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Edun O, Okell L, Chun H, Bissek ACZ, Ndongmo CB, Shang JD, Brou H, Ehui E, Ekra AK, Nuwagaba-Biribonwoha H, Dlamini SS, Ginindza C, Eshetu F, Misganie YG, Desta SL, Achia TNO, Aoko A, Jonnalagadda S, Wafula R, Asiimwe FM, Lecher S, Nkanaunena K, Nyangulu MK, Nyirenda R, Beukes A, Klemens JO, Taffa N, Abutu AA, Alagi M, Charurat ME, Dalhatu I, Aliyu G, Kamanzi C, Nyagatare C, Rwibasira GN, Jalloh MF, Maokola WM, Mgomella GS, Kirungi WL, Mwangi C, Nel JA, Minchella PA, Gonese G, Nasr MA, Bodika S, Mungai E, Patel HK, Sleeman K, Milligan K, Dirlikov E, Voetsch AC, Shiraishi RW, Imai-Eaton JW. HIV risk behaviour, viraemia, and transmission across HIV cascade stages including low-level viremia: Analysis of 14 cross-sectional population-based HIV Impact Assessment surveys in sub-Saharan Africa. PLOS Glob Public Health 2024; 4:e0003030. [PMID: 38573931 PMCID: PMC10994324 DOI: 10.1371/journal.pgph.0003030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 02/25/2024] [Indexed: 04/06/2024]
Abstract
As antiretroviral treatment (ART) coverage for people living with HIV (PLHIV) increases, HIV programmes require up-to-date information about evolving HIV risk behaviour and transmission risk, including those with low-level viremia (LLV; >50 to ≤1000 copies/mL), to guide prevention priorities. We aimed to assess differences in sexual risk behaviours, distribution of viral load (VL) and proportion of transmission across PLHIV subgroups. We analysed data from Population-based HIV Impact Assessment surveys in 14 sub-Saharan African countries during 2015-2019. We estimated adjusted prevalence ratios (aPR) of self-reported HIV high-risk behaviour (multiple partners and condomless sex) across cascade stages via generalised estimation equations. We modelled the proportions of transmission from each subgroup using relative self-reported sexual risk, a Hill function for transmission rate by VL, and proportions within cascade stages from surveys and UNAIDS country estimates for 2010-2020. Compared to PLHIV with undetectable VL (≤50 copies/mL), undiagnosed PLHIV (aPR women: 1.28 [95% CI: 1.08-1.52]; men: 1.61 [1.33-1.95]) and men diagnosed but untreated (2.06 [1.52-2.78]) were more likely to self-report high-risk sex. High-risk behaviour was not significantly associated with LLV. Mean VL was similar among undiagnosed, diagnosed but untreated, and on ART but non-suppressed sub-groups. Across surveys, undiagnosed and diagnosed but untreated contributed most to transmission (40-91% and 1-41%, respectively), with less than 1% from those with LLV. Between 2010 and 2020, the proportion of transmission from individuals on ART but non-suppressed increased. In settings with high ART coverage, effective HIV testing, ART linkage, and retention remain priorities to reduce HIV transmission. Persons with LLV are an increasing share of PLHIV but their contribution to HIV transmission was small. Improving suppression among PLHIV on ART with VL ≥1000 copies/mL will become increasingly important.
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Affiliation(s)
- Olanrewaju Edun
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Lucy Okell
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Helen Chun
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Atlanta, Georgia, United States of America
| | - Anne-Cecile Z. Bissek
- Division of Health Operations Research, Ministry of Public Health, Yaoundé, Cameroon
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé, Yaoundé, Cameroon
| | - Clement B. Ndongmo
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Yaoundé, Cameroon
| | - Judith D. Shang
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Yaoundé, Cameroon
| | - Hermann Brou
- ICAP, Columbia University, Abidjan, Côte d’Ivoire
| | - Eboi Ehui
- National AIDS Control Programme, Ministry of Health, Public Hygiene and Universal Health Coverage, Abidjan, Côte d’Ivoire
| | - Alexandre K. Ekra
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Abidjan, Côte d’Ivoire
| | | | | | | | - Frehywot Eshetu
- U.S. Centers for Disease Control and Prevention Division of Global HIV/TB, Center for Global Health, Addis Ababa, Ethiopia
| | - Yimam G. Misganie
- Ethiopian Public Health Institute, HIV/AIDS and TB Research Directorate, Addis Ababa, Ethiopia
- School of Medicine, Zhejiang University, Hangzhou, China
| | - Sileshi Lulseged Desta
- ICAP in Ethiopia, Mailman School of Public Health, Columbia University, Addis Ababa, Ethiopia
| | - Thomas N. O. Achia
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Nairobi, Kenya
| | - Appolonia Aoko
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Nairobi, Kenya
| | - Sasi Jonnalagadda
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Nairobi, Kenya
| | - Rose Wafula
- National AIDS and STI Control Programme, Ministry of Health, Nairobi, Kenya
| | - Fred M. Asiimwe
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Maseru, Lesotho
| | - Shirley Lecher
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Maseru, Lesotho
| | - Kondwani Nkanaunena
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Lilongwe, Malawi
| | - Mtemwa K. Nyangulu
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Lilongwe, Malawi
| | - Rose Nyirenda
- Department of HIV/AIDS, Ministry of Health, Lilongwe, Malawi
| | - Anita Beukes
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Windhoek, Namibia
| | | | - Negussie Taffa
- Ministry of Health and Social Services, Windhoek, Namibia
| | - Andrew A. Abutu
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Abuja, Nigeria
| | - Matthias Alagi
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Abuja, Nigeria
| | - Man E. Charurat
- Center for International Health, Education, and Biosecurity (Ciheb), University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Ibrahim Dalhatu
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Abuja, Nigeria
| | - Gambo Aliyu
- National Agency for the Control of AIDS, Abuja, Nigeria
| | | | - Celestine Nyagatare
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Kigali, Rwanda
| | - Gallican N. Rwibasira
- HIV, STIs, Viral Hepatitis & OVDC Department, Rwanda Biomedical Center, Kigali, Rwanda
| | - Mohamed F. Jalloh
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Dar es Salaam, Tanzania
| | - Werner M. Maokola
- National AIDS Control Programme, Tanzania Ministry of Health, Dar es Salaam, Tanzania
| | - George S. Mgomella
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Dar es Salaam, Tanzania
| | | | - Christina Mwangi
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Kampala, Uganda
| | - Jennifer A. Nel
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Kampala, Uganda
| | - Peter A. Minchella
- U.S. Centers for Disease Control and Prevention Division of Global HIV/TB, Center for Global Health, Lusaka, Zambia
| | - Gloria Gonese
- Zimbabwe Technical Assistance, Training and Education Center for Health (Zim-TTECH), Harare, Zimbabwe
| | - Melodie A. Nasr
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Harare, Zimbabwe
- Public Health Institute, Global Health Fellowship Program, United States of America
| | - Stephane Bodika
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Atlanta, Georgia, United States of America
| | - Elisabeth Mungai
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Atlanta, Georgia, United States of America
- eTeam, Somerset, New Jersey, United States of America
| | - Hetal K. Patel
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Atlanta, Georgia, United States of America
| | - Katrina Sleeman
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Atlanta, Georgia, United States of America
| | - Kyle Milligan
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Atlanta, Georgia, United States of America
- Peraton, Herndon, Virginia, United States of America
| | - Emilio Dirlikov
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Atlanta, Georgia, United States of America
| | - Andrew C. Voetsch
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Atlanta, Georgia, United States of America
| | - Ray W. Shiraishi
- U.S. Centers for Disease Control and Prevention - Division of Global HIV/TB, Center for Global Health, Atlanta, Georgia, United States of America
| | - Jeffrey W. Imai-Eaton
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
- Department of Epidemiology, Center for Communicable Disease Dynamics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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Ntimana CB, Mashaba RG, Seakamela KP, Netshapapame T, Maimela E. Risky sexual behaviors and associated factors among adult patients on antiretroviral treatment at Mankweng Hospital in Limpopo Province, South Africa. Front Public Health 2023; 11:1245178. [PMID: 37900040 PMCID: PMC10602805 DOI: 10.3389/fpubh.2023.1245178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 09/28/2023] [Indexed: 10/31/2023] Open
Abstract
Background Worldwide, it is estimated that 38 million people are HIV-positive and that over 36 million people have died from the virus. In South Africa, the prevalence of HIV was reported to be 20.6% with Limpopo Province having 17% HIV. Given the high rate of new HIV infection in Limpopo, there is therefore a need to assess factors promoting risky sexual behavior among people living with HIV in order to help design and develop behavioral interventions aimed at reducing risky behaviors among people living with HIV. Methods This was a quantitative cross-sectional prospective study, conducted in Mankweng Hospital. The study consisted of 116 participants of which 40 were males and 76 were females aged 18 years and above. The participants were selected using purposive sampling. The data was analyzed using Statistical Package for Social Sciences version 27. A comparison of proportions was performed using Chi-Square. The association between risky sexual practice and sociodemographic factors was analyzed using multivariate logistic regression. Results The proportion of risky sexual practices in the total population was 48.3%. Participants who were married, those aged 35-44, and those with tertiary qualifications were more likely to engage in risky sexual practices. Multivariate logistic regression showed widowed participants were less likely to practice risky sexual practices. Conclusion The present study reported a high prevalence of risky sexual practices of 48.3%. Risky sexual behavior was determined by age, marital status, and level of education. The proportion of married participants was higher in risky sexual behavior. Based on the findings of the present study, it is recommended that targeted interventions and educational programs should be implemented to reduce risky sexual behavior among married individuals, individuals aged 35-44, and individuals with tertiary qualifications.
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Affiliation(s)
- Cairo B. Ntimana
- DIMAMO Population Health Research Centre, University of Limpopo, Polokwane, South Africa
| | - Reneilwe G. Mashaba
- DIMAMO Population Health Research Centre, University of Limpopo, Polokwane, South Africa
| | - Kagiso P. Seakamela
- DIMAMO Population Health Research Centre, University of Limpopo, Polokwane, South Africa
| | | | - Eric Maimela
- DIMAMO Population Health Research Centre, University of Limpopo, Polokwane, South Africa
- Department of Public Health, University of Limpopo, Polokwane, South Africa
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Wilson E, Donnell D, Skalland T, Floyd S, Moore A, Bell-Mandla N, Bwalya J, Kasese N, Dunbar R, Shanaube K, Kosloff B, Laeyendecker O, Agyei Y, Hoddinott G, Bock P, Fidler S, Hayes R, Ayles H. Impact of universal testing and treatment on sexual risk behaviour and herpes simplex virus type 2: a prespecified secondary outcomes analysis of the HPTN 071 (PopART) community-randomised trial. Lancet HIV 2022; 9:e760-e770. [PMID: 36332653 PMCID: PMC9646971 DOI: 10.1016/s2352-3018(22)00253-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 08/23/2022] [Accepted: 09/01/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Comprehensive HIV prevention strategies have raised concerns that knowledge of interventions to reduce risk of HIV infection might mitigate an individual's perception of risk, resulting in riskier sexual behaviour. We investigated the prespecified secondary outcomes of the HPTN 071 (PopART) trial to determine whether a combination HIV prevention strategy, including universal HIV testing and treatment, changed sexual behaviour; specifically, we investigated whether there was evidence of sexual risk compensation. METHODS HPTN 071 (PopART) was a cluster-randomised trial conducted during 2013-18, in which we randomly assigned 21 communities with high HIV prevalence in Zambia and South Africa (total population, approximately 1 million) to combination prevention intervention with universal antiretroviral therapy (ART; arm A), prevention intervention with ART provided according to local guidelines (universal since 2016; arm B), or standard of care (arm C). The trial included a population cohort of approximately 2000 randomly selected adults (aged 18-44 years) in each community (N=38 474 at baseline) who were followed up for 36 months. A prespecified secondary objective was to evaluate the impact of the PopART intervention compared with standard of care on herpes simplex virus type 2 (HSV-2) and sexual behaviour (N=20 422 completed final visit). Secondary endpoints included differences in sexual risk behaviour measures at 36 months and were assessed using a two-stage method for matched cluster-randomised trials. This trial is registered with ClinicalTrials. gov, number NCT01900977. FINDINGS The PopART intervention did not substantially change probability of self-reported multiple sex partners, sexual debut, or pregnancy in women at 36 months. Adjusted for baseline community prevalence, reported condomless sex was significantly lower in arm A versus arm C (adjusted prevalence ratio 0·80 [95% CI 0·64-0·99]; p=0·04) but not in arm B versus arm C (0·94 [0·76-1·17]; p=0·55). 3-year HSV-2 incidence was reduced in arm B versus arm C (adjusted risk ratio 0·76 [95% CI 0·63-0·92]; p=0·010); no significant change was shown between arm A versus arm C (0·89 [0·73-1·08]; p=0·199). INTERPRETATION We found little evidence of any change in sexual behaviour owing to the PopART interventions, and reassuringly for public health, we saw no evidence of sexual risk compensation. The findings do not help to explain the differences between the two intervention groups of the HPTN 071 (PopART) trial. FUNDING National Institute of Allergy and Infectious Diseases, the National Institutes of Health, the International Initiative for Impact Evaluation (3ie), the Bill & Melinda Gates Foundation, the US President's Emergency Plan for AIDS Relief, and the Medical Research Council UK.
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Affiliation(s)
- Ethan Wilson
- Fred Hutchinson Cancer Center, Seattle, WA, USA.
| | | | | | - Sian Floyd
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Nomtha Bell-Mandla
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | | | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Barry Kosloff
- London School of Hygiene and Tropical Medicine, London, UK; Zambart, Lusaka, Zambia
| | - Oliver Laeyendecker
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA; Johns Hopkins Univiersity School of Medicine, Baltimore, MD, USA
| | - Yaw Agyei
- Johns Hopkins Univiersity School of Medicine, Baltimore, MD, USA
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Sarah Fidler
- Imperial College London, London, UK; NIHR Imperial Biomedical Research Centre, London, UK
| | - Richard Hayes
- London School of Hygiene and Tropical Medicine, London, UK
| | - Helen Ayles
- London School of Hygiene and Tropical Medicine, London, UK; Zambart, Lusaka, Zambia
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Johnson LF, Meyer-Rath G, Dorrington RE, Puren A, Seathlodi T, Zuma K, Feizzadeh A. The Effect of HIV Programs in South Africa on National HIV Incidence Trends, 2000-2019. J Acquir Immune Defic Syndr 2022; 90:115-123. [PMID: 35125471 DOI: 10.1097/qai.0000000000002927] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 01/18/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recent studies have shown HIV incidence declines at a population level in several African countries. However, these studies have not directly quantified the extent to which incidence declines are attributable to different HIV programs. METHODS We calibrated a mathematical model of the South African HIV epidemic to age- and sex-specific data from antenatal surveys, household surveys, and death registration, using a Bayesian approach. The model was also parameterized using data on self-reported condom use, voluntary medical male circumcision (VMMC), HIV testing, and antiretroviral treatment (ART). Model estimates of HIV incidence were compared against the incidence rates that would have been expected had each program not been implemented. RESULTS The model estimated incidence in 15-49 year olds of 0.84% (95% CI: 0.75% to 0.96%) at the start of 2019. This represents a 62% reduction (95% CI: 55% to 66%) relative to 2000, a 47% reduction (95% CI: 42% to 51%) relative to 2010, and a 73% reduction (95% CI: 68% to 77%) relative to the incidence that would have been expected in 2019 in the absence of any interventions. The reduction in incidence in 2019 because of interventions was greatest for ART and condom promotion, with VMMC and behavior change after HIV testing having relatively modest impacts. HIV program impacts differed significantly by age and sex, with condoms and VMMC having greatest impact in youth, and overall incidence reductions being greater in men than in women. CONCLUSIONS HIV incidence in South Africa has declined substantially since 2000, with ART and condom promotion contributing most significantly to this decline.
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Affiliation(s)
- Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine University of Cape Town, Cape Town, South Africa
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office, Wits Health Consortium, University of Witwatersrand, Johannesburg, South Africa
- Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA
| | - Rob E Dorrington
- Centre for Actuarial Research, School of Management Studies, University of Cape Town, Cape Town, South Africa
| | - Adrian Puren
- Division of Virology, School of Pathology, University of Witwatersrand, Johannesburg, South Africa
| | - Thapelo Seathlodi
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine University of Cape Town, Cape Town, South Africa
| | - Khangelani Zuma
- Human Sciences Research Council, Pretoria, South Africa ; and
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