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Hunt JH, Mwinnyaa G, Patel EU, Grabowski MK, Kagaayi J, Gray RH, Ssekasanvu J, Wawer MJ, Kigozi G, Chang LW, Kalibbala S, Nakalanzi M, Ndyanabo A, Quinn TC, Serwadda D, Reynolds SJ, Galiwango RM, Laeyendecker O. Longitudinal patterns in indeterminate HIV rapid antibody test results: a population-based, prospective cohort study. Microbiol Spectr 2024; 12:e0325323. [PMID: 38189332 PMCID: PMC10845946 DOI: 10.1128/spectrum.03253-23] [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: 09/07/2023] [Accepted: 11/03/2023] [Indexed: 01/09/2024] Open
Abstract
Rapid HIV tests are critical to HIV surveillance and universal testing and treatment programs. We assessed longitudinal patterns in indeterminate HIV rapid test results in an African population-based cohort. Prospective HIV rapid antibody test results, defined by two parallel rapid tests, among participants aged 15-49 years from three survey rounds of the Rakai Community Cohort Study, Uganda, from 2013 to 2018, were assessed. An indeterminate result was defined as any weak positive result or when one test was negative and the other was positive. A total of 31,405 participants contributed 54,459 person-visits, with 15,713 participants contributing multiple visits and 7,351 participants contributing 3 visits. The prevalence of indeterminate results was 2.7% (1,490/54,469). Of the participants with multiple visits who initially tested indeterminate (n = 591), 40.4% were negative, 18.6% were positive, and 41.0% were indeterminate at the subsequent visit. Of the participants with two consecutive indeterminate results who had a third visit (n = 67), 20.9% were negative, 9.0% were positive, and 70.2% remained indeterminate. Compared to a prior negative result, a prior indeterminate result was strongly associated with a subsequent indeterminate result [adjusted prevalence ratio, 23.0 (95% CI = 20.0-26.5)]. Compared to men, women were more likely to test indeterminate than negative [adjusted odds ratio, 2.3 (95% CI = 2.0-2.6)]. Indeterminate rapid HIV test results are highly correlated within an individual and 0.6% of the population persistently tested indeterminate over the study period. A substantial fraction of people with an indeterminate result subsequently tested HIV positive at the next visit, underscoring the importance of follow-up HIV testing protocols.IMPORTANCERapid HIV tests are a critical tool for expanding HIV testing and treatment to end the HIV epidemic. The interpretation and management of indeterminate rapid HIV test results pose a unique challenge for connecting all people living with HIV to the necessary care and treatment. Indeterminate rapid HIV test results are characterized by any weak positive result or discordant results (when one test is negative and the other is positive). We systematically tested all participants of a Ugandan population-based, longitudinal cohort study regardless of prior test results or HIV status to quantify longitudinal patterns in rapid HIV test results. We found that a substantial fraction (>15%) of participants with indeterminate rapid test results subsequently tested positive upon follow-up testing at the next visit. Our findings demonstrate the importance of follow-up HIV testing protocols for indeterminate rapid HIV test results.
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Affiliation(s)
- Joanne H. Hunt
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - George Mwinnyaa
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Eshan U. Patel
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - M. Kate Grabowski
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
| | | | - Ronald H. Gray
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Maria J. Wawer
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Larry W. Chang
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
| | | | | | | | - Thomas C. Quinn
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David Serwadda
- Rakai Health Sciences Program, Kalisizo, Uganda
- Makerere University, Kampala, Uganda
| | - Steven J. Reynolds
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
| | | | - Oliver Laeyendecker
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Sharkey T, Parker R, Wall KM, Malama K, Pappas-DeLuca K, Tichacek A, Peeling R, Kilembe W, Inambao M, Allen S. Use of "Strengthening Our Vows" Video Intervention to Encourage Negotiated Explicit Sexual Agreements in Zambian Heterosexual HIV Seroconcordant-Negative Couples. ARCHIVES OF SEXUAL BEHAVIOR 2023; 52:2649-2667. [PMID: 37024634 PMCID: PMC10524092 DOI: 10.1007/s10508-023-02590-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 02/09/2023] [Accepted: 03/14/2023] [Indexed: 06/19/2023]
Abstract
Negotiating sexual agreements in combination with couples' voluntary HIV counseling and testing (CVCT) may help further reduce HIV transmission in Zambian concordant HIV-negative couples (CNC). Though CVCT has been shown to reduce HIV transmission in CNC by 47%, approximately half of residual infections occur in this group. We developed a "Strengthening Our Vows" video session to foster communication and negotiation of explicit sexual agreements to reduce concurrent sexual exposures and prevent HIV transmission to the spouse due to unprotected, extramarital sex. CNC were recruited through CVCT services at five clinics in Lusaka and Ndola in 2016. Enrolled CNC attending the facilitated group video sessions were encouraged to discuss sexual agreements at home and return 1-2 weeks later for follow-up assessment. One-fourth of the 580 CNC returning reported a history of extramarital partners and/or a sexually transmitted infection (STI) prior to enrollment. More than 95% reported a friendly, supportive 15-60 min negotiation culminating in an agreement to remain monogamous or disclose sexual contacts and use condoms together until a repeat HIV test 30 days after an outside sexual exposure. Two-thirds of participants identified at least one threat to adherence of their agreements including alcohol use, financial pressures, travel, discord in the home, and post-partum or menstrual abstinence. CNC negotiated explicit sexual agreements to avoid exposure to HIV through concurrent partnerships and protect the spouse in the event of an outside sexual contact. Open communication was a consistent theme to facilitate mutual protective efforts. Long-term follow-up of HIV/STI incidence is ongoing to assess the impact of these agreements.Trial registration This sub-study is part of a trial retrospectively registered on ClinicalTrials.gov (Identifier: NCT02744586) on April 20, 2016.
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Affiliation(s)
- Tyronza Sharkey
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA.
- Department of Clinical Research, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK.
| | - Rachel Parker
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Kristin M Wall
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
- Department of Epidemiology, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, USA
| | - Kalonde Malama
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Katina Pappas-DeLuca
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Amanda Tichacek
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Rosanna Peeling
- Department of Clinical Research, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
| | - William Kilembe
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Mubiana Inambao
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Susan Allen
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
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Wall KM, Karita E, Nyombayire J, Ingabire R, Mukamuyango J, Parker R, Brill I, Price M, Haddad LB, Tichacek A, Hunter E, Allen S. Genital Abnormalities, Hormonal Contraception, and Human Immunodeficiency Virus Transmission Risk in Rwandan Serodifferent Couples. J Infect Dis 2021; 224:81-91. [PMID: 33560366 PMCID: PMC8253127 DOI: 10.1093/infdis/jiab071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 02/02/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND We explored the role of genital abnormalities and hormonal contraception in human immunodeficiency virus (HIV) transmission among heterosexual serodifferent couples in Rwanda. METHODS From 2002 to 2011, HIV-serodifferent couples who were not using antiretroviral treatment were followed up, and sociodemographic and clinical data were collected, family planning provided, and HIV-negative partners retested. Couples were assessed for genital ulcers; nonulcerative genital sexually transmitted infection (STIs), including gonorrhea, chlamydia, and trichomoniasis; and non-STI vaginal infections, including bacterial vaginosis and candida. Multivariable models evaluated associations between covariates and HIV transmission genetically linked to the index partner. RESULTS Among 877 couples in which the man was HIV positive, 37 linked transmissions occurred. Factors associated with women's HIV acquisition included genital ulceration in the female partner (adjusted hazard ratio, 14.1) and nonulcerative STI in the male partner (8.6). Among 955 couples in which the woman was HIV positive, 46 linked transmissions occurred. Factors associated with HIV acquisition in men included nonulcerative STI in the female partner (adjusted hazard ratio, 4.4), non-STI vaginal dysbiosis (7.1), and genital ulceration in the male partner (2.6). Hormonal contraception use was not associated with HIV transmission or acquisition. CONCLUSIONS Our findings underscore the need for integrating HIV services with care for genital abnormalities. Barriers (eg, cost of training, demand creation, advocacy, and client education; provider time; and clinic space) to joint HIV/STI testing need to be considered and addressed.
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Affiliation(s)
- Kristin M Wall
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, Georgia, USA
| | - Etienne Karita
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Projet San Francisco, Kigali, Rwanda
| | - Julien Nyombayire
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Projet San Francisco, Kigali, Rwanda
| | - Rosine Ingabire
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Projet San Francisco, Kigali, Rwanda
| | - Jeannine Mukamuyango
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Projet San Francisco, Kigali, Rwanda
| | - Rachel Parker
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Ilene Brill
- Department of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Matt Price
- IAVI, New York, New York, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Lisa B Haddad
- Center for Biomedical Research, Population Council, New York, New York, USA
| | - Amanda Tichacek
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - Susan Allen
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Nyombayire J, Ingabire R, Mukamuyango J, Karita E, Mazzei A, Wall KM, Parker R, Tichacek A, Allen S, Hunter E, Price MA. Antiretroviral Therapy Use and HIV Transmission Among Discordant Couples in Nonresearch Settings in Kigali, Rwanda. Sex Transm Dis 2021; 48:424-428. [PMID: 33433171 PMCID: PMC10881059 DOI: 10.1097/olq.0000000000001350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Antiretroviral therapy (ART) efficacy for HIV prevention among discordant couples has been demonstrated in clinical trials. Effectiveness outside of research settings is less well understood. METHODS HIV-discordant couples were enrolled in couples' testing and follow-up at 20 government clinics in Kigali from 2010 to 2014. We performed viral linkage analysis on seroconverting couples to determine infection sources (intracouple vs. extracouple). Antiretroviral therapy use in index partners was collected at baseline and during follow-up by self-report with verification of government medical records. RESULTS A total of 3777 HIV-discordant couples were identified and followed up at government health clinics. Fifty-four incident HIV infections were identified, of which 36 were confirmed linked to the index partner, 4 were unlinked, and 14 were unknown. Among the 50 linked or unknown transmission pairs, 38% occurred among couples in which the index partner was on ART (HIV incidence rate of 0.63/100 person-years), whereas 62% occurred among couples in which the index partner was not on ART (HIV incidence rate of 5.51/100 person-years; adjusted rate ratio, 6.9). HIV acquisition was higher in women than in men with non-ART using index partners (P < 0.001). CONCLUSIONS Couples in a government clinic couples' HIV testing and follow-up program in Rwanda had an 89% reduction in HIV incidence when index partners were using ART, slightly lower than efficacy estimates from randomized trials. Antiretroviral therapy for prevention should be prioritized for key populations including discordant couples identified via couples' voluntary counseling and testing, with increased efforts to improve uptake, adherence, and viral load monitoring.
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Affiliation(s)
- Julien Nyombayire
- From the Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
| | - Rosine Ingabire
- From the Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
| | | | - Etienne Karita
- From the Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
| | - Amelia Mazzei
- From the Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
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Use of Point-of-Care Nucleic Acid Tests Beyond Early Infant Diagnosis of HIV: A Retrospective Case Review in Lesotho. J Acquir Immune Defic Syndr 2021; 84 Suppl 1:S78-S83. [PMID: 32520919 DOI: 10.1097/qai.0000000000002381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rapid diagnostic tests (RDTs) for HIV antibodies remain the primary method of diagnosis of HIV in individuals over age 18 months in Lesotho. Although antibody tests have high sensitivity and specificity, up to 2.3% of serial two-test algorithms can have discrepant results between RDTs. In the case of inconclusive RDT results, Lesotho guidelines at the time of this study recommended either repeat testing with the same RDT algorithm after 14 days or immediately collect a blood sample to be sent for laboratory-based polymerase chain reaction testing. Point-of-care qualitative nucleic acid tests (POC qual NAT) may have benefits in rapidly resolving these inconclusive results, particularly when compared with repeating RDTs later or conventional polymerase chain reaction testing at the National Reference Laboratory. SETTING Hospitals and clinics at 29 locations throughout Lesotho that had access to point-of-care nucleic acid testing. METHODS Retrospective case review. RESULTS We identified 100 testing records where POC qual NAT was used to resolve inconclusive RDTs per Lesotho guidelines. Eighty-nine percent of patients received their results in a median of one day from their inconclusive RDT result (interquartile range 0-7 days). Sixty-eight patients (68%) were determined to be HIV positive based on POC nucleic acid tests (NATs), of which 54 (79%) were started on antiretroviral therapy (ART). Median time from inconclusive RDT result to initiation of ART therapy was 2 days (interquartile range 0-14 days). Three patients in this review were pregnant at the time of testing; one was HIV positive by POC qual NAT and was started on ART therapy the same day. CONCLUSION As the availability of POC qual NAT platforms increases, they may serve as feasible options for rapid resolution of inconclusive results and initiation of ART, particularly in populations with high risk of imminent transmission.
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Mwinnyaa G, Grabowski MK, Gray RH, Wawer M, Chang LW, Ssekasanvu J, Kagaayi J, Kigozi G, Kalibbala S, Galiwango RM, Ndyanabo A, Serwadda D, Quinn TC, Reynolds SJ, Laeyendecker O. HIV serologically indeterminate individuals: Future HIV status and risk factors. PLoS One 2020; 15:e0237633. [PMID: 32845933 PMCID: PMC7449388 DOI: 10.1371/journal.pone.0237633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 07/30/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Indeterminate HIV test results are common, but little is known about the evolution of indeterminate serology and its sociodemographic and behavioral correlates. We assessed future HIV serological outcomes for individuals with indeterminate results and associated factors in Rakai, Uganda. METHODS 115,944 serological results, defined by two enzyme immunoassay (EIAs), among 39,440 individuals aged 15-49 years in the Rakai Community Cohort Study were assessed. Indeterminate results were defined as contradictory EIAs. Modified Poisson regression models with generalized estimating equations were used to assess prevalence ratios (PRs) of subsequent HIV serological outcomes and factors associated with HIV indeterminate results. RESULTS The prevalence of HIV serologically indeterminate results was 4.9%. Indeterminate results were less likely among women than men (adjPR 0.76, 95% CI 0.71,0.81), in unmarried participants than married participants (adjPR 0.92, 95% CI 0.85,99), and in individuals with primary (adjPR 0.90, 95% CI 0.80,1.02), secondary (adjPR 0.83, 95% CI 0.73,0.96) and post-secondary (adjPR 0.75, 95% CI 0.60,0.94) education, relative to no education. The proportions of persons with indeterminate results progressing to HIV positive, negative or indeterminate results in subsequent visits was 5%, 71% and 24%, respectively. CONCLUSION HIV serologically indeterminate results were associated with gender and marital status. HIV surveillance programs should develop a protocol for reporting individuals with mixed or persistently indeterminate HIV results on multiple follow-up visits. Most indeterminate results became HIV-negative over time, but follow-up is still needed to detect positive serologies.
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Affiliation(s)
| | - Mary K. Grabowski
- Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Ronald H. Gray
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Maria Wawer
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Larry W. Chang
- Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Joseph Ssekasanvu
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States of America
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Mukamuyango J, Ingabire R, Parker R, Nyombayire J, Abaasa A, Asiki G, Easter SR, Wall KM, Nyirazinyoye L, Tichacek A, Kaslow N, Price MA, Allen S, Karita E. Uptake of long acting reversible contraception following integrated couples HIV and fertility goal-based family planning counselling in Catholic and non-Catholic, urban and rural government health centers in Kigali, Rwanda. Reprod Health 2020; 17:126. [PMID: 32807177 PMCID: PMC7433361 DOI: 10.1186/s12978-020-00981-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 08/11/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND When integrated with couples' voluntary HIV counselling and testing (CVCT), family planning including long acting reversible contraceptives (LARC) addresses prongs one and two of prevention of mother-to-child transmission (PMTCT). METHODS In this observational study, we enrolled equal numbers of HIV concordant and discordant couples in four rural and four urban clinics, with two Catholic and two non-Catholic clinics in each area. Eligible couples were fertile, not already using a LARC method, and wished to limit or delay fertility for at least 2 years. We provided CVCT and fertility goal-based family planning counselling with the offer of LARC and conducted multivariate analysis of clinic, couple, and individual predictors of LARC uptake. RESULTS Of 1290 couples enrolled, 960 (74%) selected LARC: Jadelle 5-year implant (37%), Implanon 3-year implant (26%), or copper intrauterine device (IUD) (11%). Uptake was higher in non-Catholic clinics (85% vs. 63% in Catholic clinics, p < 0.0001), in urban clinics (82% vs. 67% in rural clinics, p < 0.0001), and in HIV concordant couples (79% vs. 70% of discordant couples, p = .0005). Religion of the couple was unrelated to clinic religious affiliation, and uptake was highest among Catholics (80%) and lowest among Protestants (70%) who were predominantly Pentecostal. In multivariable analysis, urban location and non-Catholic clinic affiliation, Catholic religion of woman or couple, younger age of men, lower educational level of both partners, non-use of condoms or injectable contraception at enrollment, prior discussion of LARC by the couple, and women not having concerns about negative side effects of implant were associated with LARC uptake. CONCLUSIONS Fertility goal-based LARC recommendations combined with couples' HIV counselling and testing resulted in a high uptake of LARC methods, even among discordant couples using condoms for HIV prevention, in Catholic clinics, and in rural populations. This model successfully integrates prevention of HIV and unplanned pregnancy.
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Affiliation(s)
| | - Rosine Ingabire
- Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
| | - Rachel Parker
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Julien Nyombayire
- Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
| | - Andrew Abaasa
- London School of Hygiene & Tropical Medicine (LSHTM), Keppel Street, London, WC1E 7HT, UK
- Medical Research Council, Uganda Vaccine Research Institute & LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Gershim Asiki
- Medical Research Council, Uganda Vaccine Research Institute & LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Sarah Rae Easter
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kristin M Wall
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Nadine Kaslow
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, Atlanta, GA, USA
| | - Matt A Price
- International AIDS Vaccine Initiative, New York, NY, USA
- Department of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, CA, USA
| | - Susan Allen
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA.
| | - Etienne Karita
- Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
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Mukamuyango J, Ingabire R, Parker R, Nyombayire J, Easter SR, Wall KM, Tichacek A, Nyirazinyoye L, Kaslow N, Allen S, Karita E. Motivational interviewing to promote long-acting reversible contraception among Rwandan couples wishing to prevent or delay pregnancy. Am J Obstet Gynecol 2020; 222:S919.e1-S919.e12. [PMID: 31838122 DOI: 10.1016/j.ajog.2019.11.1280] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/19/2019] [Accepted: 11/27/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Few family-planning programs in Africa base demand creation and service delivery on theoretical models. Motivational interviewing is a counseling modality that facilitates reflection on the benefits and disadvantages of a health outcome to encourage behavior change. OBJECTIVES We evaluate a couples-focused joint family-planning and HIV counseling intervention using motivational interviewing to enhance uptake of long-acting reversible contraception (Paragard copper intrauterine device or Jadelle hormonal implant) among Rwandan couples. STUDY DESIGN In this experimental study, couples receiving care at 8 government health clinics in Kigali, the capital city, were referred from a parent study of couples who did not want more children or wanted to wait at least 2 years for their next pregnancy. Long-acting reversible contraception methods were offered on site following joint HIV testing and family-planning counseling. At the first follow-up visit 1 month after enrollment in the parent study, couples who had not yet chosen a long-acting reversible contraception method were interviewed separately using motivational interviewing and then brought together and again offered long-acting reversible contraception. RESULTS Following motivational interviewing, 78 of 229 couples (34%) requested a long-acting reversible contraception method (68 implant and 10 intrauterine device). Long-acting reversible contraception uptake after motivational interviewing was associated with the woman being Catholic (vs Protestant/Muslim/other, adjusted odds ratio, 2.87, 95% confidence interval, 1.19-6.96, P = .019) or having an income (vs no income, adjusted odds ratio, 2.54, 95% confidence interval, 1.12-5.73, P = .025); the couple having previously discussed long-acting reversible contraception (adjusted odds ratio, 8.38, 95% confidence interval, 2.54-27.59, P = .0005); either partner believing that unplanned pregnancy was likely with their current method (adjusted odds ratio, 6.67, 95% confidence interval, 2.77-16.11, P < .0001); or that they might forget to take or make an appointment for their current method (adjusted odds ratio, 4.04, 95% confidence interval, 1.32-12.34, P = .014). Neither partner mentioning that condoms also prevent HIV/sexually transmitted infection was associated with long-acting reversible contraception uptake (adjusted odds ratio, 2.86, 95% confidence interval, 1.17-7.03, P = .022), as was the woman citing long-term duration of action of the implant as an advantage (adjusted odds ratio, 5.41, 95% confidence interval, 1.86-15.76, P = .002). The woman not listing any side effects or disadvantages of implants was associated with long-acting reversible contraception uptake (adjusted odds ratio, 5.42, 95% confidence interval, 2.33-12.59, P < .0001). Clinic location (rural vs urban), couple HIV status, and concerns about negative economic effects of an unplanned pregnancy were significant in bivariate but not multivariate analysis. CONCLUSION Encouraging couples to reflect on the benefits and disadvantages of long-acting reversible contraception methods, the likelihood of unplanned pregnancy with their current contraception, and the impact of an unplanned pregnancy is an effective motivational interviewing technique in family-planning counseling. One third of couples who did not want a pregnancy for at least 2 years but had not chosen a long-acting reversible contraception method when provided with standard family-planning counseling did so after motivational interviewing. Involving the male partner in family-planning discussions facilitates joint decision making about fertility goals and contraceptive choice. Combining family planning and joint HIV testing for couples allows targeted focus on dual-method use with discordant couples, who are advised to use condoms for HIV/sexually transmitted infection prevention along with a more effective contraceptive for added protection against unplanned pregnancy.
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Hormonal Contraception and Vaginal Infections Among Couples Who Are Human Immunodeficiency Virus Serodiscordant in Lusaka, Zambia. Obstet Gynecol 2020; 134:573-580. [PMID: 31403592 DOI: 10.1097/aog.0000000000003404] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the relationship between hormonal contraception and vaginal infections with bacterial vaginosis, vaginal candidiasis, or trichomoniasis. METHODS Couples who were human immunodeficiency virus (HIV) serodiscordant in Zambia were enrolled in a longitudinal cohort study. From 1994 to 2002, both partners were seen quarterly and received physical exams including genital examinations. Separate rates for three outcome infections of interest (bacterial vaginosis, vaginal candidiasis, and trichomoniasis) were calculated. Bivariate associations between baseline and time-varying covariates and outcome infections of interest were evaluated using unadjusted Anderson-Gill survival models. Adjusted hazard ratios (aHRs) were generated using multivariable Anderson-Gill survival models that included demographic and clinical factors associated with both hormonal contraceptive use and each infection of interest. RESULTS There were 1,558 cases of bacterial vaginosis, 1,529 cases of vaginal candidiasis, and 574 cases of trichomoniasis over 2,143 person-years of observation. Depot medroxyprogesterone acetate (DMPA) users had significantly lower rates of trichomoniasis and bacterial vaginosis. In adjusted models, DMPA was protective for bacterial vaginosis (aHR=0.72; 95% CI 0.54-0.95), candidiasis (aHR 0.75, 95% CI 0.57-1.00) and trichomoniasis (aHR=0.43, 95% CI 0.25-0.74). Oral contraceptive pills were protective for candidiasis (aHR=0.79, 95% CI 0.65-0.97). CONCLUSION We confirm that DMPA use was associated with reduced rates of the three most common causes of vaginitis, and oral contraceptive pill use was associated with reduced rates of candidiasis among women in couples who were HIV discordant.
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Kilembe W, Inambao M, Sharkey T, Wall KM, Parker R, Himukumbwa C, Tichacek A, Malama K, Visoiu AM, Price M, Chomba E, Allen S. Single Mothers and Female Sex Workers in Zambia Have Similar Risk Profiles. AIDS Res Hum Retroviruses 2019; 35:814-825. [PMID: 31204869 DOI: 10.1089/aid.2019.0013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The aim of the study was to compare reproductive health and high-risk behaviors in female sex workers (FSWs) and single mothers (SMs) in Zambia's two largest cities, Lusaka and Ndola. FSWs were invited from known community hot spots, and sexually active HIV- SMs were referred from infant vaccination services for free and anonymous screening and treatment for HIV and other sexually transmitted infections (STIs) and long acting reversible contraception. A subset completed an interviewer-administered survey. From 2012 to 2016, 1,893 women (1,377 FSWs and 516 HIV- SMs) responded to referrals. HIV prevalence was 50% in Lusaka and 33% in Ndola FSWs. Positive syphilis serology (rapid plasmin reagin) was found in 29%-31% of HIV+ FSWs and 9%-12% of HIV- FSWs and SMs. Trichomonas was more common in Ndola (11%-12%), compared with Lusaka (3%-7%). Antiretroviral therapy (ART) use among HIV+ FSWs was 9%-15%. In all groups, consistent condom use (8%-11%) and modern contraceptive use (35%-65%) were low. Low literacy and reported coercion at first sexual intercourse were common in both FSWs and SMs, as was alcohol use during sex among FSWs. Zambian FSWs and SMs have low condom use and high HIV/STI and unplanned pregnancy risk. Many FSWs and half of SMs are ≥25 years of age, and thus too old for HIV prevention services targeting "adolescent girls and young women" (aged 15-24). Tailored and targeted reproductive health services are needed to reduce HIV, STI, and unplanned pregnancy in these vulnerable women.
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Affiliation(s)
| | | | | | - Kristin M. Wall
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
| | - Rachel Parker
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
| | | | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
| | | | | | - Matt Price
- International AIDS Vaccine Initiative (IAVI), New York, New York
| | - Elwyn Chomba
- Levy Mwanawasa Medical University, Lusaka, Zambia
| | - Susan Allen
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
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Cost implications of HIV retesting for verification in Africa. PLoS One 2019; 14:e0218936. [PMID: 31260467 PMCID: PMC6602186 DOI: 10.1371/journal.pone.0218936] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 06/12/2019] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION HIV misdiagnosis leads to severe individual and public health consequences. Retesting for verification of all HIV-positive cases prior to antiretroviral therapy initiation can reduce HIV misdiagnosis, yet this practice has not been not widely implemented. METHODS We evaluated and compared the cost of retesting for verification of HIV seropositivity (retesting) to the cost of antiretroviral treatment (ART) for misdiagnosed cases in the absence of retesting (no retesting), from the perspective of the health care system. We estimated the number of misdiagnosed cases based on a review of misdiagnosis rates, and the number of positives persons needing ART initiation by 2020. We presented the total and per person costs of retesting as compared to no retesting, over a ten-year horizon, across 50 countries in Africa grouped by income level. We conducted univariate sensitivity analysis on all model input parameters, and threshold analysis to evaluate the parameter values where the total costs of retesting and the costs no retesting are equivalent. Cost data were adjusted to 2017 United States Dollars. RESULTS AND DISCUSSION The estimated number of misdiagnoses, in the absence of retesting was 156,117, 52,720 and 29,884 for lower-income countries (LICs), lower-middle income countries (LMICs), and upper middle-income countries (UMICs), respectively, totaling 240,463 for Africa. Under the retesting scenario, costs per person initially diagnosed were: $40, $21, and $42, for LICs, LMICs, and UMICs, respectively. When retesting for verification is implemented, the savings in unnecessary ART were $125, $43, and $75 per person initially diagnosed, for LICs, LMICs, and UMICs, respectively. Over the ten-year horizon, the total costs under the retesting scenario, over all country income levels, was $475 million, and was $1.192 billion under the no retesting scenario, representing total estimated savings of $717 million in HIV treatment costs averted. CONCLUSIONS Results show that to reduce HIV misdiagnosis, countries in Africa should implement the WHO's recommendation of retesting for verification prior to ART initiation, as part of a comprehensive quality assurance program for HIV testing services.
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Ingabire R, Parker R, Nyombayire J, Ko JE, Mukamuyango J, Bizimana J, Price MA, Laufer D, Tichacek A, Wall K, Allen S, Karita E. Female sex workers in Kigali, Rwanda: a key population at risk of HIV, sexually transmitted infections, and unplanned pregnancy. Int J STD AIDS 2019; 30:557-568. [PMID: 30727831 PMCID: PMC6512058 DOI: 10.1177/0956462418817050] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 11/12/2018] [Indexed: 12/17/2022]
Abstract
Female sex workers (FSWs) were recruited from known hotspots in Kigali, Rwanda, and offered free, anonymous human immunodeficiency virus (HIV) counseling and testing, diagnosis and treatment of sexually transmitted infections (STIs) and long-acting reversible contraception (LARC). From September 2012 to March 2015, 1168 FSWs sought services, including 587 (50%) who were HIV-positive. More than 90% had previously tested for HIV, and 26% who reported previously testing negative had seroconverted. Of the 349 who already knew their HIV-positive status, 74% were on antiretroviral treatment. The prevalence of serologic syphilis was 43% in HIV-positive and 19% in HIV-negative FSWs (p < 0.0001), and Trichomonas vaginalis was found in vaginal wet mounts in 21% of HIV-positive and 13% of HIV-negative FSWs (p < 0.0001). Signs and symptoms of STIs were found in 35% of HIV-positive compared with 21% of HIV-negative FSWs (p < 0.0001). Only one-third reported consistent condom use in the last month. Modern contraceptive use was reported by 43% of HIV-positive and 56% of HIV-negative FSWs (p < 0.0001). Current pregnancy was reported by 4% of HIV-positive and 6% of HIV-negative FSWs (p = 0.0409). Despite Rwanda's successes with preventing 70% of new infections in the general population through nationwide couples' testing in antenatal clinics, prevention and timely treatment in key populations including FSWs are lacking. The prevalence of HIV - including many new cases - and STIs among FSWs in Kigali is high and condom and contraceptive use are low. Tailored and integrated HIV/STIs and family planning programs are urgently needed for FSWs.
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Affiliation(s)
- Rosine Ingabire
- Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali,
Rwanda
| | - Rachel Parker
- Rwanda Zambia HIV Research Group, Department of Pathology &
Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA,
USA
| | - Julien Nyombayire
- Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali,
Rwanda
| | - Jasmine E Ko
- Rwanda Zambia HIV Research Group, Department of Pathology &
Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA,
USA
| | | | - Jean Bizimana
- Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali,
Rwanda
| | - Matt A Price
- International AIDS Vaccine Initiative, New York, NY, USA
- Department of Epidemiology and Biostatistics, University of
California at San Francisco, San Francisco, CA, USA
| | - Dagna Laufer
- International AIDS Vaccine Initiative, New York, NY, USA
| | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, Department of Pathology &
Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA,
USA
| | - Kristin Wall
- Department of Epidemiology, Rollins School of Public Health,
Emory University, Atlanta, GA, USA
| | - Susan Allen
- Rwanda Zambia HIV Research Group, Department of Pathology &
Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA,
USA
| | - Etienne Karita
- Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali,
Rwanda
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Cao B, Saffer AJ, Yang C, Chen H, Peng K, Pan SW, Durvasula M, Liu C, Fu H, Ong JJ, Tang W, Tucker JD. MSM Behavior Disclosure Networks and HIV Testing: An Egocentric Network Analysis Among MSM in China. AIDS Behav 2019; 23:1368-1374. [PMID: 30680538 PMCID: PMC6511288 DOI: 10.1007/s10461-019-02404-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Men who have sex with men (MSM) disclose same-sex behaviors with others, creating disclosure networks. This study examined the characteristics of disclosure networks that are associated with HIV testing among MSM in China through an online nationwide survey. Name-generator questions were used to ask each participant ("ego") to nominate up to five social network members ("alters") with whom he had disclosed same-sex behaviors. Among the 806 men, the average disclosure network size was 4.05. MSM who reported larger disclosure networks were more likely to have been tested for HIV (aOR 1.21, 95% CI 1.08-1.34). The most common disclosure network alters were friends (45.1%), followed by sex partners (18.7%) and healthcare professionals (2.5%). Men who disclosed to healthcare professionals were more likely to test for HIV compared to men who disclosed to family members (aOR 5.43, 95% CI 2.11-14.04). Our findings can inform disclosure network-based interventions to promote MSM HIV testing.
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Affiliation(s)
- Bolin Cao
- School of Media and Communication, Shenzhen University, Shenzhen, China
- University of North Carolina Project-China, Guangzhou, China
- Social Entrepreneurship to Spur Health (SESH), Guangzhou, China
| | - Adam J Saffer
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Cui Yang
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Hexin Chen
- Department of Media and Communication, City University of Hong Kong, Hong Kong, Hong Kong
| | - Kun Peng
- Faculty of Humanities and Arts, Macau University of Science and Technology, Taipa, Macau, China
| | - Stephen W Pan
- University of North Carolina Project-China, Guangzhou, China
- Social Entrepreneurship to Spur Health (SESH), Guangzhou, China
- Department of Public Health, Xi'an Jiaotong-Liverpool University, Suzhou, China
| | - Maya Durvasula
- Sanford School of Public Policy, Duke University, Durham, USA
| | - Chuncheng Liu
- University of North Carolina Project-China, Guangzhou, China
- Social Entrepreneurship to Spur Health (SESH), Guangzhou, China
- Department of Sociology, University of California, San Diego, La Jolla, USA
| | - Hongyun Fu
- Eastern Virginia Medical University, Norfolk, USA
| | - Jason J Ong
- Social Entrepreneurship to Spur Health (SESH), Guangzhou, China
- London School of Hygiene and Tropical Medicine, London, UK
| | - Weiming Tang
- University of North Carolina Project-China, Guangzhou, China
- Social Entrepreneurship to Spur Health (SESH), Guangzhou, China
- Guangdong Provincial Centre for Skin Diseases and STI Control, Number 2 Lujing Road, Guangzhou, China
| | - Joseph D Tucker
- University of North Carolina Project-China, Guangzhou, China.
- Social Entrepreneurship to Spur Health (SESH), Guangzhou, China.
- University of North Carolina at Chapel Hill, Chapel Hill, USA.
- London School of Hygiene and Tropical Medicine, London, UK.
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Wall KM, Kilembe W, Vwalika B, Dinh C, Livingston P, Lee YM, Lakhi S, Boeras D, Naw HK, Brill I, Chomba E, Sharkey T, Parker R, Shutes E, Tichacek A, Secor WE, Allen S. Schistosomiasis is associated with incident HIV transmission and death in Zambia. PLoS Negl Trop Dis 2018; 12:e0006902. [PMID: 30543654 PMCID: PMC6292564 DOI: 10.1371/journal.pntd.0006902] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 10/04/2018] [Indexed: 12/11/2022] Open
Abstract
Background We examined relationships between schistosome infection, HIV transmission or acquisition, and all-cause death. Methods We retrospectively tested baseline sera from a heterosexual HIV-discordant couple cohort in Lusaka, Zambia with follow-up from 1994–2012 in a nested case-control design. Schistosome-specific antibody levels were measured by ELISA. Associations between baseline antibody response to schistosome antigens and incident HIV transmission, acquisition, and all-cause death stratified by gender and HIV status were assessed. In a subset of HIV- women and HIV+ men, we performed immunoblots to evaluate associations between Schistosoma haematobium or Schistosoma mansoni infection history and HIV incidence. Results Of 2,145 individuals, 59% had positive baseline schistosome-specific antibody responses. In HIV+ women and men, baseline schistosome-specific antibodies were associated with HIV transmission to partners (adjusted hazard ratio [aHR] = 1.8, p<0.005 and aHR = 1.4, p<0.05, respectively) and death in HIV+ women (aHR = 2.2, p<0.001). In 250 HIV- women, presence of S. haematobium-specific antibodies was associated with increased risk of HIV acquisition (aHR = 1.4, p<0.05). Conclusion Schistosome infections were associated with increased transmission of HIV from both sexes, acquisition of HIV in women, and increased progression to death in HIV+ women. Establishing effective prevention and treatment strategies for schistosomiasis, including in urban adults, may reduce HIV incidence and death in HIV+ persons living in endemic areas. This study explored the association between schistosome infections (a disease caused by parasitic flatworms, also known as ‘snail fever’, which is very common throughout sub-Saharan Africa) and human immunodeficiency virus (HIV). We found in Lusaka, the capital of Zambia, that schistosome infections were associated with transmission of HIV from adult men and women, and schistosome infections were also associated with increased HIV acquisition in adult women. We additionally found that schistosome infections were associated with death in HIV+ adult women. Since treatment of schistosome infections with praziquantel is inexpensive, effective, and safe, schistosomiasis prevention and treatment strategies may be a cost-effective way to reduce not only the symptoms associated with the infection, but also new cases of HIV and death among HIV+ persons. Though often viewed as an infection of predominantly rural areas and children, this study highlights that schistosomiasis prevention and treatment efforts are also needed in urban areas and among adults.
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Affiliation(s)
- Kristin M Wall
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America.,Department of Epidemiology, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, Georgia, United States of America
| | - William Kilembe
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Bellington Vwalika
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America.,Department of Gynecology and Obstetrics, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Cecile Dinh
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Paul Livingston
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Yeuk-Mui Lee
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Shabir Lakhi
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America.,Department of Internal Medicine, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Debi Boeras
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Htee Khu Naw
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Ilene Brill
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America.,Department of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Elwyn Chomba
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America.,Ministry of Home Affairs, Zambian Ministry of Health, Lusaka, Zambia.,School of Medicine, University of Zambia, Lusaka, Zambia
| | - Tyronza Sharkey
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Rachel Parker
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Erin Shutes
- Malaria Team, Global Health Program, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - W Evan Secor
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Susan Allen
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
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Alert, but not alarmed - a comment on "Towards more accurate HIV testing in sub-Saharan Africa: a multi-site evaluation of HIV RDTs and risk factors for false positives (Kosack et al. 2017)". J Int AIDS Soc 2018; 20:22042. [PMID: 28664683 PMCID: PMC5515062 DOI: 10.7448/ias.20.1.22042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Abstract
Objective: To examine bacterial vaginosis as an effect modifier for the association between hormonal contraception and incident HIV infection. Design: Serodiscordant couples enrolled in an open longitudinal cohort in Lusaka, Zambia from 1994 to 2012. This analysis was restricted to couples with an HIV-positive man enrolled between1994 and 2002 when a quarterly genital tract examination and HIV testing was performed. Methods: Multivariate Cox models evaluated the association between contraceptive method and HIV-acquisition, stratified by time-varying bacterial vaginosis status. Results: Among 564 couples contributing 1137.2 couple-years of observation, bacterial vaginosis was detected at 15.5% of study visits. Twenty-two of 106 seroconversions occurred during intervals after bacterial vaginosis was detected [12 on no method/nonhormonal method (nonhormonal contraception), two on injectables, eight on oral contraceptive pills (OCPs)]. Unadjusted seroincidence rates per 100 couple-years for nonhormonal contraception, injectable, and OCP users, respectively, during intervals with bacterial vaginosis were 8.3, 20.8, and 31.0 and during intervals without bacterial vaginosis were 8.2, 9.7, and 12.3. In the bacterial vaginosis-positive model, there was a significant increase in incident HIV among those using injectables (adjusted hazard ratio, aHR 6.55, 95% CI 1.14–37.77) and OCPs (aHR 5.20, 95% CI 1.68–16.06) compared with nonhormonal contraception. Hormonal contraception did not increase the hazard of HIV acquisition in bacterial vaginosis-negative models. These findings persisted in sensitivity analyses whenever all covariates from the nonstratified model previously published were included, whenever other genital tract findings were excluded from the model and with the addition of condom-less sex and sperm on wet-prep. Conclusion: Future research should consider a potential interaction with bacterial vaginosis whenever evaluating the impact of hormonal contraception on HIV acquisition.
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Inambao M, Kilembe W, Canary LA, Czaicki NL, Kakungu-Simpungwe M, Chavuma R, Wall KM, Tichacek A, Pulerwitz J, Thior I, Chomba E, Allen SA. Transitioning couple's voluntary HIV counseling and testing (CVCT) from stand-alone weekend services into routine antenatal and VCT services in government clinics in Zambia's two largest cities. PLoS One 2017; 12:e0185142. [PMID: 29036208 PMCID: PMC5642897 DOI: 10.1371/journal.pone.0185142] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 08/30/2017] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Most HIV infections in Africa are acquired by married/cohabiting adults and WHO recommends couple's voluntary HIV counseling and testing (CVCT) for prevention. The handover from NGO-sponsored weekend CVCT to government-sponsored services in routine weekday antenatal care (ANC) and individual voluntary testing and counseling (VCT) services in Zambia's two largest cities from 2009-2015 is described. METHODS Government clinic counselors were trained to provide CVCT, and along with community health workers they promoted CVCT services in their clinic and surrounding areas. When client volume exceeded the capacity of on-duty staff in ANC and VCT, non-governmental organization (NGO) subsidies were offered for overtime pay. RESULTS Implementation of routine CVCT services varied greatly by clinic and city. The 12 highest volume clinics were examined further, while 13 clinics had CVCT numbers that were too low to warrant further investigation. In Lusaka, the proportion of pregnant women whose partners were tested rose from 2.6% in 2009 to a peak of 26.2% in 2012 and 24.8% in 2015. Corresponding reports in Ndola were 2.0% in 2009, 17.0% in 2012 and 14.5% in 2015. Obstacles to CVCT included: limited space and staffing, competing priorities, record keeping not adapted for couples, and few resources for promotion and increasing male involvement. Conflicting training models for 'partner testing' with men and women separately vs. CVCT with joint post-test counseling led to confusion in reporting to district health authorities. DISCUSSION A focused and sustained effort will be required to reach a meaningful number of couples with CVCT to prevent heterosexual and perinatal HIV transmission. Establishing targets and timelines, funding for dedicated and appropriately trained staff, adoption of standardized data recording instruments with couple-level indicators, and expansion of community and clinic-based promotions using proven models are recommended.
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Affiliation(s)
- Mubiana Inambao
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
- Zambia Emory HIV Research Project (ZEHRP), Ndola, Zambia
| | - William Kilembe
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
- Zambia Emory HIV Research Project (ZEHRP), Lusaka, Zambia
| | - Lauren A. Canary
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Nancy L. Czaicki
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Matilda Kakungu-Simpungwe
- District Health Management team (DHMT), Ministry of Community Development, Maternal and Child Health (MCDMCH), Lusaka, Zambia
| | - Roy Chavuma
- District Health Management team (DHMT), Ministry of Community Development, Maternal and Child Health (MCDMCH), Lusaka, Zambia
| | - Kristin M. Wall
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | | | - Ibou Thior
- PATH, Washington, DC, United States of America
| | - Elwyn Chomba
- Ministry of Community Development, Maternal and Child Health (MCDMCH), Lusaka, Zambia
| | - Susan A. Allen
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
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Wall KM, Kilembe W, Vwalika B, Haddad LB, Hunter E, Lakhi S, Chavuma R, Htee Khu N, Brill I, Vwalika C, Mwananyanda L, Chomba E, Mulenga J, Tichacek A, Allen S. Risk of heterosexual HIV transmission attributable to sexually transmitted infections and non-specific genital inflammation in Zambian discordant couples, 1994-2012. Int J Epidemiol 2017; 46:1593-1606. [PMID: 28402442 PMCID: PMC5837621 DOI: 10.1093/ije/dyx045] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/24/2017] [Accepted: 03/01/2017] [Indexed: 12/13/2022] Open
Abstract
Background Studies have demonstrated the role of ulcerative and non-ulcerative sexually transmitted infections (STI) in HIV transmission/acquisition risk; less is understood about the role of non-specific inflammatory genital abnormalities. Methods HIV-discordant heterosexual Zambian couples were enrolled into longitudinal follow-up (1994-2012). Multivariable models estimated the effect of genital ulcers and inflammation in both partners on time-to-HIV transmission within the couple. Population-attributable fractions (PAFs) were calculated. Results A total of 207 linked infections in women occurred over 2756 couple-years (7.5/100 CY) and 171 in men over 3216 CY (5.3/100 CY). Incident HIV among women was associated with a woman's non-STI genital inflammation (adjusted hazard ratio (aHR) = 1.55; PAF = 8%), bilateral inguinal adenopathy (BIA; aHR = 2.33; PAF = 8%), genital ulceration (aHR = 2.08; PAF = 7%) and the man's STI genital inflammation (aHR = 3.33; PAF = 5%), BIA (aHR = 3.35; PAF = 33%) and genital ulceration (aHR = 1.49; PAF = 9%). Infection among men was associated with a man's BIA (aHR = 4.11; PAF = 22%) and genital ulceration (aHR = 3.44; PAF = 15%) as well as with the woman's non-STI genital inflammation (aHR = 1.92; PAF = 13%) and BIA (aHR = 2.76; PAF = 14%). In HIV-M+F- couples, the man being uncircumcised. with foreskin smegma. was associated with the woman's seroconversion (aHR = 3.16) relative to being circumcised. In F+M- couples, uncircumcised men with BIA had an increased hazard of seroconversion (aHR = 13.03 with smegma and 4.95 without) relative to being circumcised. Self-reporting of symptoms was low for ulcerative and non-ulcerative STIs. Conclusions Our findings confirm the role of STIs and highlight the contribution of non-specific genital inflammation to both male-to-female and female-to-male HIV transmission/acquisition risk. Studies are needed to characterize pathogenesis of non-specific inflammation including inguinal adenopathy. A better understanding of genital practices could inform interventions.
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Affiliation(s)
- Kristin M Wall
- Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - William Kilembe
- Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Bellington Vwalika
- Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
- Departments of Gynecology and Obstetrics (B.V.), Internal Medicine (S.L.) and Surgery (R.C.), School of Medicine, University of Zambia, Lusaka, Zambia
| | - Lisa B Haddad
- Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
- Department of Gynecology and Obstetrics, Emory University, School of Medicine, Atlanta, GA, USA
| | - Eric Hunter
- Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Shabir Lakhi
- Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
- Departments of Gynecology and Obstetrics (B.V.), Internal Medicine (S.L.) and Surgery (R.C.), School of Medicine, University of Zambia, Lusaka, Zambia
| | - Roy Chavuma
- Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
- Departments of Gynecology and Obstetrics (B.V.), Internal Medicine (S.L.) and Surgery (R.C.), School of Medicine, University of Zambia, Lusaka, Zambia
| | - Naw Htee Khu
- Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Ilene Brill
- Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
- Department of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA and
| | - Cheswa Vwalika
- Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Lawrence Mwananyanda
- Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Elwyn Chomba
- Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
- Ministry of Community Development, Mother and Child Health, Lusaka, Zambia
| | - Joseph Mulenga
- Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Amanda Tichacek
- Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Susan Allen
- Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
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A public health approach to addressing and preventing misdiagnosis in the scale-up of HIV rapid testing programmes. J Int AIDS Soc 2017. [DOI: 10.7448/ias.20.7.22290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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20
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A public health approach to addressing and preventing misdiagnosis in the scale-up of HIV rapid testing programmes. J Int AIDS Soc 2017; 20:22190. [PMID: 28872270 PMCID: PMC5625588 DOI: 10.7448/ias.20.7.22190] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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21
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Johnson CC, Fonner V, Sands A, Ford N, Obermeyer CM, Tsui S, Wong V, Baggaley R. To err is human, to correct is public health: a systematic review examining poor quality testing and misdiagnosis of HIV status. J Int AIDS Soc 2017; 20:21755. [PMID: 28872271 PMCID: PMC5625583 DOI: 10.7448/ias.20.7.21755] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 03/07/2017] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION In accordance with global testing and treatment targets, many countries are seeking ways to reach the "90-90-90" goals, starting with diagnosing 90% of all people with HIV. Quality HIV testing services are needed to enable people with HIV to be diagnosed and linked to treatment as early as possible. It is essential that opportunities to reach people with undiagnosed HIV are not missed, diagnoses are correct and HIV-negative individuals are not inadvertently initiated on life-long treatment. We conducted this systematic review to assess the magnitude of misdiagnosis and to describe poor HIV testing practices using rapid diagnostic tests. METHODS We systematically searched peer-reviewed articles, abstracts and grey literature published from 1 January 1990 to 19 April 2017. Studies were included if they used at least two rapid diagnostic tests and reported on HIV misdiagnosis, factors related to potential misdiagnosis or described quality issues and errors related to HIV testing. RESULTS Sixty-four studies were included in this review. A small proportion of false positive (median 3.1%, interquartile range (IQR): 0.4-5.2%) and false negative (median: 0.4%, IQR: 0-3.9%) diagnoses were identified. Suboptimal testing strategies were the most common factor in studies reporting misdiagnoses, particularly false positive diagnoses due to using a "tiebreaker" test to resolve discrepant test results. A substantial proportion of false negative diagnoses were related to retesting among people on antiretroviral therapy. Conclusions HIV testing errors and poor practices, particularly those resulting in false positive or false negative diagnoses, do occur but are preventable. Efforts to accelerate HIV diagnosis and linkage to treatment should be complemented by efforts to improve the quality of HIV testing services and strengthen the quality management systems, particularly the use of validated testing algorithms and strategies, retesting people diagnosed with HIV before initiating treatment and providing clear messages to people with HIV on treatment on the risk of a "false negative" test result.
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Affiliation(s)
- Cheryl C. Johnson
- Department of HIV, World Health Organization, Geneva, Switzerland
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Virginia Fonner
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Anita Sands
- Department of Essential Medicines and Health Products, World Health Organization, Geneva, Switzerland
| | - Nathan Ford
- Department of HIV, World Health Organization, Geneva, Switzerland
| | - Carla Mahklouf Obermeyer
- Department of Epidemiology and Population Health, American University of Beirut, Beirut, Lebanon
| | - Sharon Tsui
- Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | - Vincent Wong
- US Agency for International Development, Washington, DC, USA
| | - Rachel Baggaley
- Department of HIV, World Health Organization, Geneva, Switzerland
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22
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Wall KM, Kilembe W, Vwalika B, Haddad LB, Khu NH, Brill I, Onwubiko U, Chomba E, Tichacek A, Allen S. Optimizing Prevention of HIV and Unplanned Pregnancy in Discordant African Couples. J Womens Health (Larchmt) 2017; 26:900-910. [PMID: 28829720 PMCID: PMC5576260 DOI: 10.1089/jwh.2016.6169] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Dual method use, which combines condoms with a more effective modern contraceptive to optimize prevention of HIV and unplanned pregnancy, is underutilized in high-risk heterosexual couples. MATERIALS AND METHODS Heterosexual HIV-discordant Zambian couples were enrolled from couples' voluntary HIV counseling and testing services into an open cohort with 3-monthly follow-up (1994-2012). Relative to dual method use, defined as consistent condom use plus modern contraception, we examine predictors of (1) condom-only use (suboptimal pregnancy prevention) or (2) modern contraceptive use with inconsistent condom use (effective pregnancy prevention and suboptimal HIV prevention). RESULTS Among 3,049 couples, dual method use occurred in 28% of intervals in M+F- and 23% in M-F+, p < 0.01; condom-only use in 56% in M+F- and 61% in M-F+, p < 0.01; and modern contraceptive use with inconsistent condom use in 16% regardless of serostatus. Predictors (p < 0.05) of condom-only use included the man being HIV+ (adjusted hazard ratio, aHR = 1.15); baseline oral contraceptive pill (aHR = 0.76), injectable (aHR = 0.48), or implant (aHR = 0.60) use; woman's age (aHR = 1.04 per 5 years) and lifetime number of sex partners (aHR = 1.01); postpartum periods (aHR = 1.25); and HIV stage of the index partner III/IV versus I (aHR = 1.10). Predictors (p < 0.05) of modern contraceptive use with inconsistent condom use included woman's age (aHR = 0.94 per 5 years) and HIV+ male circumcision (aHR = 1.51), while time-varying implant use was associated with more consistent condom use (aHR = 0.80). CONCLUSIONS Three-quarters of follow-up intervals did not include dual method use. This highlights the need for counseling to reduce unintended pregnancy and HIV transmission and enable safer conception.
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Affiliation(s)
- Kristin M. Wall
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Department of Epidemiology, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, Georgia
| | - William Kilembe
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Bellington Vwalika
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Departments of Gynecology and Obstetrics (BV), Internal Medicine (SL) and Surgery (RC), School of Medicine, University of Zambia, Lusaka, Zambia
| | - Lisa B. Haddad
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Department of Gynecology and Obstetrics, Emory University, School of Medicine, Atlanta, Georgia
| | - Naw Htee Khu
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Ilene Brill
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Department of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Udodirim Onwubiko
- Department of Epidemiology, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, Georgia
| | - Elwyn Chomba
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Ministry of Home Affairs and University of Zambia School of Medicine Lusaka, Lusaka, Zambia
| | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Susan Allen
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
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23
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Joseph Davey D, Kilembe W, Wall KM, Khu NH, Brill I, Vwalika B, Chomba E, Mulenga J, Tichacek A, Javanbakht M, Comulada WS, Allen S, Gorbach PM. Risky Sex and HIV Acquisition Among HIV Serodiscordant Couples in Zambia, 2002-2012: What Does Alcohol Have To Do With It? AIDS Behav 2017; 21:1892-1903. [PMID: 28243934 PMCID: PMC5493513 DOI: 10.1007/s10461-017-1733-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
In this paper we evaluate the effects of heavy alcohol consumption on sexual behavior, HIV acquisition, and antiretroviral treatment (ART) initiation in a longitudinal open cohort of 1929 serodiscordant couples in Lusaka, Zambia from 2002 to 2012. We evaluated factors associated with baseline heavy alcohol consumption and its association with condomless sex with the study partner, sex outside of the partnership, and ART initiation using multivariable logistic regression. We estimated the effect of alcohol consumption on HIV acquisition using multivariable Cox models. Baseline factors significantly associated with women’s heavy drinking (drunk weekly or more in 12-months before enrollment) included woman’s older age (adjusted prevalence odds ratio [aPOR] = 1.04), partner heavy drinking (aPOR = 3.93), and being HIV-infected (aPOR = 2.03). Heavy drinking among men was associated with less age disparity with partner (aPOR per year disparity = 0.97) and partner heavy drinking (aPOR = 1.63). Men’s being drunk daily (aOR = 1.18), women’s being drunk less than monthly (aOR = 1.39) vs. never drunk and being in a male HIV-negative and female HIV-positive union (aOR = 1.45) were associated with condomless sex. Heavy alcohol use was associated with having 1 or more outside sex partners among men (aOR drunk daily = 1.91, drunk weekly = 1.32, drunk monthly = 2.03 vs. never), and women (aOR drunk monthly = 2.75 vs. never). Being drunk weekly or more increased men’s risk of HIV acquisition (adjusted hazard ratio [aHR] = 1.72). Men and women being drunk weekly or more was associated (p < 0.1) with women’s seroconversion (aHR = 1.42 and aHR = 3.71 respectively). HIV-positive women who were drunk monthly or more had lower odds of initiating ART (aOR = 0.83; 95% CI = 0.70–0.99) adjusting for age, months since baseline and previous pregnancies. Individuals in HIV-serodiscordant couples who reported heavy drinking had more outside sex partnerships and condomless sex with their study partner and were more likely to acquire HIV. HIV-positive women had lower odds of initiating ART if they were heavy drinkers.
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Affiliation(s)
- Dvora Joseph Davey
- Rwanda Zambia HIV Research Group (RZHRG), Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA.
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, 650 Charles E. Young Drive South, Los Angeles, CA, 90095, USA.
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa.
| | - William Kilembe
- Rwanda Zambia HIV Research Group (RZHRG), Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kristin M Wall
- Rwanda Zambia HIV Research Group (RZHRG), Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Epidemiology, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, USA
| | - Naw Htee Khu
- Rwanda Zambia HIV Research Group (RZHRG), Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Ilene Brill
- Rwanda Zambia HIV Research Group (RZHRG), Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Bellington Vwalika
- Rwanda Zambia HIV Research Group (RZHRG), Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Obstetrics and Gynecology, University of Zambia, Lusaka, Zambia
| | - Elwyn Chomba
- School of Medicine, University of Zambia, Lusaka, Zambia
| | - Joseph Mulenga
- Rwanda Zambia HIV Research Group (RZHRG), Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Zambia National Blood Transfusion Service, Lusaka, Zambia
| | - Amanda Tichacek
- Rwanda Zambia HIV Research Group (RZHRG), Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Marjan Javanbakht
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, 650 Charles E. Young Drive South, Los Angeles, CA, 90095, USA
| | - W Scott Comulada
- Department of Psychology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Susan Allen
- Rwanda Zambia HIV Research Group (RZHRG), Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Pamina M Gorbach
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, 650 Charles E. Young Drive South, Los Angeles, CA, 90095, USA
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Wall KM, Kilembe W, Vwalika B, Haddad LB, Lakhi S, Onwubiko U, Htee Khu N, Brill I, Chavuma R, Vwalika C, Mwananyanda L, Chomba E, Mulenga J, Tichacek A, Allen S. Sustained effect of couples' HIV counselling and testing on risk reduction among Zambian HIV serodiscordant couples. Sex Transm Infect 2017; 93:259-266. [PMID: 28082662 PMCID: PMC5520263 DOI: 10.1136/sextrans-2016-052743] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 11/23/2016] [Accepted: 12/21/2016] [Indexed: 01/26/2023] Open
Abstract
Background We present temporal trends in self-reported and biological markers of unprotected sex and sex with concurrent partners in discordant couples receiving couples' voluntary HIV counselling and testing (CVCT). Methods Heterosexual Zambian HIV-serodiscordant couples were enrolled into longitudinal follow-up in an open cohort (1994–2012). Multivariable Anderson-Gill models explored predictors of self-report and biological indicators of unprotected sex within (including sperm on a vaginal swab, incident pregnancy or incident linked HIV infection) and outside (including self-report, STI and unlinked HIV infection) the union. Measures of secular trends in baseline measures were also examined. Results At enrolment of 3049 couples, men were 35 years old on average, women were 29 years, and couples had been together for an average of 7 years. M+F− couples reported an average of 16.6 unprotected sex acts in the 3 months prior to enrolment (pre-CVCT), dropping to 5.3 in the >0–3 month interval, and 2.0 in >6 month intervals (p-trend <0.001). Corresponding values for M−F+ couples were 22.4 unprotected sex acts in the 3 months prior enrolment, dropping to 5.2 in the >0–3 month interval, and 3.1 in >6 month intervals (p-trend <0.001). Significant reductions in self-report and biological markers of outside partners were also noted. Predictors of unprotected sex between study partners after CVCT included prevalent pregnancy (adjusted HR, aHR=1.6–1.9); HIV+ men being circumcised (aHR=1.2); and HIV− women reporting sex with outside partners (aHR=1.3), alcohol (aHR=1.2), injectable (aHR=1.4) or oral (aHR=1.4) contraception use. Fertility intentions were also predictive of unprotected sex (aHR=1.2–1.4). Secular trends indicated steady declines in reported outside partners and STIs. Conclusion Reductions in self-reported unprotected sex after CVCT were substantial and sustained. Reinforced risk-reduction counselling in pregnant couples, couples desiring children and couples with HIV− women having outside partners or using alcohol or injectable or oral contraception are indicated.
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Affiliation(s)
- Kristin M Wall
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,Department of Epidemiology, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, Georgia, USA
| | - William Kilembe
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Bellington Vwalika
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,Department of Gynaecology and Obstetrics (BV), Internal Medicine (SL) and Surgery (RC), School of Medicine, University of Zambia, Lusaka, Zambia
| | - Lisa B Haddad
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,Department of Gynaecology and Obstetrics, Emory University, School of Medicine, Atlanta, Georgia, USA
| | - Shabir Lakhi
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,Department of Gynaecology and Obstetrics (BV), Internal Medicine (SL) and Surgery (RC), School of Medicine, University of Zambia, Lusaka, Zambia
| | - Udodirim Onwubiko
- Department of Epidemiology, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, Georgia, USA
| | - Naw Htee Khu
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Ilene Brill
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,Department of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Roy Chavuma
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,Department of Gynaecology and Obstetrics (BV), Internal Medicine (SL) and Surgery (RC), School of Medicine, University of Zambia, Lusaka, Zambia
| | - Cheswa Vwalika
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lawrence Mwananyanda
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Elwyn Chomba
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,Ministry of Community Development, Mother and Child Health, Lusaka, Zambia
| | - Joseph Mulenga
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Susan Allen
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Wall KM, Kilembe W, Vwalika B, Ravindhran P, Khu NH, Brill I, Chomba E, Johnson BA, Haddad LB, Tichacek A, Allen S. Hormonal Contraceptive Use Among HIV-Positive Women and HIV Transmission Risk to Male Partners, Zambia, 1994-2012. J Infect Dis 2016; 214:1063-71. [PMID: 27462093 PMCID: PMC5021237 DOI: 10.1093/infdis/jiw322] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 07/20/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Evidence on the association between female-to-male human immunodeficiency virus (HIV) transmission risk and hormonal contraception is sparse and conflicting. METHODS Heterosexual HIV-discordant couples from Lusaka, Zambia, were followed longitudinally at 3 month-intervals from 1994 to 2012. The impact of hormonal contraception on time to HIV transmission from HIV-positive women to their HIV-negative male partners (M-F+) was evaluated. RESULTS Among 1601 M-F+ couples, 171 genetically linked HIV transmissions occurred in men over 3216 couple-years (5.3 transmissions/100 couple-years; 95% confidence interval [CI], 4.5-6.2). In multivariable Cox models, neither injectable (adjusted hazard ratio [aHR], 0.6; 95% CI, .4-1.2), oral contraceptive pill (aHR, 0.8; 95% CI, .3-2.1), nor implant (aHR, 0.8; 95% CI, .5-1.4) use was associated with HIV transmission, relative to nonhormonal methods, after controlling for the man's age at baseline and time-varying measures of pregnancy, self-reported unprotected sex with the study partner, sperm present on a vaginal swab wet mount, genital inflammation of either partner, genital ulceration of the man, and first follow-up interval. Sensitivity analyses, including marginal structural modeling and controlling for viral load and fertility intentions available in a subset of couples, led to similar conclusions. CONCLUSIONS Our findings suggest null associations between hormonal contraception and risk of female-to-male HIV transmission. We support efforts to increase the contraceptive method mix for all women, regardless of HIV serostatus, along with reinforced condom counseling for HIV-serodiscordant couples.
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Affiliation(s)
- Kristin M Wall
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health Department of Epidemiology, Rollins School of Public Health and Laney Graduate School
| | - William Kilembe
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health
| | - Bellington Vwalika
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health Department of Gynecology and Obstetrics, School of Medicine, University of Zambia
| | - Preeti Ravindhran
- Department of Epidemiology, Rollins School of Public Health and Laney Graduate School
| | - Naw Htee Khu
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health
| | - Ilene Brill
- Department of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham
| | - Elwyn Chomba
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health Ministry of Community Development, Mother and Child Health, Lusaka, Zambia
| | - Brent A Johnson
- Department of Biostatistics and Computational Biology, School of Medicine and Dentistry, University of Rochester Medical Center, New York
| | - Lisa B Haddad
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health Department of Gynecology and Obstetrics, School of Medicine, Emory University, Atlanta, Georgia
| | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health
| | - Susan Allen
- Rwanda Zambia HIV Research Group, Department of Pathology and Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health
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Hormonal Contraception, Pregnancy, Breastfeeding, and Risk of HIV Disease Progression Among Zambian Women. J Acquir Immune Defic Syndr 2016; 71:345-52. [PMID: 26379070 PMCID: PMC4752415 DOI: 10.1097/qai.0000000000000848] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background: Some studies suggest that hormonal contraception, pregnancy, and/or breastfeeding may influence rates of HIV disease progression. Methods: From 1994 to 2012, HIV discordant couples recruited at couples' voluntary HIV counseling and testing centers in Lusaka were followed 3-monthly. Multivariate survival analyses explored associations between time-varying contraception, pregnancy, and breastfeeding and 2 outcomes among HIV-positive women: (1) time to death and (2) time to antiretroviral treatment (ART) initiation. Results: Among 1656 female seropositive, male seronegative couples followed for 3359 person-years (PY), 224 women died [6.7/100 PY; 95% confidence interval (CI): 5.8 to 7.6]. After 2003, 290 women initiated ART (14.5/100 PY; 95% CI: 12.9 to 16.2). In a multivariate model of time to death, hormonal implant [adjusted hazard ratio (aHR) = 0.30; 95% CI: 0.10 to 0.98] and injectable (aHR = 0.59; 95% CI: 0.36 to 0.97) were significantly protective relative to nonhormonal method use, whereas oral contraceptive pill (OCP) use was not (aHR = 1.08; 95% CI: 0.74 to 1.57) controlling for baseline HIV disease stage, time-varying pregnancy, time-varying breastfeeding, and year of enrollment. In a multivariate model of time-to-ART initiation, implant was significantly protective (aHR = 0.54; 95% CI: 0.31 to 0.95), whereas OCP (aHR = 0.70; 95% CI: 0.44 to 1.10) and injectable (aHR = 0.85; 95% CI: 0.55 to 1.32) were not relative to nonhormonal method use controlling for variables above, woman's age, and literacy. Pregnancy was not significantly associated with death (aHR = 1.07; 95% CI: 0.68 to 1.66) or ART initiation (aHR = 1.24; 95% CI: 0.83 to 1.86), whereas breastfeeding was protective for death (aHR = 0.34; 95% CI: 0.19 to 0.62) and ART initiation (aHR = 0.49; 95% CI: 0.29 to 0.85). Conclusions: Hormonal implants and injectables significantly predicted lower mortality; implants were protective for ART initiation. OCPs and pregnancy were not associated with death or ART initiation, whereas breastfeeding was protective for both. Findings from this 18-year cohort study suggest that (1) HIV-positive women desiring pregnancy can be counseled to do so and breastfeed and (2) all effective contraceptive methods, including injectables and implants, should be promoted to prevent unintended pregnancy.
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Determination of HIV Status in African Adults With Discordant HIV Rapid Tests. J Acquir Immune Defic Syndr 2015; 69:430-8. [PMID: 25835607 DOI: 10.1097/qai.0000000000000610] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In resource-limited settings, HIV infection is often diagnosed using 2 rapid tests. If the results are discordant, a third tie-breaker test is often used to determine HIV status. This study characterized samples with discordant rapid tests and compared different testing strategies for determining HIV status in these cases. METHODS Samples were previously collected from 173 African adults in a population-based survey who had discordant rapid test results. Samples were classified as HIV positive or HIV negative using a rigorous testing algorithm that included two fourth-generation tests, a discriminatory test, and 2 HIV RNA tests. Tie-breaker tests were evaluated, including rapid tests (1 performed in-country), a third-generation enzyme immunoassay, and two fourth-generation tests. Selected samples were further characterized using additional assays. RESULTS Twenty-nine samples (16.8%) were classified as HIV positive and 24 of those samples (82.8%) had undetectable HIV RNA. Antiretroviral drugs were detected in 1 sample. Sensitivity was 8.3%-43% for the rapid tests; 24.1% for the third-generation enzyme immunoassay; 95.8% and 96.6% for the fourth-generation tests. Specificity was lower for the fourth-generation tests than the other tests. Accuracy ranged from 79.5% to 91.3%. CONCLUSIONS In this population-based survey, most HIV-infected adults with discordant rapid tests were virally suppressed without antiretroviral drugs. Use of individual assays as tie-breaker tests was not a reliable method for determining HIV status in these individuals. More extensive testing algorithms that use a fourth-generation screening test with a discriminatory test and HIV RNA test are preferable for determining HIV status in these cases.
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Simoncini GM, Megill M, van den Berg-Wolf M. Reducing False-Positive HIV Diagnosis in Niger: A Women's Issue. J Int Assoc Provid AIDS Care 2015; 15:15-8. [PMID: 25979258 DOI: 10.1177/2325957415586260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The entry into both HIV care and secondary prevention is first through the knowledge of one's own HIV status. Testing for HIV remains challenging in countries where clinicians rely on rapid testing algorithms because the routine use of confirmatory Western blot technology is unavailable. In this case report, we describe the case of a pregnant woman in Niger, who was falsely labeled as HIV positive during prenatal visits. We also describe our clinical algorithm that was developed to facilitate retesting in patients who initially tested HIV positive or indeterminant with rapid diagnostic tests. Vigilance is necessary to ensure that appropriate identification and treatment of HIV is provided to reduce mother-to-child transmission of HIV, to appropriately allocate resources, and to avoid falsely labeling patients with HIV.
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Affiliation(s)
- Gina M Simoncini
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
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Dilution testing using rapid diagnostic tests in a HIV diagnostic algorithm: a novel alternative for confirmation testing in resource limited settings. Virol J 2015; 12:75. [PMID: 25972188 PMCID: PMC4432962 DOI: 10.1186/s12985-015-0306-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 05/04/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Current WHO testing guidelines for resource limited settings diagnose HIV on the basis of screening tests without a confirmation test due to cost constraints. This leads to a potential risk of false positive HIV diagnosis. In this paper, we evaluate the dilution test, a novel method for confirmation testing, which is simple, rapid, and low cost. The principle of the dilution test is to alter the sensitivity of a rapid diagnostic test (RDT) by dilution of the sample, in order to screen out the cross reacting antibodies responsible for falsely positive RDT results. METHODS Participants were recruited from two testing centres in Ethiopia where a tiebreaker algorithm using 3 different RDTs in series is used to diagnose HIV. All samples positive on the initial screening RDT and every 10th negative sample underwent testing with the gold standard and dilution test. Dilution testing was performed using Determine™ rapid diagnostic test at 6 different dilutions. Results were compared to the gold standard of Western Blot; where Western Blot was indeterminate, PCR testing determined the final result. RESULTS 2895 samples were recruited to the study. 247 were positive for a prevalence of 8.5 % (247/2895). A total of 495 samples underwent dilution testing. The RDT diagnostic algorithm misclassified 18 samples as positive. Dilution at the level of 1/160 was able to correctly identify all these 18 false positives, but at a cost of a single false negative result (sensitivity 99.6 %, 95 % CI 97.8-100; specificity 100 %, 95 % CI: 98.5-100). Concordance between the gold standard and the 1/160 dilution strength was 99.8 %. CONCLUSION This study provides proof of concept for a new, low cost method of confirming HIV diagnosis in resource-limited settings. It has potential for use as a supplementary test in a confirmatory algorithm, whereby double positive RDT results undergo dilution testing, with positive results confirming HIV infection. Negative results require nucleic acid testing to rule out false negative results due to seroconversion or misclassification by the lower sensitivity dilution test. Further research is needed to determine if these results can be replicated in other settings. TRIAL REGISTRATION ClinicalTrials.gov, NCT01716299 .
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Kilembe W, Wall KM, Mokgoro M, Mwaanga A, Dissen E, Kamusoko M, Phiri H, Sakulanda J, Davitte J, Reddy T, Brockman M, Ndung’u T, Allen S. Knowledge of HIV serodiscordance, transmission, and prevention among couples in Durban, South Africa. PLoS One 2015; 10:e0124548. [PMID: 25894583 PMCID: PMC4403857 DOI: 10.1371/journal.pone.0124548] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 03/15/2015] [Indexed: 11/19/2022] Open
Abstract
Objective Couples’ voluntary HIV counseling and testing (CVCT) significantly decreases HIV transmission within couples, the largest risk group in sub-Saharan Africa, but it is not currently offered in most HIV testing facilities. To roll out such an intervention, understanding locale-specific knowledge barriers is critical. In this study, we measured knowledge of HIV serodiscordance, transmission, and prevention before and after receipt of CVCT services in Durban. Design Pre- and post-CVCT knowledge surveys were administered to a selection of individuals seeking CVCT services. Methods Changes in knowledge scores were assessed with McNemar Chi-square tests for balanced data and generalized estimating equation methods for unbalanced data. Results The survey included 317 heterosexual black couples (634 individuals) who were primarily Zulu (87%), unemployed (47%), and had at least a secondary level education (78%). 28% of couples proved to be discordant. Only 30% of individuals thought serodiscordance between couples was possible pre‐CVCT compared to 95% post-CVCT. One-third thought there was at least one benefit of CVCT pre‐CVCT, increasing to 96% post‐CVCT. Overall, there were positive changes in knowledge about HIV transmission and prevention. However, many respondents thought all HIV positive mothers give birth to babies with AIDS (64% pre-CVCT, 59% post-CVCT) and that male circumcision does not protect negative men against HIV (70% pre-CVCT, 67% post-CVCT). Conclusions CVCT was well received and was followed by improvements in understanding of discordance, the benefits of joint testing, and HIV transmission. Country-level health messaging would benefit from targeting gaps in knowledge about serodiscordance, vertical transmission, and male circumcision.
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Affiliation(s)
- William Kilembe
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Kristin M. Wall
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
- Department of Epidemiology, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, Georgia, United States of America
- * E-mail:
| | - Mammekwa Mokgoro
- HIV Pathogenesis Programme, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Annie Mwaanga
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Elisabeth Dissen
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Miriam Kamusoko
- HIV Pathogenesis Programme, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Hilda Phiri
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Jean Sakulanda
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Jonathan Davitte
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Tarylee Reddy
- Medical Research Council, Biostatistics Unit, Durban, South Africa
| | - Mark Brockman
- Faculty of Health Sciences and Faculty of Science, Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Thumbi Ndung’u
- HIV Pathogenesis Programme, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
- KwaZulu-Natal Research Institute for Tuberculosis and HIV (K-RITH), University of KwaZulu-Natal, Durban, South Africa
| | - Susan Allen
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
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Wall KM, Kilembe W, Vwalika B, Htee Khu N, Brill I, Chomba E, Johnson BA, Haddad L, Tichacek A, Allen S. Hormonal contraception does not increase women's HIV acquisition risk in Zambian discordant couples, 1994-2012. Contraception 2015; 91:480-7. [PMID: 25708502 DOI: 10.1016/j.contraception.2015.02.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 02/09/2015] [Accepted: 02/10/2015] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To determine the impact of hormonal contraceptive methods on risk of HIV acquisition among HIV-negative women cohabiting with HIV-positive male partners. STUDY DESIGN From 1994-2012, HIV discordant couples recruited from a couples' voluntary HIV counseling and testing center in Lusaka, Zambia were followed longitudinally. HIV-negative partners were tested quarterly. This analysis is restricted to couples in which the man was HIV-positive and the woman was HIV-negative at enrollment and the man was not on antiretroviral treatment. Multivariate Cox models evaluated associations between time-varying contraceptive methods and HIV acquisition among women. Sensitivity analyses explored exposure misclassification and time-varying confounder mediation. RESULTS Among 1393 couples, 252 incident infections occurred in women over 2842 couple-years (8.9 infections per 100 couple-years; 95% CI, 7.8-10.0). Multivariate Cox models indicated that neither injectable [adjusted hazard ratio (aHR)=1.2; 95% CI, 0.8-1.7], oral contraceptive pill (OCP, aHR=1.3; 95% CI, 0.9-1.8), or implant (aHR=1.1; 95% CI, 0.5-2.2) use was significantly associated with HIV acquisition relative to non-hormonal contraception controlling for woman's age, literacy and time-varying measures of genital ulceration/inflammation. This remained true when only looking at the subset of infections acquired from the spouse (82% of infections) and additionally controlling for baseline HIV viral load of the male partner, pregnancy status, and time-varying measures of sperm on a vaginal swab wet prep and self-reported unprotected sex. OCP and injectable users reported more unprotected sex (p<.001), and OCP users were more likely to have sperm on vaginal swab (p=.1) than nonhormonal method users. CONCLUSIONS We found no association between hormonal contraception and HIV acquisition risk in women. Condom use and reinforced condom counseling should always be recommended for HIV discordant couples. HIV testing of sex partners together is critical to establish HIV risk, ascertain couple fertility intentions and counsel appropriately. IMPLICATIONS These findings add to a controversial literature and uniquely address several common design and analytic challenges faced by previous studies. After controlling for confounders, we found no association between hormonal contraception and HIV acquisition risk in women. We support promoting condoms for HIV prevention and increasing the contraceptive method mix to decrease unintended pregnancy.
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Affiliation(s)
- Kristin M Wall
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Department of Epidemiology, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, USA.
| | - William Kilembe
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Bellington Vwalika
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Department of Gynecology and Obstetrics, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Naw Htee Khu
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Ilene Brill
- Department of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elwyn Chomba
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Ministry of Community Development, Mother and Child Health, Lusaka, Zambia
| | - Brent A Johnson
- Department of Biostatistics and Computational Biology, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, NY, USA
| | - Lisa Haddad
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Department of Gynecology and Obstetrics, Emory University, School of Medicine, Atlanta, GA, USA
| | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Susan Allen
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Shanks L, Siddiqui MR, Kliescikova J, Pearce N, Ariti C, Muluneh L, Pirou E, Ritmeijer K, Masiga J, Abebe A. Evaluation of HIV testing algorithms in Ethiopia: the role of the tie-breaker algorithm and weakly reacting test lines in contributing to a high rate of false positive HIV diagnoses. BMC Infect Dis 2015; 15:39. [PMID: 25645240 PMCID: PMC4331460 DOI: 10.1186/s12879-015-0769-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 01/19/2015] [Indexed: 11/29/2022] Open
Abstract
Background In Ethiopia a tiebreaker algorithm using 3 rapid diagnostic tests (RDTs) in series is used to diagnose HIV. Discordant results between the first 2 RDTs are resolved by a third ‘tiebreaker’ RDT. Médecins Sans Frontières uses an alternate serial algorithm of 2 RDTs followed by a confirmation test for all double positive RDT results. The primary objective was to compare the performance of the tiebreaker algorithm with a serial algorithm, and to evaluate the addition of a confirmation test to both algorithms. A secondary objective looked at the positive predictive value (PPV) of weakly reactive test lines. Methods The study was conducted in two HIV testing sites in Ethiopia. Study participants were recruited sequentially until 200 positive samples were reached. Each sample was re-tested in the laboratory on the 3 RDTs and on a simple to use confirmation test, the Orgenics Immunocomb Combfirm® (OIC). The gold standard test was the Western Blot, with indeterminate results resolved by PCR testing. Results 2620 subjects were included with a HIV prevalence of 7.7%. Each of the 3 RDTs had an individual specificity of at least 99%. The serial algorithm with 2 RDTs had a single false positive result (1 out of 204) to give a PPV of 99.5% (95% CI 97.3%-100%). The tiebreaker algorithm resulted in 16 false positive results (PPV 92.7%, 95% CI: 88.4%-95.8%). Adding the OIC confirmation test to either algorithm eliminated the false positives. All the false positives had at least one weakly reactive test line in the algorithm. The PPV of weakly reacting RDTs was significantly lower than those with strongly positive test lines. Conclusion The risk of false positive HIV diagnosis in a tiebreaker algorithm is significant. We recommend abandoning the tie-breaker algorithm in favour of WHO recommended serial or parallel algorithms, interpreting weakly reactive test lines as indeterminate results requiring further testing except in the setting of blood transfusion, and most importantly, adding a confirmation test to the RDT algorithm. It is now time to focus research efforts on how best to translate this knowledge into practice at the field level. Trial registration Clinical Trial registration #: NCT01716299
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Affiliation(s)
- Leslie Shanks
- Médecins Sans Frontières, Amsterdam, The Netherlands.
| | | | | | - Neil Pearce
- London School of Hygiene and Tropical Medicine, London, UK.
| | - Cono Ariti
- London School of Hygiene and Tropical Medicine, London, UK.
| | - Libsework Muluneh
- Ethiopian Health and Nutrition Research Institute, Addis Ababa, Ethiopia.
| | - Erwan Pirou
- Médecins Sans Frontières, Amsterdam, The Netherlands.
| | | | | | - Almaz Abebe
- Ethiopian Health and Nutrition Research Institute, Addis Ababa, Ethiopia.
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Czaicki NL, Davitte J, Siangonya B, Kastner R, Ahmed N, Khu NH, Kuo WH, Abdallah J, Wall KM, Tichacek A, Inambao M, Simpungwe K, Thior I, Allen S. Predictors of first follow-up HIV testing for couples' voluntary HIV counseling and testing in Ndola, Zambia. J Acquir Immune Defic Syndr 2014; 66:e1-7. [PMID: 24326600 PMCID: PMC3981940 DOI: 10.1097/qai.0000000000000076] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION We describe predictors of first follow-up testing for concordant negative and discordant couples seeking joint voluntary HIV counseling and testing in Ndola, Zambia, where cohabiting couples account for an estimated two-thirds of incident HIV infections. METHODS Demographic and serostatus data were collected from couples' voluntary HIV testing and counseling and follow-up testing services implemented in government clinics. We calculated follow-up testing rates by serostatus and compared rates before and after the introduction of a Good Health Package (GHP). RESULTS The follow-up testing rate from May 2011 to December 2012 was 12.2% for concordant negative (M-F-) couples and 24.5% for discordant (M+F- or M-F+) couples. Significant predictors of follow-up testing in multivariate analyses included increasing age of the man [adjusted odds ratio (aOR) = 1.02 per year] and the woman (aOR = 1.02 per year), and either partner being HIV+ (aOR = 2.57 for HIV+ man, aOR = 1.89 for HIV+ woman). The man (aOR = 1.29) and the couple (aOR = 1.22) having been previously tested for HIV were predictive of follow-up testing among concordant negative couples. Introduction of a GHP increased follow-up testing among discordant (aOR = 2.93) and concordant negative (aOR = 2.06) couples. CONCLUSIONS A low-cost GHP, including prevention, screening, and treatment for common causes of morbidity and mortality resulted in increased follow-up testing rates among HIV discordant and concordant negative couples. Overall follow-up testing rates remain low, and efforts to increase these rates are necessary to ensure linkage to combination prevention, reduce HIV transmission within couples, and identify seroconversions promptly. Further investigation of low-cost sustainable incentives and other factors influencing follow-up HIV testing for couples is needed.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Kristin M Wall
- Department of Epidemiology, Rollins School of Public
Health, Emory University, Atlanta, Georgia, USA
| | | | | | | | - Ibou Thior
- Program for Appropriate Technology in Health (PATH),
Washington, DC, USA
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Cappello JM, Gunasekera A, Gunasekera D, Esfandiari J, Ippolito T. A multicenter performance evaluation of the DPP® HIV-1/2 assay for the detection of HIV antibodies in various HIV testing algorithms. J Clin Virol 2013; 58 Suppl 1:e59-64. [DOI: 10.1016/j.jcv.2013.08.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2013] [Revised: 08/15/2013] [Accepted: 08/26/2013] [Indexed: 11/15/2022]
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False positive HIV diagnoses in resource limited settings: operational lessons learned for HIV programmes. PLoS One 2013; 8:e59906. [PMID: 23527284 PMCID: PMC3603939 DOI: 10.1371/journal.pone.0059906] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 02/19/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Access to HIV diagnosis is life-saving; however the use of rapid diagnostic tests in combination is vulnerable to wrongly diagnosing HIV infection when both screening tests give a false positive result. Misclassification of HIV patients can also occur due to poor quality control, administrative errors and lack of supervision and training of staff. Médecins Sans Frontières discovered in 2004 that HIV negative individuals were enrolled in some HIV programmes. This paper describes the result of an audit of three sites to review testing practices, implement improved testing algorithms and offer re-testing to clients enrolled in the HIV clinic. FINDINGS In the Democratic Republic of Congo (DRC), Burundi and Ethiopia patients were identified for HIV retesting. In total, 44 false-positive patients were identified in HIV programmes in DRC, two in Burundi and seven in Ethiopia. Some of those identified had been abandoned by partners or started on anti-retroviral therapy or prophylaxis. Despite potential damage to programme reputations, no impact in terms of testing uptake occurred with mean monthly testing volumes stable after introduction of re-testing. In order to prevent the problem, training, supervision and quality control of testing procedures were strengthened. A simple and feasible confirmation test was added to the test algorithm. Prevalence of false positives after introducing the changes varied from zero percent (95% CI 0%-8.2%) to 10.3 percent (95% CI: 7.2%-14.1%) in Burundi and DRC respectively. CONCLUSION False HIV diagnoses were found in a variety of programme settings and had devastating individual consequences. We re-tested individuals in our programmes while instituting improved testing procedures without a negative impact on test uptake. Considering the importance of correct diagnosis to the individual, as well as the resources needed to care for someone with HIV, it is critical to ensure that all patients registered in HIV programmes are accurately diagnosed.
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Dionne-Odom J, Karita E, Kilembe W, Henderson F, Vwalika B, Bayingana R, Li Z, Mulenga J, Chomba E, Del Rio C, Khu NH, Tichacek A, Allen S. Syphilis treatment response among HIV-discordant couples in Zambia and Rwanda. Clin Infect Dis 2013; 56:1829-37. [PMID: 23487377 DOI: 10.1093/cid/cit146] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Syphilis continues to be a common sexually transmitted infection, despite the availability of inexpensive and effective treatment. Infection in human immunodeficiency virus (HIV)-discordant couples is important because syphilis increases the risk of HIV acquisition. Current US treatment guidelines recommend 1 dose of benzathine penicillin for early syphilis, irrespective of HIV status, but data from coinfected patients are limited. METHODS Retrospective analysis of 1321 individuals in 2 African HIV-discordant couple cohorts was performed. Cox proportional hazards analysis and multivariable modeling were used to assess predictors of serologic response to treatment at 180 days and 400 days. Modeling was performed for all episodes of positive rapid plasma reagin (RPR) test results and on a subset with higher RPR titers (≥1:4). RESULTS A total of 1810 episodes of syphilis among 1321 individuals were treated with penicillin between 2002 and 2008. Although a positive RPR was more common in the HIV-infected partners, HIV infection did not impact the likelihood of serologic response to therapy (odds ratio [OR], 1.001; P = .995). By 400 days, 67% had responded to therapy, 27% were serofast, and 6.5% had documented reinfection. Prevalent infections were more likely to remain serofast than incident infections (33% vs 20% at 400 days). CONCLUSIONS In 2 HIV-serodiscordant couple cohorts in Africa, incident syphilis had a very good likelihood of response to penicillin therapy, irrespective of HIV infection. This supports current Centers for Disease Control and Prevention treatment guidelines. A high proportion of prevalent RPR-positive infections remain serofast despite treatment.
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Affiliation(s)
- Jodie Dionne-Odom
- Geisel School of Medicine at Dartmouth, Dartmouth Hitchcock Medical Center, Lebanon, NH 03756, USA.
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Basu D, Kraft CS, Murphy MK, Campbell PJ, Yu T, Hraber PT, Irene C, Pinter A, Chomba E, Mulenga J, Kilembe W, Allen SA, Derdeyn CA, Hunter E. HIV-1 subtype C superinfected individuals mount low autologous neutralizing antibody responses prior to intrasubtype superinfection. Retrovirology 2012; 9:76. [PMID: 22995123 PMCID: PMC3477039 DOI: 10.1186/1742-4690-9-76] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 09/03/2012] [Indexed: 11/23/2022] Open
Abstract
Background The potential role of antibodies in protection against intra-subtype HIV-1 superinfection remains to be understood. We compared the early neutralizing antibody (NAb) responses in three individuals, who were superinfected within one year of primary infection, to ten matched non-superinfected controls from a Zambian cohort of subtype C transmission cases. Sequence analysis of single genome amplified full-length envs from a previous study showed limited diversification in the individuals who became superinfected with the same HIV-1 subtype within year one post-seroconversion. We hypothesized that this reflected a blunted NAb response, which may have made these individuals more susceptible to superinfection. Results Neutralization assays showed that autologous plasma NAb responses to the earliest, and in some cases transmitted/founder, virus were delayed and had low to undetectable titers in all three superinfected individuals prior to superinfection. In contrast, NAbs with a median IC50 titer of 1896 were detected as early as three months post-seroconversion in non-superinfected controls. Early plasma NAbs in all subjects showed limited but variable levels of heterologous neutralization breadth. Superinfected individuals also exhibited a trend toward lower levels of gp120- and V1V2-specific IgG binding antibodies but higher gp120-specific plasma IgA binding antibodies. Conclusions These data suggest that the lack of development of IgG antibodies, as reflected in autologous NAbs as well as gp120 and V1V2 binding antibodies to the primary infection virus, combined with potentially competing, non-protective IgA antibodies, may increase susceptibility to superinfection in the context of settings where a single HIV-1 subtype predominates.
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Affiliation(s)
- Debby Basu
- Immunology and Molecular Pathogenesis Graduate Program, Emory University, Atlanta, GA, USA
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Kilembe W, Keeling M, Karita E, Lakhi S, Chetty P, Price MA, Makkan H, Latka M, Likoti M, Ilukui K, Hurlston M, Allen S, Stevens G, Hunter E. Failure of a novel, rapid antigen and antibody combination test to detect antigen-positive HIV infection in African adults with early HIV infection. PLoS One 2012; 7:e37154. [PMID: 22715363 PMCID: PMC3371037 DOI: 10.1371/journal.pone.0037154] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Accepted: 04/15/2012] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Acute HIV infection (prior to antibody seroconversion) represents a high-risk window for HIV transmission. Development of a test to detect acute infection at the point-of-care is urgent. METHODS Volunteers enrolled in a prospective study of HIV incidence in four African cities, Kigali in Rwanda and Ndola, Kitwe and Lusaka in Zambia, were tested regularly for HIV by rapid antibody test and p24 antigen ELISA. Five subgroups of samples were also tested by the Determine Ag/Ab Combo test 1) Antigen positive, antibody negative (acute infection); 2) Antigen positive, antibody positive; 3) Antigen negative, antibody positive; 4) Antigen negative, antibody negative; and 5) Antigen false positive, antibody negative (HIV uninfected). A sixth group included serial dilutions from a p24 antigen-positive control sample. Combo test results were reported as antigen positive, antibody positive, or both. RESULTS Of 34 group 1 samples with VL between 5x105 and >1.5x107 copies/mL (median 3.5x106), 1 (2.9%) was detected by the Combo antigen component, 7 (20.6%) others were positive by the Combo antibody component. No group 2 samples were antigen positive by the Combo test (0/18). Sensitivity of the Combo antigen test was therefore 1.9% (1/52, 95% CI 0.0, 9.9). One false positive Combo antibody result (1/30, 3.3%) was observed in group 4. No false-positive Combo antigen results were observed. The Combo antigen test was positive in group 6 at concentrations of 80 pg/mL, faintly positive at 40 and 20 pg/mL, and negative thereafter. The p24 ELISA antigen test remained positive at 5 pg/mL. CONCLUSIONS Although the antibody component of the Combo test detected antibodies to HIV earlier than the comparison antibody tests used, less than 2% of the cases of antigen-positive HIV infection were detected by the Combo antigen component. The development of a rapid point-of-care test to diagnose acute HIV infection remains an urgent goal.
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Affiliation(s)
- William Kilembe
- Rwanda Zambia HIV Research Group, Kigali, Rwanda, and Lusaka, Kitwe and Ndola, Zambia
- Emory University, Atlanta, Georgia, United States of America
- * E-mail: (WK); (MK)
| | - Michelle Keeling
- Emory University, Atlanta, Georgia, United States of America
- * E-mail: (WK); (MK)
| | - Etienne Karita
- Rwanda Zambia HIV Research Group, Kigali, Rwanda, and Lusaka, Kitwe and Ndola, Zambia
- Emory University, Atlanta, Georgia, United States of America
| | - Shabir Lakhi
- Rwanda Zambia HIV Research Group, Kigali, Rwanda, and Lusaka, Kitwe and Ndola, Zambia
- Emory University, Atlanta, Georgia, United States of America
| | - Paramesh Chetty
- International AIDS Vaccine Initiative, New York, New York, United States of America
| | - Matt A. Price
- International AIDS Vaccine Initiative, New York, New York, United States of America
| | - Heeran Makkan
- Aurum Institute for Health Research, Johannesburg, Republic of South Africa
| | - Mary Latka
- Aurum Institute for Health Research, Johannesburg, Republic of South Africa
| | - Morongwe Likoti
- Aurum Institute for Health Research, Johannesburg, Republic of South Africa
| | - Kenneth Ilukui
- Rwanda Zambia HIV Research Group, Kigali, Rwanda, and Lusaka, Kitwe and Ndola, Zambia
- Emory University, Atlanta, Georgia, United States of America
| | - Mackenzie Hurlston
- Rwanda Zambia HIV Research Group, Kigali, Rwanda, and Lusaka, Kitwe and Ndola, Zambia
- Emory University, Atlanta, Georgia, United States of America
| | - Susan Allen
- Rwanda Zambia HIV Research Group, Kigali, Rwanda, and Lusaka, Kitwe and Ndola, Zambia
- Emory University, Atlanta, Georgia, United States of America
| | - Gwynn Stevens
- International AIDS Vaccine Initiative, New York, New York, United States of America
| | - Eric Hunter
- Rwanda Zambia HIV Research Group, Kigali, Rwanda, and Lusaka, Kitwe and Ndola, Zambia
- Emory University, Atlanta, Georgia, United States of America
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Kraft CS, Basu D, Hawkins PA, Hraber PT, Chomba E, Mulenga J, Kilembe W, Khu NH, Derdeyn CA, Allen SA, Manigart O, Hunter E. Timing and source of subtype-C HIV-1 superinfection in the newly infected partner of Zambian couples with disparate viruses. Retrovirology 2012; 9:22. [PMID: 22433432 PMCID: PMC3349552 DOI: 10.1186/1742-4690-9-22] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Accepted: 03/20/2012] [Indexed: 02/07/2023] Open
Abstract
Background HIV-1 superinfection occurs at varying frequencies in different at risk populations. Though seroincidence is decreased, in the negative partner of HIV-discordant couples after joint testing and counseling in the Zambia Emory HIV Research Project (ZEHRP) cohort, the annual infection rate remains relatively high at 7-8%. Based on sequencing within the gp41 region of each partner's virus, 24% of new infections between 2004 and 2008 were the result of transmission from a non-spousal partner. Since these seroconvertors and their spouses have disparate epidemiologically-unlinked viruses, there is a risk of superinfection within the marriage. We have, therefore, investigated the incidence and viral origin of superinfection in these couples. Results Superinfection was detected by heteroduplex mobility assay (HMA), degenerate base counting of the gp41 sequence, or by phylogenetic analysis of the longitudinal sequences. It was confirmed by full-length env single genome amplification and phylogenetic analysis. In 22 couples (44 individuals), followed for up to five years, three of the newly infected (initially HIV uninfected) partners became superinfected. In each case superinfection occurred during the first 12 months following initial infection of the negative partner, and in each case the superinfecting virus was derived from a non-spousal partner. In addition, one probable case of intra-couple HIV-1 superinfection was observed in a chronically infected partner at the time of his seroconverting spouse's initial viremia. Extensive recombination within the env gene was observed following superinfection. Conclusions In this subtype-C discordant couple cohort, superinfection, during the first year after HIV-1 infection of the previously negative partner, occurred at a rate similar to primary infection (13.6% [95% CI 5.2-34.8] vs 7.8% [7.1-8.6]). While limited intra-couple superinfection may in part reflect continued condom usage within couples, this and our lack of detecting newly superinfected individuals after one year of primary infection raise the possibility that immunological resistance to intra-subtype superinfection may develop over time in subtype C infected individuals.
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Affiliation(s)
- Colleen S Kraft
- Emory Vaccine Center at Yerkes National Primate Research Center, Emory University, Atlanta, GA, USA
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Prevalence of seroconversion symptoms and relationship to set-point viral load: findings from a subtype C epidemic, 1995-2009. AIDS 2012; 26:175-84. [PMID: 22089380 DOI: 10.1097/qad.0b013e32834ed8c8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To describe symptoms, physical examination findings, and set-point viral load associated with acute HIV seroconversion in a heterosexual cohort of HIV-discordant couples in Zambia. DESIGN We followed HIV serodiscordant couples in Lusaka, Zambia from 1995 to 2009 with HIV testing of negative partners and symptom inventories 3 monthly, and physical examinations annually. METHODS We compared prevalence of self-reported or treated symptoms (malaria syndrome, chronic diarrhea, asthenia, night sweats, and oral candidiasis) and annual physical examination findings (unilateral or bilateral neck, axillary, or inguinal adenopathy; and dermatosis) in seroconverting vs. HIV-negative or HIV-positive intervals, controlling for repeated observations, age, and sex. A composite score comprised of significant symptoms and physical examination findings predictive of seroconversion vs. HIV-negative intervals was constructed. We modeled the relationship between number of symptoms and physical examination findings at seroconversion and log set-point viral load using linear regression. RESULTS Two thousand, three hundred and eighty-eight HIV-negative partners were followed for a median of 18 months; 429 seroconversions occurred. Neither symptoms nor physical examination findings were reported for most seroconverters. Seroconversion was significantly associated with malaria syndrome among nondiarrheic patients [adjusted odds ratio (aOR) = 4.0], night sweats (aOR = 1.4), and bilateral axillary (aOR = 1.6), inguinal (aOR = 2.2), and neck (aOR = 2.2) adenopathy relative to HIV-negative intervals. Median number of symptoms and findings was positively associated with set-point viral load (P < 0.001). CONCLUSION Although most acute and early infections were asymptomatic, malaria syndrome was more common and more severe during seroconversion. When present, symptoms and physical examination findings were nonspecific and associated with higher set-point viremia.
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Wall K, Karita E, Nizam A, Bekan B, Sardar G, Casanova D, Joseph Davey D, De Clercq F, Kestelyn E, Bayingana R, Tichacek A, Allen S. Influence network effectiveness in promoting couples' HIV voluntary counseling and testing in Kigali, Rwanda. AIDS 2012; 26:217-27. [PMID: 22008653 PMCID: PMC3679893 DOI: 10.1097/qad.0b013e32834dc593] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify predictors of promotion of couples' HIV voluntary counseling and testing (CVCT) in Kigali, Rwanda. DESIGN Analysis of CVCT promotional agent [influential network leaders (INLs), influential network agents (INAs)], and couple/invitation-level predictors of CVCT uptake. METHODS Number of invitations and couples tested were evaluated by INL, INA, and couple/contextual factors. Multivariable logistic regression accounting for two-level clustering analyzed factors predictive of couples' testing. RESULTS Twenty-six INLs recruited and mentored 118 INAs who delivered 24 991 invitations. 4513 couples sought CVCT services after invitation. INAs distributed an average of 212 invitations resulting in an average of 38 couples tested/agent. Characteristics predictive of CVCT in multivariate analyses included the invitee and INA being socially acquainted [adjusted odds ratio (aOR) = 1.4; 95% confidence interval (CI) 1.2-1.6]; invitations delivered after public endorsement (aOR = 1.3; 95% CI 1.1-1.5); and presence of a mobile testing unit (aOR = 1.4; 95% CI 1.0-2.0). In stratified analyses, predictors significant among cohabiting couples included invitation delivery to the couple (aOR = 1.2; 95% CI 1.0-1.4) and in the home (aOR = 1.3; 95% CI 1.1-1.4), whereas among noncohabiting couples, predictors included invitations given by unemployed INAs (aOR = 1.7; 95% CI 1.1-2.7). Cohabiting couples with older men were more likely to test, whereas younger age was associated with testing among men in noncohabiting unions. CONCLUSIONS Invitations distributed by influential people were successful in prompting couples to seek joint HIV testing, particularly if the invitation was given in the home to someone known to the INA and accompanied by a public endorsement of CVCT. Mobile units also increased the number of couples tested. Country-specific strategies to promote CVCT programs are needed to reduce HIV transmission among those at highest risk for HIV in sub-Saharan Africa.
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Affiliation(s)
- Kristin Wall
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia 30322, USA.
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Wall KM, Kilembe W, Nizam A, Vwalika C, Kautzman M, Chomba E, Tichacek A, Sardar G, Casanova D, Henderson F, Mulenga J, Kleinbaum D, Allen S. Promotion of couples' voluntary HIV counselling and testing in Lusaka, Zambia by influence network leaders and agents. BMJ Open 2012; 2:bmjopen-2012-001171. [PMID: 22956641 PMCID: PMC3467632 DOI: 10.1136/bmjopen-2012-001171] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Hypothesising that couples' voluntary counselling and testing (CVCT) promotions can increase CVCT uptake, this study identified predictors of successful CVCT promotion in Lusaka, Zambia. DESIGN Cohort study. SETTING Lusaka, Zambia. PARTICIPANTS 68 influential network leaders (INLs) identified 320 agents (INAs) who delivered 29 119 CVCT invitations to heterosexual couples. INTERVENTION The CVCT promotional model used INLs who identified INAs, who in turn conducted community-based promotion and distribution of CVCT invitations in two neighbourhoods over 18 months, with a mobile unit in one neighbourhood crossing over to the other mid-way through. PRIMARY OUTCOME The primary outcome of interest was couple testing (yes/no) after receipt of a CVCT invitation. INA, couple and invitation characteristics predictive of couples' testing were evaluated accounting for two-level clustering. RESULTS INAs delivered invitations resulting in 1727 couples testing (6% success rate). In multivariate analyses, INA characteristics significantly predictive of CVCT uptake included promoting in community-based (adjusted OR (aOR)=1.3; 95% CI 1.0 to 1.8) or health (aOR=1.5; 95% CI 1.2 to 2.0) networks versus private networks; being employed in the sales/service industry (aOR=1.5; 95% CI 1.0 to 2.1) versus unskilled manual labour; owning a home (aOR=0.7; 95% CI 0.6 to 0.9) versus not; and having tested for HIV with a partner (aOR=1.4; 95% CI 1.1 to 1.7) or alone (aOR=1.3; 95% CI 1.0 to 1.6) versus never having tested. Cohabiting couples were more likely to test (aOR=1.4; 95% CI 1.2 to 1.6) than non-cohabiting couples. Context characteristics predictive of CVCT uptake included inviting couples (aOR=1.2; 95% CI 1.0 to 1.4) versus individuals; the woman (aOR=1.6; 95% CI 1.2 to 2.2) or couple (aOR=1.4; 95% CI 1.0 to 1.8) initiating contact versus the INA; the couple being socially acquainted with the INA (aOR=1.6; 95% CI 1.4 to 1.9) versus having just met; home invitation delivery (aOR=1.3; 95% CI 1.1 to 1.5) versus elsewhere; and easy invitation delivery (aOR=1.8; 95% CI 1.4 to 2.2) versus difficult as reported by the INA. CONCLUSIONS This study demonstrated the ability of influential people to promote CVCT and identified agent, couple and context-level factors associated with CVCT uptake in Lusaka, Zambia. We encourage the development of CVCT promotions in other sub-Saharan African countries to support sustained CVCT dissemination.
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Affiliation(s)
- Kristin M Wall
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - William Kilembe
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Zambia Emory HIV Research Project, Lusaka, Zambia
| | - Azhar Nizam
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Cheswa Vwalika
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Zambia Emory HIV Research Project, Lusaka, Zambia
| | - Michelle Kautzman
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Zambia Emory HIV Research Project, Lusaka, Zambia
| | - Elwyn Chomba
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Zambia Emory HIV Research Project, Lusaka, Zambia
- University Teaching Hospital and University of Zambia School of Medicine, Lusaka, Zambia
| | - Amanda Tichacek
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Gurkiran Sardar
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Zambia Emory HIV Research Project, Lusaka, Zambia
- College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Deborah Casanova
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Zambia Emory HIV Research Project, Lusaka, Zambia
| | - Faith Henderson
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Zambia Emory HIV Research Project, Lusaka, Zambia
| | - Joseph Mulenga
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Zambia Emory HIV Research Project, Lusaka, Zambia
- Zambia National Blood Transfusion Services, Lusaka, Zambia
| | - David Kleinbaum
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Susan Allen
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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