIV link to care in the United States.

This study tested a programme whereby health care navigators helped newly-diagnosed HIV-positive people to link to HIV care, and if necessary also to tuberculosis treatment. The navigators had a counselling role, and also contacted patients by phone or text message reminders. Disappointingly, the programme did not improve outcomes at nine months after enrolment. All-cause mortality was high at around 14% by nine months, and was not reduced by the programme. This is an important result, contrasting with findings from other studies. The SEARCH trial in Uganda illustrated more rapid ART initiation resulting from a complex programme, primarily targeting health system rather than individual barriers. However, the primary outcome of the SEARCH analysis was ART initiation; there was no detectable effect on mortality, which was very low, suggesting a lower-risk study population. In the REMSTART study, a programme including point-of-care testing for cryptococcal antigen plus adherence support from community counsellors (along with routine tuberculosis investigation in both arms) was associated with a reduction in early mortality; the “active ingredient” of this programme was not clearly defined. Ideally, people with HIV need to start ART before they reach the stage of advanced disease. However, given the reality that many people do present with advanced disease, more work is necessary to define which programme could reduce their risk of mortality.

Africa
South Africa
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