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Chaila MJ, Mcleod D, Vermund SH, Mbolongwe-Thornicroft M, Mbewe M, Mubekapi-Musadaidzwa C, Harper A, Schaap A, Floyd S, Hoddinott G, Hayes R, Fidler S, Ayles H, Shanaube K. Assessment of a screening tool to aid home-based identification of adolescents (aged 10-14) living with HIV in Zambia and South Africa: HPTN 071 (PopART) study. PLoS One 2024; 19:e0266573. [PMID: 38363733 PMCID: PMC10871489 DOI: 10.1371/journal.pone.0266573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 09/05/2023] [Indexed: 02/18/2024] Open
Abstract
INTRODUCTION The HPTN071 (PopART) for Youth (P-ART-Y) study evaluated the acceptability and uptake of a community-level combination HIV prevention package including universal testing and treatment (UTT) among young people in Zambia and South Africa. We determined whether a four-question primary care level screening tool, validated for use in clinical settings, could enhance community (door-to-door) identification of undiagnosed HIV-positive younger adolescents (aged 10-14) who are frequently left out of HIV interventions. METHOD Community HIV-care Providers (CHiPs) contacted and consented adolescents in their homes and offered them participation in the PopART intervention. CHiPs used a four question-screening tool, which included: history of hospital admission; recurring skin problems; poor health in last 3 months; and death of at least one parent. A "yes" response to one or more questions was classified as being "at risk" of being HIV-positive. Rapid HIV tests were offered to all children. Data were captured through an electronic data capture device from August 2016 to December 2017. The sensitivity, specificity, positive predictive value and negative predictive value were estimated for the screening tool, using the rapid HIV test result as the gold standard. RESULTS In our 14 study sites, 33,710 adolescents aged 10-14 in Zambia and 8,610 in South Africa participated in the study. About 1.3% (427/33,710) and 1.2% (106/8,610) self-reported to be HIV positive. Excluding the self-reported HIV-positive, we classified 11.3% (3,746/33,283) of adolescents in Zambia and 17.5% (1,491/8,504) in South Africa as "at risk". In Zambia the estimated sensitivity was 35.3% (95% CI 27.3%-44.2%) and estimated specificity was 88.9% (88.5%-89.2%). In South Africa the sensitivity was 72.3% (26.8%-94.9%) and specificity was 82.5% (81.6-83.4%). CONCLUSION The sensitivity of the screening tool in a community setting in Zambia was low, so this tool should not be considered a substitute for universal testing where that is possible. In South Africa the sensitivity was higher, but with a wide confidence interval. Where universal testing is not possible the tool may help direct resources to adolescents more likely to be living with undiagnosed HIV. TRIAL REGISTRATION Clinical Trial Number: NCT01900977.
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Affiliation(s)
- Mwate Joseph Chaila
- Zambart, University of Zambia School of Medicine, Ridgeway Campus, Lusaka, Zambia
| | - David Mcleod
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sten H Vermund
- Yale School of Public Health, New Haven, Connecticut, United States of America
| | | | - Madalitso Mbewe
- Zambart, University of Zambia School of Medicine, Ridgeway Campus, Lusaka, Zambia
| | - Constance Mubekapi-Musadaidzwa
- Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Abigail Harper
- Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Albertus Schaap
- Zambart, University of Zambia School of Medicine, Ridgeway Campus, Lusaka, Zambia
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Graeme Hoddinott
- Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sarah Fidler
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Helen Ayles
- Zambart, University of Zambia School of Medicine, Ridgeway Campus, Lusaka, Zambia
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kwame Shanaube
- Zambart, University of Zambia School of Medicine, Ridgeway Campus, Lusaka, Zambia
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Nardell MF, Govathson C, Mngadi-Ncube S, Ngcobo N, Letswalo D, Lurie M, Miot J, Long L, Katz IT, Pascoe S. Migrant men and HIV care engagement in Johannesburg, South Africa. BMC Public Health 2024; 24:435. [PMID: 38347453 PMCID: PMC10860300 DOI: 10.1186/s12889-024-17833-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/20/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND South Africa (SA) has one of the highest rates of migration on the continent, largely comprised of men seeking labor opportunities in urban centers. Migrant men are at risk for challenges engaging in HIV care. However, rates of HIV and patterns of healthcare engagement among migrant men in urban Johannesburg are poorly understood. METHODS We analyzed data from 150 adult men (≥ 18 years) recruited in 10/2020-11/2020 at one of five sites in Johannesburg, Gauteng Province, SA where migrants typically gather for work, shelter, transit, or leisure: a factory, building materials store, homeless shelter, taxi rank, and public park. Participants were surveyed to assess migration factors (e.g., birth location, residency status), self-reported HIV status, and use and knowledge of HIV and general health services. Proportions were calculated with descriptive statistics. Associations between migration factors and health outcomes were examined with Fisher exact tests and logistic regression models. Internal migrants, who travel within the country, were defined as South African men born outside Gauteng Province. International migrants were defined as men born outside SA. RESULTS Two fifths (60/150, 40%) of participants were internal migrants and one fifth (33/150, 22%) were international migrants. More internal migrants reported living with HIV than non-migrants (20% vs 6%, p = 0.042), though in a multi-variate analysis controlling for age, being an internal migrant was not a significant predictor of self-reported HIV positive status. Over 90% all participants had undergone an HIV test in their lifetime. Less than 20% of all participants had heard of pre-exposure prophylaxis (PrEP), with only 12% international migrants having familiarity with PrEP. Over twice as many individuals without permanent residency or citizenship reported "never visiting a health facility," as compared to citizens/permanent residents (28.6% vs. 10.6%, p = 0.073). CONCLUSIONS Our study revealed a high proportion of migrants within our community-based sample of men and demonstrated a need for HIV and other healthcare services that effectively reach migrants in Johannesburg. Future research is warranted to further disaggregate this heterogenous population by different dimensions of mobility and to understand how to design HIV programs in ways that will address migrants' challenges.
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Affiliation(s)
- Maria Francesca Nardell
- Division of Global Health Equity, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Caroline Govathson
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sithabile Mngadi-Ncube
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nkosinathi Ngcobo
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Daniel Letswalo
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Lurie
- Brown University School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Jacqui Miot
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Ingrid Theresa Katz
- Harvard Medical School, Boston, MA, USA
- Division of Women's Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Phiri MM, Hensen B, Sigande LM, Floyd S, Schaap AJ, Simuyaba M, Mwenge L, Zulu-Phiri R, Mwape L, Fidler S, Simwinga M, Hayes R, Ayles HM. Factors associated with use of community-based, peer-led sexual and reproductive health services by adolescent boys and young men aged 18-24 in Lusaka, Zambia: A case control study nested in the Yathu Yathu trial. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002446. [PMID: 37963113 PMCID: PMC10645296 DOI: 10.1371/journal.pgph.0002446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 10/03/2023] [Indexed: 11/16/2023]
Abstract
INTRODUCTION Adolescents and young people (AYP) aged 15-24 years have the least access to facility-based sexual and reproductive health (SRH) services, including HIV services. The Yathu-Yathu cluster-randomized trial (CRT) in Zambia tested whether a novel peer-led community-based approach increased knowledge of HIV status amongst AYP. In this nested case-control study, we aimed to identify factors associated with non-attendance to the Yathu Yathu hubs by adolescent boys and young men (ABYM) aged 18-24-years. METHODS Yathu Yathu was a CRT conducted in two communities in Lusaka, Zambia, with 10 intervention and 10 control zones. AYP in all zones were offered prevention points cards (PPC), which incentivized and tracked service use at the hubs and health facility. In intervention zones, services were provided to AYP through community-based spaces (hubs) led by peer support workers. In these zones, cases were defined as those not having accessed any service at a hub and controls as those that accessed at least one service. Data were collected from October 2020 to January 2021 and analysed using methods appropriate for unmatched case-control studies. RESULTS 161 cases and 160 controls consented to participate in the study. Participants aged 20-24 years (adjOR 1.99, 95%CI 1.26-3.12, p = 0.003), who were educated up to college level (adjOR 8.47,95%CI 2.08-34.53, p = 0.001) or who reported being employed in the last 12 months (adjOR 2.15, 95%CI 1.31-3.53, p = 0.002) were more likely to not attend the hubs. ABYM who had a friend with a PPC were more likely to attend the hubs (adjOR 0.18 95%CI 0.09-0.35, p<0.001). Most cases reported having their last HIV test at the local government health facility (58%) while most controls reported HIV-testing at a Yathu Yathu hub (82%). Among the controls, 84% (134/160) rated the hub experience as excellent. Among cases, 65% (104/161) stated they didn't visit the hubs "due to employment". CONCLUSIONS Despite Yathu Yathu services being community-based and more accessible compared to health facilities, we found age, education and employment were associated with not attending hubs. Strategies are needed to reach employed young men who may not have access to SRH/HIV services during conventional working hours and to better utilise peer networks to increase service use.
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Affiliation(s)
| | - Bernadette Hensen
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Albertus J. Schaap
- Zambart, Lusaka, Zambia
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | | | - Sarah Fidler
- Faculty of Medicine, Department of Infectious Disease, Imperial College, London, United Kingdom
| | | | - Richard Hayes
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Helen M. Ayles
- Zambart, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Nyirenda HC, Foloko M, Bolton-Moore C, Vera J, Sharma A. Drivers of uptake of HIV testing services, a snapshot of barriers and facilitators among adolescent boys and young men in Lusaka: a qualitative study. BMJ Open 2023; 13:e062928. [PMID: 37696636 PMCID: PMC10496706 DOI: 10.1136/bmjopen-2022-062928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 08/28/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Striking gender and rural-urban disparities highlight the need to redesign HIV services to improve HIV testing and linkage by adolescent boys and young men (ABYM) in sub-Saharan African cities. PURPOSE We sought to understand drivers of HIV testing among ABYM living in urban Lusaka in order to design a targeted intervention that may increase their entry into the HIV prevention and treatment cascade. METHODS In May and June 2019, two male moderators conducted three focus group discussions lasting 1.25 hours with seven to nine ABYM per group and six in-depth interviews with healthcare providers (HCPs) working with adolescents. ABYM were conveniently selected from first aid training, sports and youth-friendly sites in three settlement areas. We purposefully selected HCP from community, facility and district levels. Thematic analyses using inductive reasoning were applied. RESULTS The 24 ABYM were 18-24 years old (median 21 years), single, from 11 different neighbourhoods and 79% had 9-12 years of education. Facilitators of HIV testing uptake included the importance ABYM placed on good health and planning their future in order to fulfil their masculine identity and societal roles. Barriers included peer norms, life-long treatment along with anticipated changes to sexual life and alcohol use, fear of results and judgement and disappointment among HCP. HCPs agreed that masculine roles ('many things to do') and arduous clinical processes deterred ABYM from accessing testing services. They suggested that ABYM were prone to depression which both caused and resulted from behavioural issues such as alcohol use and risk-taking, which prevented uptake of HIV testing services. Both parties agreed that ABYM needed services specifically designed for them and that offered convenient, private, swift and non-judgemental services. CONCLUSIONS ABYM disillusioned by standard counselling procedures, systemic barriers and stigma, avoid HIV test and treat services. Innovative ways and youth-specific spaces are needed to increase access to non-judgemental services that facilitate entry into the HIV prevention and treatment cascade in this population.
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Affiliation(s)
| | - Marksman Foloko
- Center for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton-Moore
- Center for Infectious Disease Research in Zambia, Lusaka, Zambia
- Infectious Disease, University of Alabama at Birmingham, Alabama, Alabama, USA
| | - Jaime Vera
- Sussex Institute, Brighton, Brighton and Hove, UK
| | - Anjali Sharma
- Center for Infectious Disease Research in Zambia, Lusaka, Zambia
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Bose DL, Hundal A, Singh S, Singh S, Seth K, Hadi SU, Saran A, Joseph J, Goyal K, Salve S. Evidence and gap map report: Social and Behavior Change Communication (SBCC) interventions for strengthening HIV prevention and research among adolescent girls and young women (AGYW) in low- and middle-income countries (LMICs). CAMPBELL SYSTEMATIC REVIEWS 2023; 19:e1297. [PMID: 36911864 PMCID: PMC9831290 DOI: 10.1002/cl2.1297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
BACKGROUND Adolescent girls and young women (AGYW), aged 15-24 years, are disproportionately affected by HIV and other sexual and reproductive health (SRH) risks due to varying social, cultural, and economic factors that affect their choices and shape their knowledge, understanding, and practices with regard to their health. Socio-Behavioral Change Communication (SBCC) interventions targeted at strengthening the capabilities of individuals and their networks have supported the demand and uptake of prevention services and participation in biomedical research. However, despite growing global recognition of the domain, high-quality evidence on the effectiveness of SBCC remains scattered. This evidence and gap map (EGM) report characterizes the evidence base on SBCC interventions for strengthening HIV Prevention and Research among AGYW in low- and middle-income countries (LMICs), identifying evidence gaps and outlining the scope of future research and program design. OBJECTIVES The objectives of the proposed EGM are to: (a) identify and map existing EGMs in the use of diverse SBCC strategies to strengthen the adoption of HIV prevention measures and participation in research among AGYW in LMICs and (b) identify areas where more interventions and evidence are needed to inform the design of future SBCC strategies and programs for AGYW engagement in HIV prevention and research. METHODS This EGM is based on a comprehensive search of systematic reviews and impact evaluations corresponding to a range of interventions and outcomes-aimed at engaging AGYW in HIV prevention and research - that were published in LMICs from January 2000 to April 2021. Based on guidance for producing a Campbell Collaboration EGM, the intervention and outcome framework was designed in consultation with a group of experts. These interventions were categorized across four broad intervention themes: mass-media, community-based, interpersonal, and Information Communication and Technology (ICT)/Digital Media-based interventions. They were further sub-categorized into 15 intervention categories. Included studies looked at 23 unique behavioral and health outcomes such as knowledge attitude and skills, relationship dynamics, household dynamics, health care services, and health outcomes and research engagement. The EGM is presented as a matrix in which the rows are intervention categories/sub-categories, and the columns are outcome domains/subdomains. Each cell is mapped to an intervention targeted at outcomes. Additional filters like region, country, study design, age group, funding agency, influencers, population group, publication status, study confidence, setting, and year of publication have been added. SELECTION CRITERIA To be eligible, studies must have tested the effectiveness of SBCC interventions at engaging AGYW in LMICs in HIV prevention and research. The study sample must have consisted of AGYW between the ages of 15-24, as defined by UNAIDS. Both experimental (random assignment) and quasi-experimental studies that included a comparison group were eligible. Relevant outcomes included those at the individual, influencer, and institutional levels, along with those targeting research engagement and prevention-related outcomes. RESULTS This EGM comprises 415 impact evaluations and 43 systematic reviews. Interventions like peer-led interactions, counseling, and community dialogues were the most dominant intervention sub-types. Despite increased digital penetration use of media and technology-driven interventions are relatively less studied. Most of the interventions were delivered by peers, health care providers, and educators, largely in school-based settings, and in many cases are part of sex-education curricula. Evidence across geographies was mostly concentrated in Sub-Saharan Africa (70%). Most measured outcomes focused on disease-related knowledge dissemination and enhancing awareness of available prevention options/strategies. These included messaging around consistent condom use, limiting sexual partners, routine testing, and awareness. Very few studies were able to include psychographic, social, and contextual factors influencing AGYW health behaviors and decisions, especially those measuring the impact of social and gender norms, relationship dynamics, and household dynamics-related outcomes. Outcomes related to engagement in the research were least studied. CONCLUSION This EGM highlights that evidence is heavily concentrated within the awareness-intent spectrum of behavior change and gets lean for outcomes situated within the intent-action and the action-habit formation spectrum of the behavior change continuum. Most of the evidence was concentrated on increasing awareness, knowledge, and building risk perception around SRH domains, however, fewer studies focused on strengthening the agency and self-efficacy of individuals. Similarly, evidence on extrinsic factors-such as strengthening social and community norms, relationships, and household dynamics-that determine individual thought and action such as negotiation and life skills were also found to be less populated. Few studies explore the effectiveness of these interventions across diverse AGYW identities, like pregnant women and new mothers, sex workers, and people living with HIV, leading to limited understanding of the use of these interventions across multiple user segments including key influencers such as young men, partners, families, religious leaders, and community elders was relatively low. There is a need for better quality evidence that accounts for the diversity of experiences within these populations to understand what interventions work, for whom, and toward what outcome. Further, the evidence for use of digital and mass-media tools remains poorly populated. Given the increasing penetration of these tools and growing media literacy on one end, with widening gender-based gaps on the other, it is imperative to gather more high-quality evidence on their effectiveness. Timely evidence generation can help leverage these platforms appropriately and enable intervention designs that are responsive to changing communication ecologies of AGYW. SBCC can play a critical role in helping researchers meaningfully engage and collaborate with communities as equal stakeholders, however, this remains poorly evidenced and calls for investigation and investment. A full list of abbreviations and acronyms are available in Supporting Information: Appendix F.
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Groves AK, Stankard P, Bowler SL, Jamil MS, Gebrekristos LT, Smith PD, Quinn C, Ba NS, Chidarikire T, Nguyen VTT, Baggaley R, Johnson C. A systematic review and meta-analysis of the evidence for community-based HIV testing on men's engagement in the HIV care cascade. Int J STD AIDS 2022; 33:1090-1105. [PMID: 35786140 PMCID: PMC9660288 DOI: 10.1177/09564624221111277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/29/2022] [Accepted: 06/13/2022] [Indexed: 12/04/2022]
Abstract
OBJECTIVE Men with HIV are less likely than women to know their status, be on antiretroviral therapy, and be virally suppressed. This review examined men's community-based HIV testing services (CB-HTS) outcomes. DESIGN Systematic review and meta-analysis. METHODS We searched seven databases and conference abstracts through July 2018. We estimated pooled proportions and/or risk ratios (for meta-analyses) for each outcome using random effects models. RESULTS 188 studies met inclusion criteria. Common testing models included targeted outreach (e.g. mobile testing), home-based testing, and testing at stand-alone community sites. Across 25 studies reporting uptake, 81% (CI: 75-86%) of men offered testing accepted it. Uptake was higher among men reached through CB-HTS than facility-based HTS (RR = 1.39; CI: 1.13-1.71). Over 69% (CI: 64-71%) of those tested through CB-HTS were men, across 184 studies. Across studies reporting new HIV-positivity among men (n = 18), 96% were newly diagnosed (CI: 77-100%). Across studies reporting linkage to HIV care (n = 8), 70% (CI: 36-103%) of men were linked to care. Across 57 studies reporting sex-disaggregated data for CB-HTS conducted among key populations, men's uptake was high (80%; CI: 70-88%) and nearly all were newly diagnosed and linked to care (95%; CI: 94-100%; and 94%; CI: 88-100%, respectively). CONCLUSION CB-HTS is an important strategy for reaching undiagnosed men with HIV from the general population and key population groups, particularly using targeted outreach models. When compared to facility-based HIV testing services, men tested through CB-HTS are more likely to uptake testing, and nearly all men who tested positive through CB-HTS were newly diagnosed. Linkage to care may be a challenge following CB-HTS, and greater efforts and research are needed to effectively implement testing strategies that facilitate rapid ART initiation and linkage to prevention services.
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Affiliation(s)
- Allison K Groves
- Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | | | - Sarah L Bowler
- Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Muhammad S Jamil
- Department of HIV/AIDS, World Health
Organization, Geneva, Switzerland
| | | | - Patrick D Smith
- Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Caitlin Quinn
- Department of HIV/AIDS, World Health
Organization, Geneva, Switzerland
| | - Ndoungou Salla Ba
- Department of HIV/AIDS, World Health
Organization, Geneva, Switzerland
| | - Thato Chidarikire
- HIV Prevention Programmes, National Department of
Health, Johannesburg, South Africa
| | | | - Rachel Baggaley
- Department of HIV/AIDS, World Health
Organization, Geneva, Switzerland
| | - Cheryl Johnson
- Department of HIV/AIDS, World Health
Organization, Geneva, Switzerland
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Bhebhe L, Moyo S, Gaseitsiwe S, Pretorius-Holme M, Yankinda EK, Manyake K, Kgathi C, Mmalane M, Lebelonyane R, Gaolathe T, Bachanas P, Ussery F, Letebele M, Makhema J, Wirth KE, Lockman S, Essex M, Novitsky V, Ragonnet-Cronin M. Epidemiological and viral characteristics of undiagnosed HIV infections in Botswana. BMC Infect Dis 2022; 22:710. [PMID: 36031617 PMCID: PMC9420270 DOI: 10.1186/s12879-022-07698-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 08/17/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
HIV-1 is endemic in Botswana. The country’s primary challenge is identifying people living with HIV who are unaware of their status. We evaluated factors associated with undiagnosed HIV infection using HIV-1 phylogenetic, behavioural, and demographic data.
Methods
As part of the Botswana Combination Prevention Project, 20% of households in 30 villages were tested for HIV and followed from 2013 to 2018. A total of 12,610 participants were enrolled, 3596 tested HIV-positive at enrolment, and 147 participants acquired HIV during the trial. Extensive socio-demographic and behavioural data were collected from participants and next-generation sequences were generated for HIV-positive cases. We compared three groups of participants: (1) those previously known to be HIV-positive at enrolment (n = 2995); (2) those newly diagnosed at enrolment (n = 601) and (3) those who tested HIV-negative at enrolment but tested HIV-positive during follow-up (n = 147). We searched for differences in demographic and behavioural factors between known and newly diagnosed group using logistic regression. We also compared the topology of each group in HIV-1 phylogenies and used a genetic diversity-based algorithm to classify infections as recent (< 1 year) or chronic (≥ 1 year).
Results
Being male (aOR = 2.23) and younger than 35 years old (aOR = 8.08) was associated with undiagnosed HIV infection (p < 0.001), as was inconsistent condom use (aOR = 1.76). Women were more likely to have undiagnosed infections if they were married, educated, and tested frequently. For men, being divorced increased their risk. The genetic diversity-based algorithm classified most incident infections as recent (75.0%), but almost none of known infections (2.0%). The estimated proportion of recent infections among new diagnoses was 37.0% (p < 0.001).
Conclusion
Our results indicate that those with undiagnosed infections are likely to be young men and women who do not use condoms consistently. Among women, several factors were predictive: being married, educated, and testing frequently increased risk. Men at risk were more difficult to delineate. A sizeable proportion of undiagnosed infections were recent based on a genetic diversity-based classifier. In the era of “test and treat all”, pre-exposure prophylaxis may be prioritized towards individuals who self-identify or who can be identified using these predictors in order to halt onward transmission in time.
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Martelli G, Van Duffel L, Kwezi EC, Cavallin F, Salehe IA, Torelli GF, Putoto G, Hermans S, Rinke de Wit TF, Pozniak A. Community- and facility-based HIV testing interventions in northern Tanzania: Midterm results of Test & Treat Project. PLoS One 2022; 17:e0266870. [PMID: 35413074 PMCID: PMC9004748 DOI: 10.1371/journal.pone.0266870] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 03/29/2022] [Indexed: 11/18/2022] Open
Abstract
Test & Treat Project offers universal HIV testing and access to antiretroviral treatment in Northern Tanzania. The current cross-sectional study provides midterm results on HIV testing and counseling activities through community outreaches and facility-based services. A total 255,329 HIV tests were performed: 198,451 (77.7%) during testing campaigns in the villages, 12,592 (4.9%) during special events outreach and 44,286 (17.4%) in the health facilities. Females represented 53.8% (23,809) among those tested in the health facilities, while males were the majority in the community (54.4%, 114,835). Over one third of tests (n = 104,605, 41%) were performed among first-time testers. The overall HIV positivity rate was 1.2%, ranging from 0.7% in the community to 3.8% in the health facilities and decreased over time. Using a multivariable analysis, a positive test result was associated with age ≥ 50 years (PR 1.22, 95% CI 1.11 to 1.34), with female gender (PR 1.61, 95% CI 1.50 to 1.73), being tested in health facilities (PR 5.00, 95% CI 4.65 to 5.36) and for the first time (PR 1.86, 95% CI 1.73 to 2.00). The estimated proportion of PLHIV who knew their status of the project area increased by 28.6% (from 35.7% to 64.3%) and 11.1% (from 57.7% to 68.8%) in the project areas of Shinyanga and Simiyu regions respectively. Reaching the first UNAIDS 90 target by the end of this project seems possible. Future strategies should focus on improving PITC coverage, implementing more targeted testing modalities, together with current universal community-based approach.
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Affiliation(s)
| | | | | | | | | | | | | | - Sabine Hermans
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Tobias F. Rinke de Wit
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anton Pozniak
- HIV and Sexual Health Clinic, Chelsea and Westminster Hospital NHS Foundation Trust London, London, United Kingdom
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9
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Nardell MF, Adeoti O, Peters C, Kakuhikire B, Govathson-Mandimika C, Long L, Pascoe S, Tsai AC, Katz IT. Men missing from the HIV care continuum in sub-Saharan Africa: a meta-analysis and meta-synthesis. J Int AIDS Soc 2022; 25:e25889. [PMID: 35324089 PMCID: PMC8944222 DOI: 10.1002/jia2.25889] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 02/01/2022] [Indexed: 02/03/2023] Open
Abstract
Introduction Men are missing along the HIV care continuum. However, the estimated proportions of men in sub‐Saharan Africa meeting the UNAIDS 95‐95‐95 goals vary substantially between studies. We sought to estimate proportions of men meeting each of the 95‐95‐95 goals across studies in sub‐Saharan Africa, describe heterogeneity, and summarize qualitative evidence on factors influencing care engagement. Methods We systematically searched PubMed and Embase for peer‐reviewed articles published between 1 January 2014 and 16 October 2020. We included studies involving men ≥15 years old, with data from 2009 onward, reporting on at least one 95‐95‐95 goal in sub‐Saharan Africa. We estimated pooled proportions of men meeting these goals using DerSimonion‐Laird random effects models, stratifying by study population (e.g. studies focusing exclusively on men who have sex with men vs. studies that did not), facility setting (healthcare vs. community site), region (eastern/southern Africa vs. western/central Africa), outcome measurement (e.g. threshold for viral load suppression), median year of data collection (before vs. during or after 2017) and quality criteria. Data from qualitative studies exploring barriers to men's HIV care engagement were summarized using meta‐synthesis. Results and discussion We screened 14,896 studies and included 129 studies in the meta‐analysis, compiling data over the data collection period. Forty‐seven studies reported data on knowledge of serostatus, 43 studies reported on antiretroviral therapy use and 74 studies reported on viral suppression. Approximately half of men with HIV reported not knowing their status (0.49 [95% CI, 0.41–0.58; range, 0.09–0.97]) or not being on treatment (0.58 [95% CI, 0.51–0.65; range, 0.07–0.97]), while over three‐quarters of men achieved viral suppression on treatment (0.79 [95% CI, 0.77–0.81; range, 0.39–0.97]. Heterogeneity was high, with variation in estimates across study populations, settings and outcomes. The meta‐synthesis of 40 studies identified three primary domains in which men described risks associated with engagement in HIV care: perceived social norms, health system challenges and poverty. Conclusions Psychosocial and systems‐level interventions that change men's perceptions of social norms, improve trust in and accessibility of the health system, and address costs of accessing care are needed to better engage men, especially in HIV testing and treatment.
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Affiliation(s)
- Maria F Nardell
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Oluwatomi Adeoti
- Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Carson Peters
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Bernard Kakuhikire
- Faculty of Business and Management Sciences, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Caroline Govathson-Mandimika
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Alexander C Tsai
- Harvard Medical School, Boston, Massachusetts, USA.,Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA.,Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Global Health Institute, Cambridge, Massachusetts, USA
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10
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Limbada M, Bwalya C, Macleod D, Shibwela O, Floyd S, Nzara D, Situmbeko V, Hayes R, Fidler S, Ayles H. Acceptability and Preferences of Two Different Community Models of ART Delivery in a High Prevalence Urban Setting in Zambia: Cluster-Randomized Trial, Nested in the HPTN 071 (PopART) Study. AIDS Behav 2022; 26:328-338. [PMID: 34304330 PMCID: PMC8813709 DOI: 10.1007/s10461-021-03385-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2021] [Indexed: 11/29/2022]
Abstract
Community delivery of Antiretroviral therapy (ART) is a novel innovation to increase sustainable ART coverage for People living with HIV (PLHIV) in resource limited settings. Within a nested cluster-randomised sub-study in two urban communities that participated in the HPTN 071 (PopART) trial in Zambia we investigated individual acceptability and preferences for ART delivery models. Stable PLHIV were enrolled in a cluster-randomized trial of three different models of ART: Facility-based delivery (SoC), Home-based delivery (HBD) and Adherence clubs (AC). Consenting individuals were asked to express their stated preference for ART delivery options. Those assigned to the community models of ART delivery arms could choose ("revealed preference") between the assigned arm and facility-based delivery. In total 2489 (99.6%) eligible individuals consented to the study and 95.6% chose community models of ART delivery rather than facility-based delivery when offered a choice. When asked to state their preference of model of ART delivery, 67.6% did not state a preference of one model over another, 22.8% stated a preference for HBD, 5.0% and 4.6% stated a preference for AC and SoC, respectively. Offering PLHIV choices of community models of ART delivery is feasible and acceptable with majority expressing HBD as their stated preferred option.
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Affiliation(s)
- Mohammed Limbada
- Zambart House, School of Medicine, University of Zambia, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - Chiti Bwalya
- Zambart House, School of Medicine, University of Zambia, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Osborn Shibwela
- Zambart House, School of Medicine, University of Zambia, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Diana Nzara
- Zambart House, School of Medicine, University of Zambia, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - Vasty Situmbeko
- Zambart House, School of Medicine, University of Zambia, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Sarah Fidler
- Imperial College, United Kingdom and Imperial College NIHR BRC, London, UK
| | - Helen Ayles
- Zambart House, School of Medicine, University of Zambia, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - the HPTN 071 (PopART) Study Team
- Zambart House, School of Medicine, University of Zambia, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
- Imperial College, United Kingdom and Imperial College NIHR BRC, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
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11
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Phiri MM, Schaap A, Simwinga M, Hensen B, Floyd S, Mulubwa C, Simuyaba M, Chiti B, Bond V, Shanaube K, Fidler S, Hayes R, Ayles H. Closing the gap: did delivery approaches complementary to home-based testing reach men with HIV testing services during and after the HPTN 071 (PopART) trial in Zambia? J Int AIDS Soc 2022; 25:e25855. [PMID: 35001530 PMCID: PMC8743361 DOI: 10.1002/jia2.25855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 11/26/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The HPTN 071 (PopART) trial demonstrated that universal HIV testing-and-treatment reduced community-level HIV incidence. Door-to-door delivery of HIV testing services (HTS) was one of the main components of the intervention. From an early stage, men were less likely to know their HIV status than women, primarily because they were not home during service delivery. To reach more men, different strategies were implemented during the trial. We present the relative contribution of these strategies to coverage of HTS and the impact of community hubs implemented after completion of the trial among men. METHODS Between 2013 and 2017, three intervention rounds (IRs) of door-to-door HTS delivery were conducted in eight PopART communities in Zambia. Additional strategies implemented in parallel, included: community-wide "Man-up" campaigns (IR1), smaller HTS campaigns at work/social places (IR2) and revisits to households with the option of HIV self-testing (HIVST) (IR3). In 2018, community "hubs" offering HTS were implemented for 7 months in all eight communities. Population enumeration data for each round of HTS provided the denominator, allowing for calculation of the proportion of men tested as a result of each strategy during different time periods. RESULTS By the end of the three IRs, 65-75% of men were reached with HTS, primarily through door-to-door service delivery. In IR1 and IR2, "Man-up" and work/social place campaigns accounted for ∼1 percentage point each and in IR3, revisits with the option of self-testing for ∼15 percentage points of this total coverage per IR. The yield of newly diagnosed HIV-positive men ranged from 2.2% for HIVST revisits to 9.9% in work/social places. At community hubs, the majority of visitors accepting services were men (62.8%). In total, we estimated that ∼36% (2.2% tested HIV positive) of men resident but not found at their household during IR3 of PopART accessed HTS provided at the hubs after trial completion. CONCLUSIONS Achieving high coverage of HTS among men requires universal, home-based service delivery combined with an option of HIVST and delivery of HTS through community-based hubs. When men are reached, they are willing to test for HIV. Reaching men thus requires implementers to adapt their HTS delivery strategies to meet men's needs. CLINICAL TRIAL NUMBER NCT01900977.
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Affiliation(s)
| | - Ab Schaap
- ZambartLusakaZambia
- Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | | | - Bernadette Hensen
- Clinical Research DepartmentLondon School of Hygiene and Tropical MedicineLondonUK
| | - Sian Floyd
- Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | | | | | | | - Virginia Bond
- ZambartLusakaZambia
- Department of Global HealthLondon School of Hygiene and Tropical MedicineLondonUK
| | | | - Sarah Fidler
- Imperial College and Imperial College NIHR BRCLondonUK
| | - Richard Hayes
- Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Helen Ayles
- ZambartLusakaZambia
- Clinical Research DepartmentLondon School of Hygiene and Tropical MedicineLondonUK
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12
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Hensen B, Phiri M, Schaap A, Sigande L, Simwinga M, Floyd S, Belemu S, Simuyaba M, Shanaube K, Fidler S, Hayes R, Ayles HM. Uptake of HIV Testing Services Through Novel Community-Based Sexual and Reproductive Health Services: An Analysis of the Pilot Implementation Phase of the Yathu Yathu Intervention for Adolescents and Young People Aged 15-24 in Lusaka, Zambia. AIDS Behav 2022; 26:172-182. [PMID: 34302282 DOI: 10.1007/s10461-021-03368-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 11/24/2022]
Abstract
Adolescents and young people aged 15-24 are underserved by available HIV-testing services (HTS). Delivering HTS through community-based, peer-led, hubs may prove acceptable and accessible to adolescents and young people, thus increasing HIV-testing coverage. We used data from the pilot phase of a cluster-randomised trial of community-based sexual and reproductive health services for adolescents and young people in Lusaka, Zambia, between September 2019 and January 2020, to explore factors associated with uptake of HTS through community-based hubs. 5,757 adolescents and young people attended the hubs (63% female), among whom 75% tested for HIV (76% of females, 75% of males). Community-based hubs provided HTS to 80% of adolescents and young people with no history of HIV-testing. Among females, uptake of HTS was lower among married/cohabiting females; among males, uptake was lower among unmarried males and among individuals at risk of hazardous alcohol use. The high number of adolescents and young people accessing hubs for HIV testing suggests they are acceptable. Enhanced targeting of HTS to groups who may not perceive their HIV risk needs to be implemented.
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Affiliation(s)
- B Hensen
- Faculty of Infectious and Tropical Diseases, Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK.
| | | | - A Schaap
- Zambart, Lusaka, Zambia
- Faculty of Epidemiology and Population Health, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - S Floyd
- Faculty of Epidemiology and Population Health, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - S Fidler
- Imperial College London, Imperial College National Institute of Heath Research BRC, London, UK
| | - R Hayes
- Faculty of Epidemiology and Population Health, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - H M Ayles
- Faculty of Infectious and Tropical Diseases, Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
- Zambart, Lusaka, Zambia
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13
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Hensen B, Phiri M, Schaap A, Floyd S, Simuyaba M, Mwenge L, Sigande L, Belemu S, Shanaube K, Simwinga M, Fidler S, Hayes R, Ayles H. Yathu Yathu ("For us, by us"): Design of a cluster-randomised trial of the impact of community-based, peer-led comprehensive sexual and reproductive health services for adolescents and young people aged 15 to 24 in Lusaka, Zambia. Contemp Clin Trials 2021; 110:106568. [PMID: 34543725 DOI: 10.1016/j.cct.2021.106568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 08/16/2021] [Accepted: 09/13/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND In sub-Saharan Africa, the growing population of adolescents and young people aged 15 to 24 face a high burden of HIV, and other preventable and treatable sexually transmitted infections. Despite this burden, adolescents and young people are the population least served by available sexual and reproductive (SRH) services. This trial aims to evaluate the impact of community-based peer-led SRH services, combined with a novel incentivised "loyalty card" system, on knowledge of HIV status and coverage of SRH services. METHODS A cluster-randomised trial (CRT) with embedded process and economic evaluation. DISCUSSION With little available evidence of the impact of community-based, peer-led services on coverage of SRH services, our study will provide evidence critical to expanding our knowledge of how to reach adolescents and young people. The "loyalty card" system is also a novel approach to providing SRH services. The delivery of community-based services supported by incentives in the form of loyalty cards is innovative, and may prove a simple strategy to improve access to SRH services. Adolescents and young people remain underserved by available SRH services; there remains a critical need to identify ways to provide adolescents and young people with access to SRH services. Rigorous evidence of whether this innovative strategy, with strong links to the local health facility, increases coverage of critical SRH services would add to the evidence-base of how to reach adolescents and young people.
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Affiliation(s)
- B Hensen
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom.
| | | | - A Schaap
- Zambart, Lusaka, Zambia; Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - S Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | | | | | | | - S Fidler
- Imperial College and Imperial College NIHR BRC, London, United Kingdom
| | - R Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - H Ayles
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom; Zambart, Lusaka, Zambia
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14
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Mwango LK, Stafford KA, Blanco NC, Lavoie MC, Mujansi M, Nyirongo N, Tembo K, Sakala H, Chipukuma J, Phiri B, Nzangwa C, Mwandila S, Nkwemu KC, Saadani A, Mwila A, Herce ME, Claassen CW. Index and targeted community-based testing to optimize HIV case finding and ART linkage among men in Zambia. J Int AIDS Soc 2021; 23 Suppl 2:e25520. [PMID: 32589360 PMCID: PMC7319128 DOI: 10.1002/jia2.25520] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Current healthcare systems fail to provide adequate HIV services to men. In Zambia, 25% of adult men living with HIV were unaware of their HIV status in 2018, and 12% of those who were unaware of their HIV statu were not receiving antiretroviral therapy (ART) due to pervasive barriers to HIV testing services (HTS) and linkage to ART. To identify men and key and priority populations living with HIV in Zambia, and link them to care and treatment, we implemented the Community Impact to Reach Key and Underserved Individuals for Treatment and Support (CIRKUITS) project. We present HTS and ART linkage results from the first year of CIRKUITS. METHODS CIRKUITS aimed to reach beneficiaries by training, mentoring, and deploying community health workers to provide index testing services and targeted community HTS. Community leaders and workplace supervisors were engaged to enable workplace HTS for men. To evaluate the effects of these interventions, we collected age- and sex-disaggregated routinely collected programme data for the first 12 months of the project (October 2018 to September 2019) across 37 CIRKUITS-supported facilities in three provinces. We performed descriptive statistics and estimated index cascades for indicators of interest, and used Chi square tests to compare indicators by age, sex, and district strata. RESULTS Over 12 months, CIRKUITS tested 38,255 persons for HIV, identifying 10,974 (29%) new people living with HIV, of whom 10,239 (93%) were linked to ART. Among men, CIRKUITS tested 18,336 clients and identified 4458 (24%) as HIV positive, linked 4132 (93%) to ART. Men who tested HIV negative were referred to preventative services. Of the men found HIV positive, and 13.0% were aged 15 to 24 years, 60.3% were aged 25 to 39, 20.9% were aged 40 to 49 and 5.8% were ≥50 years old. Index testing services identified 2186 (49%) of HIV-positive men, with a positivity yield of 40% and linkage of 88%. Targeted community testing modalities accounted for 2272 (51%) of HIV-positive men identified, with positivity yield of 17% and linkage of 97%. CONCLUSIONS Index testing and targeted community-based HTS are effective strategies to identify men living with HIV in Zambia. Index testing results in higher yield, but lower linkage and fewer absolute men identified compared to targeted community-based HTS.
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Affiliation(s)
- Linah K Mwango
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Kristen A Stafford
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA.,Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Natalia C Blanco
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA.,Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Marie-Claude Lavoie
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA.,Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Morley Mujansi
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Nasho Nyirongo
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Kalima Tembo
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Henry Sakala
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | | | - Beauty Phiri
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Carol Nzangwa
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Susan Mwandila
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | | | - Ahmed Saadani
- U.S. Center for Disease Control and Prevention, Lusaka, Zambia
| | - Annie Mwila
- U.S. Center for Disease Control and Prevention, Lusaka, Zambia
| | - Michael E Herce
- Institute for Global Health and Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC, USA.,Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Cassidy W Claassen
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia.,Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA.,Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
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15
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Abstract
Objectives: To assess the impact of a combination HIV prevention intervention including universal testing and treatment (UTT) on HIV stigma among people living with HIV, and among community members and health workers not living with HIV. Design: This HIV stigma study was nested in the HPTN 071 (PopART) trial, a three-arm cluster randomised trial conducted between 2013 and 2018 in 21 urban/peri-urban communities (12 in Zambia and nine in South Africa). Methods: Using an adjusted two-stage cluster-level analysis, controlling for baseline imbalances, we compared multiple domains of stigma between the trial arms at 36 months. Different domains of stigma were measured among three cohorts recruited across all study communities: 4178 randomly sampled adults aged 18–44 who were living with HIV, and 3487 randomly sampled adults and 1224 health workers who did not self-report living with HIV. Results: Prevalence of any stigma reported by people living with HIV at 36 months was 20.2% in arm A, 26.1% in arm B, and 19.1% in arm C (adjusted prevalence ratio, A vs. C 1.01 95% CI 0.49–2.08, B vs. C 1.34 95% CI 0.65–2.75). There were no significant differences between arms in any other measures of stigma across all three cohorts. All measures of stigma reduced over time (0.2--4.1% reduction between rounds) with most reductions statistically significant. Conclusion: We found little evidence that UTT either increased or decreased HIV stigma measured among people living with HIV, or among community members or health workers not living with HIV. Stigma reduced over time, but slowly. ClinicalTrials.gov number: NCT01900977.
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Brault MA, Spiegelman D, Abdool Karim SS, Vermund SH. Integrating and Interpreting Findings from the Latest Treatment as Prevention Trials. Curr HIV/AIDS Rep 2020; 17:249-258. [PMID: 32297219 DOI: 10.1007/s11904-020-00492-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW In 2018-2019, studies were published assessing the effectiveness of reducing HIV incidence by expanding HIV testing, linkage to HIV treatment, and assistance to persons living with HIV to adhere to their medications (the "90-90-90" strategy). These tests of "treatment as prevention" (TasP) had complex results. RECENT FINDINGS The TasP/ANRS 12249 study in South Africa, the SEARCH study in Kenya and Uganda, and one comparison (arms A to C) of the HPTN 071 (PopART) study in South Africa and Zambia did not demonstrate a community impact on HIV incidence. In contrast, the Botswana Ya Tsie study and the second comparison (arms B to C) of PopART indicated significant ≈ 30% reductions in HIV incidence in the intervention communities where TasP was expanded. We discuss the results of these trials and outline future research and challenges. These include the efficient expansion of widespread HIV testing, better linkage to care, and viral suppression among all persons living with HIV. A top implementation science priority for the next decade is to determine what strategies to use in specific local contexts.
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Affiliation(s)
- Marie A Brault
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA.
| | - Donna Spiegelman
- Department of Biostatistics; Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Salim S Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Sten H Vermund
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
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Hensen B, Schaap AJ, Mulubwa C, Floyd S, Shanaube K, Phiri MM, Bond V, Bwalya C, Simwinga M, Fidler S, Hayes R, Mwinga A, Ayles H. Who Accepts and Who Uses Community-Based Secondary Distribution HIV Self-Testing (HIVST) Kits? Findings From the Intervention Arm of a Cluster-Randomized Trial of HIVST Distribution Nested in Four HPTN 071 (PopART) Communities in Zambia. J Acquir Immune Defic Syndr 2020; 84:355-364. [PMID: 32195749 PMCID: PMC7340225 DOI: 10.1097/qai.0000000000002344] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/21/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND HPTN 071 (PopART) was a community-randomized trial of a universal testing-and-treatment intervention on HIV incidence at population level in Zambia and South Africa. In Zambia, a trial of community-based distribution of HIV self-testing (HIVST) kits, including secondary distribution, as an option for HIV-testing was nested within 4 PopART intervention communities. We used data from the intervention arm of the nested trial to measure levels of and factors associated with acceptance and use of secondary distribution HIVST kits. METHODS Community HIV care providers offered the PopART combination HIV-prevention intervention door-to-door, systematically visiting all households and enumerating all household members. From 1 February to 30 April 2017, individuals aged 16 years and older consenting to PopART were offered the option to HIV self-test, if eligible for HIV-testing services. Individuals aged 18 years and older who reported a partner absent during household visits were offered an HIVST kit for secondary distribution to this partner. We used two data sources to measure acceptance and use of secondary distribution HIVST kits. RESULTS Among 9105 individuals aged 18 years and older consenting to PopART, 9.1% (n = 825) accepted an HIVST kit for secondary distribution. Approximately 55.8% reported that the kit had been used. Women were more likely to accept, and men more likely to use, secondary distribution HIVST kits. Kits were more likely to be used by individuals aged 30+ and who had not participated in a previous round of PopART. Approximately 6.8% had a reactive result. CONCLUSIONS Community-based secondary distribution of HIVST kits reached men absent during community HIV care provider household visits and is a complement to facility- and community-based HIV-testing services, which often miss men.
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Affiliation(s)
- Bernadette Hensen
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Albertus J Schaap
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Zambart, Lusaka, Zambia
| | | | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - Virginia Bond
- Zambart, Lusaka, Zambia
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom; and
| | | | | | - Sarah Fidler
- Imperial College, London, United Kingdom and Imperial College NIHR BRC
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Helen Ayles
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Zambart, Lusaka, Zambia
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Abstract
Four of the largest HIV prevention trials have been conducted in sub-Saharan Africa, enrolling hundreds of thousands of participants in catchment areas of millions of people. The trials have focused on community-level interventions to increase diagnosis and initiation of antiretroviral therapy (ART) to improve health and reduce HIV transmission. Universal test-and-treat strategies are deployed to achieve viral suppression thereby reducing risk to uninfected persons, known as treatment as prevention (TasP).
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Bwalya C, Simwinga M, Hensen B, Gwanu L, Hang’andu A, Mulubwa C, Phiri M, Hayes R, Fidler S, Mwinga A, Ayles H, Bond V. Social response to the delivery of HIV self-testing in households: experiences from four Zambian HPTN 071 (PopART) urban communities. AIDS Res Ther 2020; 17:32. [PMID: 32527261 PMCID: PMC7288417 DOI: 10.1186/s12981-020-00287-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 05/27/2020] [Indexed: 12/22/2022] Open
Abstract
Background Door-to-door distribution of HIV self-testing kits (HIVST) has the potential to increase uptake of HIV testing services (HTS). However, very few studies have explored the social response to and implications of door-to-door including secondary distribution of HIVST on household relations and the ability of individuals to self-test with or without supervision within households. Methods A CRT of HIVST distribution was nested within the HPTN 071 (PopART) trial, in four Zambian communities randomised to receive the PopART intervention. The nested HIVST trial aimed to increase knowledge of HIV status at population level. Between February 1 and April 30, 2017, 66 zones (clusters) within these four communities were randomly allocated to either the PopART standard of care door-to-door HTS (33 clusters) or PopART standard of care door-to-door HTS plus oral HIVST (33 clusters). In clusters randomised to HIVST, trained Community HIV care provider (CHiPs) visited households and offered individuals aged ≥ 16 and eligible for an offer of HTS the choice of HIV testing using HIVST or routine door-to-door HTS (finger-prick RDT). To document participants’ experiences with HIVST, Interviews (n = 40), observations (n = 22) and group discussions (n = 91) with household members and CHiPs were conducted. Data were coded using Atlas.ti 7 and analysed thematically. Results The usage and storage of HIVST kits was facilitated by familiarity with and trust in CHiPs, the novelty of HIVST, and demonstrations and supervision provided by CHiPs. Door-to-door distribution of HIVST kits was appreciated for being novel, convenient, private, empowering, autonomous and easy-to-use. Literacy and age influenced accurate usage of HIVST kits. The novelty of using oral fluids to test for HIV raised questions, some anxiety and doubts about the accuracy of HIVST. Although HIVST protected participants from experiencing clinic-based stigma, it did not address self-stigma. Within households, HIVST usually strengthened relationships but, amongst couples, there were a few reports of social harms. Conclusion Door-to-door distribution of HIVST as a choice for how to HIV test is appreciated at community level and provides an important testing option in the sub-Saharan context. However, it should be accompanied by counselling to manage social harms and by supporting those testing HIV-positive to link to care.
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Floyd S, Shanaube K, Yang B, Schaap A, Griffith S, Phiri M, Macleod D, Sloot R, Sabapathy K, Bond V, Bock P, Ayles H, Fidler S, Hayes R. HIV testing and treatment coverage achieved after 4 years across 14 urban and peri-urban communities in Zambia and South Africa: An analysis of findings from the HPTN 071 (PopART) trial. PLoS Med 2020; 17:e1003067. [PMID: 32240156 PMCID: PMC7117659 DOI: 10.1371/journal.pmed.1003067] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 02/26/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) set the 90-90-90 targets: that 90% of people living with HIV know their HIV status, that 90% of those who know their HIV-positive status are on antiretroviral therapy (ART), and that 90% of those on treatment are virally suppressed. The aim was to reach these targets by 2020. We assessed the feasibility of achieving the first two targets, and the corresponding 81% ART coverage target, as part of the HIV Prevention Trials Network (HPTN) 071 Population Effects of Antiretroviral Therapy to Reduce HIV Transmission (PopART) community-randomized trial. METHODS AND FINDINGS The study population was individuals aged ≥15 years living in 14 urban and peri-urban "PopART intervention" communities in Zambia and South Africa (SA), with a total population of approximately 600,000 and approximately 15% adult HIV prevalence. Community HIV care providers (CHiPs) delivered the PopART intervention during 2014-2017. This was a combination HIV prevention package including universal home-based HIV testing, referral of HIV-positive individuals to government HIV clinic services that offered universal ART (Arm A) or ART according to national guidelines (Arm B), and revisits to HIV-positive individuals to support linkage to HIV care and retention on ART. The intervention was delivered in 3 "rounds," each about 15 months long, during which CHiPs visited all households and aimed to contact all individuals aged ≥15 years at least once. In Arm A in Round 3 (R3), 67% (41,332/61,402) of men and 86% (56,345/65,896) of women in Zambia and 56% (17,813/32,095) of men and 71% (24,461/34,514) of women in SA participated in the intervention, among 193,907 residents aged ≥15 years. Following participation, HIV status was known by 90% of men and women in Zambia and by 78% of men and 85% of women in SA. The median time from CHiP referral of HIV-positive individuals to ART initiation was approximately 3 months. By the end of R3, an estimated 95% of HIV-positive women and 85% of HIV-positive men knew their HIV status, and among these individuals, approximately 90% of women and approximately 85% of men were on ART. ART coverage among all HIV-positive individuals was approximately 85% in women and approximately 75% in men, up from about 45% at the start of the study. ART coverage was lowest among men aged 18 to 34 and women aged 15 to 24 years, and among mobile individuals/in-migrants. Findings from Arm B were similar. The main limitations to our study were that estimates of testing and treatment coverage among men relied on considerable extrapolation because, in each round, approximately one-third of men did not participate in the PopART intervention; that our findings are for a service delivery model that was relatively intensive; and that we did not have comparable data from the 7 "standard-of-care" (Arm C) communities. CONCLUSIONS Our study showed that very high HIV testing and treatment coverage can be achieved through persistent delivery of universal testing, facilitated linkage to HIV care, and universal treatment services. The ART coverage target of 81% was achieved overall, after 4 years of delivery of the PopART intervention, though important gaps remained among men and young people. Our findings are consistent with previously reported findings from southern and east Africa, extending their generalisability to urban settings with high rates of in-migration and mobility and to Zambia and SA. TRIAL REGISTRATION ClinicalTrials.gov NCT01900977.
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Affiliation(s)
- Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kwame Shanaube
- Zambart, University of Zambia School of Medicine, Lusaka, Zambia
| | - Blia Yang
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Ab Schaap
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Zambart, University of Zambia School of Medicine, Lusaka, Zambia
| | - Sam Griffith
- FHI 360, HIV Prevention Trials Network, Durham, North Carolina, United States of America
| | - Mwelwa Phiri
- Zambart, University of Zambia School of Medicine, Lusaka, Zambia
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Rosa Sloot
- Department of Global Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kalpana Sabapathy
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Virginia Bond
- Department of Global Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Helen Ayles
- Zambart, University of Zambia School of Medicine, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sarah Fidler
- HIV Clinical Trials Unit, Imperial College London, London, United Kingdom
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Krishnaratne S, Bond V, Stangl A, Pliakas T, Mathema H, Lilleston P, Hoddinott G, Bock P, Ayles H, Fidler S, Hargreaves JR. Stigma and Judgment Toward People Living with HIV and Key Population Groups Among Three Cadres of Health Workers in South Africa and Zambia: Analysis of Data from the HPTN 071 (PopART) Trial. AIDS Patient Care STDS 2020; 34:38-50. [PMID: 31944852 DOI: 10.1089/apc.2019.0131] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Stigma and judgment by health workers toward people living with HIV (PLHIV) and key populations can undermine the uptake of HIV services. In 2014, we recruited health workers delivering HIV services from 21 urban communities in South Africa and Zambia participating in the first year of the HPTN 071 (PopART) cluster-randomized trial. We analyzed self-reported levels of stigma and judgment toward (1) PLHIV, (2) women who sell sex, (3) men who have sex with men (MSM), and (4) young women who become pregnant before marriage. Using logistic regression, we compared responses between three health worker cadres and explored risk factors for stigmatizing attitudes. Highest levels of stigma and judgment were in relation to women who sell sex and MSM, especially in Zambia. Heath workers did not generally think that clients should be denied services, although this was reported slightly more commonly by community health workers. Higher education levels were associated with lower judgmental beliefs, whereas higher perceptions of coworker stigmatizing behaviors toward PLHIV and each key population were associated with holding judgmental beliefs. Training experience was not associated with judgmental attitudes for any of the key populations. Our findings confirm a high prevalence of judgmental attitudes toward key population groups but lower levels in relation to PLHIV, among all cadres of health workers in both countries. Planning and implementing targeted stigma reduction interventions within health settings are critical to meet the needs of vulnerable populations that face more stigmatizing attitudes from health workers.
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Affiliation(s)
- Shari Krishnaratne
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Virginia Bond
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Zambart, The School of Medicine, University of Zambia, Lusaka, Zambia
| | - Anne Stangl
- International Centre for Research on Women, Washington, District of Columbia
| | - Triantafyllos Pliakas
- Department of Public Health Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Hlengani Mathema
- Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Pamela Lilleston
- International Centre for Research on Women, Washington, District of Columbia
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Helen Ayles
- Zambart, The School of Medicine, University of Zambia, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sarah Fidler
- Department of Medicine, Imperial College London, London, United Kingdom
| | - James R. Hargreaves
- Department of Public Health Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Alwano MG, Bachanas P, Block L, Roland M, Sento B, Behel S, Lebelonyane R, Wirth K, Ussery F, Bapati W, Motswere-Chirwa C, Abrams W, Ussery G, Miller JA, Bile E, Fonjungo P, Kgwadu A, Holme MP, Del Castillo L, Gaolathe T, Leme K, Majingo N, Lockman S, Makhema J, Bock N, Moore J. Increasing knowledge of HIV status in a country with high HIV testing coverage: Results from the Botswana Combination Prevention Project. PLoS One 2019; 14:e0225076. [PMID: 31765394 PMCID: PMC6876886 DOI: 10.1371/journal.pone.0225076] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 10/27/2019] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Achieving widespread knowledge of HIV-positive status is a crucial step to reaching universal ART coverage, population level viral suppression, and ultimately epidemic control. We implemented a multi-modality HIV testing approach to identify 90% or greater of HIV-positive persons in the Botswana Combination Prevention Project (BCPP) intervention communities. METHODS BCPP is a cluster-randomized trial designed to evaluate the impact of combination prevention interventions on HIV incidence in 30 communities in Botswana. Community case finding and HIV testing that included home and targeted mobile testing were implemented in the 15 intervention communities. We described processes for identifying HIV-positive persons, uptake of HIV testing by age, gender and venue, characteristics of persons newly diagnosed through BCPP, and coverage of knowledge of status reached at the end of study. RESULTS Of the 61,655 eligible adults assessed in home or mobile settings, 13,328 HIV-positive individuals, or 93% of the estimated 14,270 positive people in the communities were identified through BCPP. Knowledge of status increased by 25% over the course of the study with the greatest increases seen among men (37%) as compared to women (19%) and among youth aged 16-24 (77%) as compared to older age groups (21%). Although more men were tested through mobile than through home-based testing, higher rates of newly diagnosed HIV-positive men were found through home than mobile testing. CONCLUSIONS Even when HIV testing coverage is high, additional gains can be made using a multi-modality HIV testing strategy to reach different sub-populations who are being missed by non-targeted program activities. Men and youth can be reached and will engage in community testing when services are brought to places they access routinely.
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Affiliation(s)
- Mary Grace Alwano
- U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Gaborone, Botswana
| | - Pamela Bachanas
- U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Atlanta, Georgia, United States of America
| | - Lisa Block
- Northrop Grumman, Atlanta, Georgia, United States of America
| | - Michelle Roland
- U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Gaborone, Botswana
| | - Baraedi Sento
- Tebelopele HIV Counseling and Testing Center, Gaborone, Botswana
| | - Stephanie Behel
- U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Atlanta, Georgia, United States of America
| | | | - Kathleen Wirth
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Faith Ussery
- U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Atlanta, Georgia, United States of America
| | - William Bapati
- Tebelopele HIV Counseling and Testing Center, Gaborone, Botswana
| | | | - William Abrams
- U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Gaborone, Botswana
| | - Gene Ussery
- Northrop Grumman, Atlanta, Georgia, United States of America
| | - James A. Miller
- Northrop Grumman, Atlanta, Georgia, United States of America
| | - Ebi Bile
- U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Gaborone, Botswana
| | - Peter Fonjungo
- U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Atlanta, Georgia, United States of America
| | - Agisanag Kgwadu
- Tebelopele HIV Counseling and Testing Center, Gaborone, Botswana
| | - Molly Pretorius Holme
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Lisetta Del Castillo
- U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Gaborone, Botswana
| | | | - Kelebemang Leme
- Tebelopele HIV Counseling and Testing Center, Gaborone, Botswana
| | | | - Shahin Lockman
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Joseph Makhema
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Naomi Bock
- U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Atlanta, Georgia, United States of America
| | - Janet Moore
- U.S. Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Atlanta, Georgia, United States of America
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23
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Seeley J, Bond V, Yang B, Floyd S, MacLeod D, Viljoen L, Phiri M, Simuyaba M, Hoddinott G, Shanaube K, Bwalya C, de Villiers L, Jennings K, Mwanza M, Schaap A, Dunbar R, Sabapathy K, Ayles H, Bock P, Hayes R, Fidler S. Understanding the Time Needed to Link to Care and Start ART in Seven HPTN 071 (PopART) Study Communities in Zambia and South Africa. AIDS Behav 2019; 23:929-946. [PMID: 30415432 PMCID: PMC6458981 DOI: 10.1007/s10461-018-2335-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
To achieve UNAIDS 90:90:90 targets at population-level, knowledge of HIV status must be followed by timely linkage to care, initiation and maintenance of antiretroviral therapy (ART) for all people living with HIV (PLHIV). Interpreting quantitative patterns using qualitative data, we investigate time taken to link to care and initiate ART amongst individuals aware of their HIV-status in high HIV-prevalence urban communities in the HPTN 071 (PopART) study, a community-randomised trial of a combination HIV prevention package, including universal testing and treatment, in 21 communities in Zambia and South Africa. Data are drawn from the seven intervention communities where immediate ART irrespective if CD4 count was offered from the trial-start in 2014. Median time from HIV-diagnosis to ART initiation reduced after 2 years of delivering the intervention from 10 to 6 months in both countries but varied by gender and community of residence. Social and health system realities impact decisions made by PLHIV about ART initiation.
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Affiliation(s)
- Janet Seeley
- London School of Hygiene and Tropical Medicine, London, UK.
| | - Virginia Bond
- London School of Hygiene and Tropical Medicine, London, UK
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Blia Yang
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | - Sian Floyd
- London School of Hygiene and Tropical Medicine, London, UK
| | - David MacLeod
- London School of Hygiene and Tropical Medicine, London, UK
| | - Lario Viljoen
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | - Mwelwa Phiri
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Melvin Simuyaba
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Graeme Hoddinott
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | - Kwame Shanaube
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Chiti Bwalya
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Laing de Villiers
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | - Karen Jennings
- City of Cape Town Health Directorate, Cape Town, South Africa
| | - Margaret Mwanza
- Zambia Prevention Care and Treatment partnership (ZPCT), Lusaka, Zambia
| | - Ab Schaap
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Rory Dunbar
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | | | - Helen Ayles
- London School of Hygiene and Tropical Medicine, London, UK
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Peter Bock
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | - Richard Hayes
- London School of Hygiene and Tropical Medicine, London, UK
| | - Sarah Fidler
- Department of Medicine, Imperial College, London, UK
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24
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Jongen VW, Lalla-Edward ST, Vos AG, Godijk NG, Tempelman H, Grobbee DE, Devillé W, Klipstein-Grobusch K. Hypertension in a rural community in South Africa: what they know, what they think they know and what they recommend. BMC Public Health 2019; 19:341. [PMID: 30909905 PMCID: PMC6434617 DOI: 10.1186/s12889-019-6642-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 03/10/2019] [Indexed: 11/10/2022] Open
Abstract
Background Hypertension is one of the most important risk factors for cardiovascular disease and has a high prevalence in South Africa and other low- and middle-income countries. However, awareness of hypertension has been reported to be low. Health programmes can increase awareness of hypertension and its causes, but hinge on the knowledge and perception of the targeted community. Therefore, this study investigated knowledge on and perceptions about hypertension of community members in a rural area in Limpopo, South Africa with the aim to increase awareness of hypertension and cardiovascular disease in the local population. Methods Using a mixed methods study approach, 451 participants of the Ndlovu Cohort Study, attending a follow-up visit between August 2017 and January 2018, completed a questionnaire on cardiovascular risk perception. A knowledge score was calculated for all participants. Sixty participants were invited to participate in six focus group discussions, of which 56 participated. Audio recordings were transcribed verbatim, transcripts coded, and thematic analysis of the data undertaken to obtain an understanding of knowledge and perception of hypertension in the community. Results Most members of the community seemed to have intermediate (74.3%) or good (14.0%) knowledge of hypertension based on the knowledge score, and only 11.8% of the population had poor knowledge. The risk factors of hypertension seemed to be well known in the community. Poverty was identified as a major vulnerability in this community limiting choices for healthy lifestyles such as nutritious foods, recreational physical activity and accessing health care timely. Participants proposed community-based activities as an effective way to reach out to community members for prevention and management of hypertension. Conclusion This study highlights the need for improved health promotion efforts to increase knowledge of hypertension in rural communities, and to address poverty as a major obstacle to healthy life-style choices. Electronic supplementary material The online version of this article (10.1186/s12889-019-6642-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Vita W Jongen
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, PO Box 85500, Utrecht, The Netherlands
| | - Samanta T Lalla-Edward
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Alinda G Vos
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, PO Box 85500, Utrecht, The Netherlands.,Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa.,Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Noortje G Godijk
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, PO Box 85500, Utrecht, The Netherlands
| | - Hugo Tempelman
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa.,Ndlovu Care Group, Elandsdoorn, South Africa
| | - Diederick E Grobbee
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, PO Box 85500, Utrecht, The Netherlands
| | - Walter Devillé
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, PO Box 85500, Utrecht, The Netherlands.,Ndlovu Care Group, Elandsdoorn, South Africa
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, PO Box 85500, Utrecht, The Netherlands. .,Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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Brief Report: "Give Me Some Time": Facilitators of and Barriers to Uptake of Home-Based HIV Testing During Household Contact Investigation for Tuberculosis in Kampala, Uganda. J Acquir Immune Defic Syndr 2019; 77:400-404. [PMID: 29300218 DOI: 10.1097/qai.0000000000001617] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Integrating home-based HIV counseling and testing (HCT) with tuberculosis (TB) evaluation could improve the uptake of HIV testing among household contacts of patients with active TB. We sought to identify the facilitators of and barriers to HCT during household contact investigation for TB in Kampala, Uganda. METHODS We nested semi-structured interviews with 28 household contacts who were offered home-based HCT in a household-randomized trial of home-based strategies for TB contact investigation. Respondents reflected on their experiences of the home visit, the social context of the household, and their decision to accept or decline HIV testing. We used content analysis to identify and evaluate facilitators of and barriers to testing, then categorized the emergent themes using the Capability, Opportunity, Motivation, and Behavior (COM-B) model. RESULTS Facilitators included a preexisting desire to confirm HIV status or to show support for the index TB patient; a perception that home-based services are convenient; and positive perceptions of lay health workers. Key barriers included fear of results and feeling psychologically unprepared to receive results. The social influence of other household members operated as both a facilitator and a barrier. CONCLUSIONS Preexisting motivation, psychological readiness to test, and the social context of the household are major contributors to the decision to test for HIV at home. Uptake might be improved by providing normalizing information about HCT before the visit, by offering a second HCT opportunity, by offering self-tests with follow-up counseling, or by introducing HCT using "opt-out" language.
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Acceptability of Home-Based Human Immunodeficiency Virus Testing and Counseling in Low- and Middle-Income Countries. POINT OF CARE 2018. [DOI: 10.1097/poc.0000000000000172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Camlin CS, Seeley J. Qualitative research on community experiences in large HIV research trials: what have we learned? J Int AIDS Soc 2018; 21 Suppl 7:e25173. [PMID: 30334379 PMCID: PMC6192898 DOI: 10.1002/jia2.25173] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 07/20/2018] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Very few pragmatic and community-level effectiveness trials integrate the use of qualitative research over all stages of the trial, to inform trial design, implementation optimization, results interpretation and post-trial policy recommendations. This is despite the growing demand for mixed methods research from funding agencies and awareness of the vital importance of qualitative and mixed methods research for understanding trial successes and challenges. DISCUSSION We offer examples from work we have been involved in to illustrate how qualitative research conducted within trials can reveal vital contextual factors that influence implementation and outcomes, can enable an informed adaptation of trials as they are being conducted and can lead to the formulation of theory regarding the social and behavioural pathways of intervention, while also enabling community engagement in trial design and implementation. These examples are based on published findings from qualitative studies embedded within two ongoing large-scale studies demonstrating the population-level impacts of universal HIV testing and treatment strategies in southern and eastern Africa, and a qualitative study conducted alongside a clinical trial testing the adaptation, acceptability and experience of short-cycle therapy in children and adolescents living with HIV. CONCLUSIONS We advocate for the integration of qualitative with clinical and survey research methods in pragmatic clinical and community-level trials and implementation studies, and for increasing visibility of qualitative and mixed methods research in medical journals. Qualitative research from trials ideally should be published along with clinical outcome data, either integrated into the "main" trial papers or published concurrently in the same journal issue. Integration of qualitative research within trials can help not only to understand the why behind success or failure of interventions in different contexts, but also inform the adaptation of interventions that can facilitate their success, and lead to new alternative strategies and to policy changes that may be vital for achieving public health goals, including the end of AIDS.
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Affiliation(s)
- Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive SciencesCenter for AIDS Prevention StudiesUniversity of CaliforniaSan FranciscoCAUSA
| | - Janet Seeley
- Department of Global Health and DevelopmentLondon School of Hygiene & Tropical MedicineLondonUK
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Abstract
The benefits of combination antiretroviral therapy (cART) for HIV replication and transmission control have led to its universal recommendation. Many people living with HIV are, however, still undiagnosed or diagnosed late, especially in sub-Saharan Africa, where the HIV disease burden is highest. Further expansion in HIV treatment options, incorporating women-centred approaches, is essential to make individualised care a reality. With a longer life expectancy than before, people living with HIV are at an increased risk of developing non-AIDS comorbidities, such as cardiovascular diseases and cancers. Antiretroviral strategies are evolving towards a decrease in drug burden, and some two-drug combinations have proven efficacy for maintenance therapy. Investigational immune checkpoint inhibitors and broadly neutralising antibodies with effector functions have energised the HIV cure research field as the search for an effective vaccine continues. In this Seminar, we review advances and challenges relating to the goal of an AIDS-free world.
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Affiliation(s)
- Jade Ghosn
- Inserm UMR-S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Babafemi Taiwo
- Division of Infectious Diseases and Center for Global Health, Northwestern University, Chicago, Illinois, USA
| | - Soraya Seedat
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Brigitte Autran
- Inserm UMR-S 1135, Centre de Recherches en Immunologie et Maladies Infectieus, CIMI-Paris, Université Pierre et Marie Curie, Paris, France
| | - Christine Katlama
- Inserm UMR-S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France; Paris-Sorbonne University, Paris, France; Assistance Publique-Hôpitaux de Paris, Department of Infectious Diseases, Hôpital Pitié Salpêtrière, Paris, France.
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Feasibility and acceptability of home-based HIV testing among refugees: a pilot study in Nakivale refugee settlement in southwestern Uganda. BMC Infect Dis 2018; 18:332. [PMID: 30012110 PMCID: PMC6048800 DOI: 10.1186/s12879-018-3238-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 07/05/2018] [Indexed: 12/28/2022] Open
Abstract
Background Refugees in sub-Saharan Africa face both the risk of HIV infection and barriers to HIV testing. We conducted a pilot study to determine the feasibility and acceptability of home-based HIV testing in Nakivale Refugee Settlement in Uganda and to compare home-based and clinic-based testing participants in Nakivale. Methods From February–March 2014, we visited homes in 3 villages in Nakivale up to 3 times and offered HIV testing. We enrolled adults who spoke English, Kiswahili, Kinyarwanda, or Runyankore; some were refugees and some Ugandan nationals. We surveyed them about their socio-demographic characteristics. We evaluated the proportion of individuals encountered (feasibility) and assessed participation in HIV testing among those encountered (acceptability). We compared characteristics of home-based and clinic-based testers (from a prior study in Nakivale) using Wilcoxon rank sum and Pearson’s chi-square tests. We examined the relationship between a limited number of factors (time of visit, sex, and number of individuals at home) on willingness to test, using logistic regression models with the generalized estimating equations approach to account for clustering. Results Of 566 adults living in 319 homes, we encountered 507 (feasibility = 90%): 353 (62%) were present at visit one, 127 (22%) additional people at visit two, and 27 (5%) additional people at visit three. Home-based HIV testing participants totaled 378 (acceptability = 75%). Compared to clinic-based testers, home-based testers were older (median age 30 [IQR 24–40] vs 28 [IQR 22–37], p < 0.001), more likely refugee than Ugandan national (93% vs 79%, < 0.001), and more likely to live ≥1 h from clinic (74% vs 52%, < 0.001). The HIV prevalence was lower, but not significantly, in home-based compared to clinic-based testing participants (1.9 vs 3.4% respectively, p = 0.27). Testing was not associated with time of visit (p = 0.50) or sex (p = 0.66), but for each additional person at home, the odds of accepting HIV testing increased by over 50% (OR 1.52, 95%CI 1.12–2.06, p = 0.007). Conclusions Home-based HIV testing in Nakivale Refugee Settlement was feasible, with 90% of eligible individuals encountered within 3 visits, and acceptable with 75% willing to test for HIV, with a yield of nearly 2% individuals tested identified as HIV-positive.
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Bond V, Ngwenya F, Thomas A, Simuyaba M, Hoddinott G, Fidler S, Hayes R, Ayles H, Seeley J. Spinning plates: livelihood mobility, household responsibility and anti-retroviral treatment in an urban Zambian community during the HPTN 071 (PopART) study. J Int AIDS Soc 2018; 21 Suppl 4:e25117. [PMID: 30027643 PMCID: PMC6053474 DOI: 10.1002/jia2.25117] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 05/09/2018] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Qualitative data are lacking on the impact of mobility among people living with HIV (PLHIV) and their decision-making around anti-retroviral treatment (ART). We describe challenges of juggling household responsibility, livelihood mobility and HIV management for six PLHIV in urban Zambia. METHODS Six PLHIV (three men and three women, aged 21 to 44) were recruited from different geographic zones in one urban community drawn from a qualitative cohort in a social science component of a cluster-randomized trial (HPTN071 PopART). Participants were on ART (n = 2), not on ART (n = 2) and had started and stopped ART (n = 2). At least two in-depth interviews and participant observations, and three drop-in household visits with each were carried out between February and August 2017. Themed and comparative analysis was conducted. RESULTS The six participants relied on the informal economy to meet basic household needs. Routine livelihood mobility, either within the community and to a nearby town centre, or further afield for longer periods of time, was essential to get by. Although aware of ART benefits, only one of the six participants managed to successfully access and sustain treatment. The other five struggled to find time to access ART alongside other priorities, routine mobility and when daily routines were more chaotic. Difficulty in accessing ART was exacerbated by local health facility factors (congestion, a culture of reprimanding PLHIV who miss appointments, sporadic rationed drug supply), stigma and more limited social capital. CONCLUSIONS Using a time-space framework illustrated how household responsibility, livelihood mobility and HIV management every day were like spinning plates, each liable to topple and demanding constant attention. If universal lifelong ART is to be delivered, the current service model needs to adjust the limited time that some PLHIV have to access ART because of household responsibilities and the need to earn a living moving around, often away from home. Practical strategies that could facilitate ART access in the context of livelihood mobility include challenging the practice of reprimand, improving drug supply, having ART services more widely distributed, mapped and available at night and weekends, and an effective centralized client health information system.
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Affiliation(s)
- Virginia Bond
- Zambart, School of MedicineUniversity of ZambiaLusakaZambia
- Department of Global Health and DevelopmentFaculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | | | - Angelique Thomas
- Desmond Tutu TB CentreStellenbosch UniversityTygerbergSouth Africa
| | | | - Graeme Hoddinott
- Desmond Tutu TB CentreStellenbosch UniversityTygerbergSouth Africa
| | - Sarah Fidler
- Department of MedicineImperial College LondonSt Mary's CampusLondonUK
| | - Richard Hayes
- Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Helen Ayles
- Zambart, School of MedicineUniversity of ZambiaLusakaZambia
- Department of Clinical ResearchLondon School of Hygiene and Tropical MedicineLondonUK
| | - Janet Seeley
- Department of Global Health and DevelopmentFaculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- MRC/UVRI Uganda Research Unit on AIDSEntebbeUganda
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Mwenge L, Sande L, Mangenah C, Ahmed N, Kanema S, d’Elbée M, Sibanda E, Kalua T, Ncube G, Johnson CC, Hatzold K, Cowan FM, Corbett EL, Ayles H, Maheswaran H, Terris-Prestholt F. Costs of facility-based HIV testing in Malawi, Zambia and Zimbabwe. PLoS One 2017; 12:e0185740. [PMID: 29036171 PMCID: PMC5642898 DOI: 10.1371/journal.pone.0185740] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 09/14/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Providing HIV testing at health facilities remains the most common approach to ensuring access to HIV treatment and prevention services for the millions of undiagnosed HIV-infected individuals in sub-Saharan Africa. We sought to explore the costs of providing these services across three southern African countries with high HIV burden. METHODS Primary costing studies were undertaken in 54 health facilities providing HIV testing services (HTS) in Malawi, Zambia and Zimbabwe. Routinely collected monitoring and evaluation data for the health facilities were extracted to estimate the costs per individual tested and costs per HIV-positive individual identified. Costs are presented in 2016 US dollars. Sensitivity analysis explored key drivers of costs. RESULTS Health facilities were testing on average 2290 individuals annually, albeit with wide variations. The mean cost per individual tested was US$5.03.9 in Malawi, US$4.24 in Zambia and US$8.79 in Zimbabwe. The mean cost per HIV-positive individual identified was US$79.58, US$73.63 and US$178.92 in Malawi, Zambia and Zimbabwe respectively. Both cost estimates were sensitive to scale of testing, facility staffing levels and the costs of HIV test kits. CONCLUSIONS Health facility based HIV testing remains an essential service to meet HIV universal access goals. The low costs and potential for economies of scale suggests an opportunity for further scale-up. However low uptake in many settings suggests that demand creation or alternative testing models may be needed to achieve economies of scale and reach populations less willing to attend facility based services.
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Affiliation(s)
| | - Linda Sande
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Collin Mangenah
- Centre for Sexual Health and HIV AIDS Research, Harare, Zimbabwe
| | - Nurilign Ahmed
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Marc d’Elbée
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Euphemia Sibanda
- Centre for Sexual Health and HIV AIDS Research, Harare, Zimbabwe
| | - Thokozani Kalua
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | | | - Cheryl C. Johnson
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | | - Frances M. Cowan
- Centre for Sexual Health and HIV AIDS Research, Harare, Zimbabwe
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Elizabeth L. Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Helen Ayles
- Zambart, Lusaka, Zambia
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Fern Terris-Prestholt
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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