Improved HIV case finding among key populations after differentiated data driven community testing approaches in Zambia

Taking the Big Leap | understanding, accessing and improving behavioural science interventions

Applied behaviour science's focus on individual-level behaviours has led to overestimation of and reliance on biases and heuristics in understanding behaviour and behaviour change. Behaviour-change interventions experience difficulties such as effect sizes, validity, scale-up, and long-term sustainability. One such area where we need to re-examine underlying assumptions for behavioural interventions in Human Immunodeficiency Virus (HIV) and Tuberculosis (TB) prevention, which seek population-level benefits and sustained, measurable impact. This requires taking a "Big Leap." In our view, taking the big leap refers to using a behavioural science-informed approach to overcome the chasms due to misaligned assumptions, tunnel focus, and overweighting immediate benefits, which can limit the effectiveness and efficiency of public health programmes and interventions. Crossing these chasms means that decision-makers should develop a system of interventions, promote end-user agency, build choice infrastructure, embrace heterogeneity, recognise social and temporal dynamics, and champion sustainability. Taking the big leap toward a more holistic approach means that policymakers, programme planners, and funding bodies should "Ask" pertinent questions to evaluate interventions to ensure they are well informed and designed.

Barriers to Accessing Antiretroviral Treatment Among Key Populations in Southwest Nigeria

Background In Nigeria, similar to most of sub-Saharan Africa, the fight against HIV/AIDS is hampered by various barriers. Particularly, key populations (KP) face unique challenges in accessing antiretroviral therapy (ART), attributed to health systems, patient-related, and community-related factors. This study aims to explore these barriers among KP in Nigeria, enhancing understanding to improve ART access and outcomes, thereby contributing to global efforts to end the HIV/AIDS epidemic. Objectives The objective of this study is to explore barriers to accessing ART services among KP living with HIV in the southwest region of Nigeria. Materials and methods This descriptive cross-sectional study, which was carried out in the southwestern Nigerian states of Ondo and Ogun, involved 4,253 KP attending ART clinics. Using a multistage sampling technique, 219 females and 154 males between the ages of 17 and 72 were chosen. Semi-structured survey questions were used to get information to elicit these barriers. SPSS Statistics (version 29.0; IBM Corp., Armonk, NY) was used for quantitative data analysis. Results Specifically, 48.3% of respondents were men, and 58.7% were women; 54.0% were female sexual workers, and the next highest percentages were men who have sex with men (27.0%) and injectable drug users (19.3%); and 79% (51.0% agreed, 28.0% strongly agreed) concurred that the barriers to accessing ART are transportation, distance, and financial challenges. Patients at ART clinics were generally satisfied with the healthcare and health workers' attitude. Measures to protect privacy and confidentiality were considered crucial by the respondents. There are significant associations between ART accessibility and socio-demographic and socio-economic characteristics (p-value <0.05). Conclusion This study probed the complex landscape of barriers to ART access faced by KP in Nigeria, underscoring the critical need for tailored, innovative strategies to overcome these obstacles and offering actionable insights for stakeholders to enhance ART adherence and access thereby significantly improving the quality of life for people living with HIV.

Initial implementation of HIV pre-exposure prophylaxis for people who are incarcerated in Zambia: a cross-sectional observational study

BACKGROUND

There are over 23 000 incarcerated people in Zambia, a population which has higher HIV prevalence than the general population yet has no access to HIV prevention. To evaluate the feasibility of HIV pre-exposure prophylaxis (PrEP) implementation in Zambian criminal justice facilities, we offered PrEP services to incarcerated people and aimed to describe early implementation outcomes.

METHODS

In this cross-sectional observational study, we implemented a PrEP programme between Oct 1, 2020, and March 31, 2021, supporting 16 criminal justice facilities in four Zambian provinces. Before implementation, we held stakeholder engagement meetings with Zambia Correctional Service officials to discuss PrEP benefits, and trained Zambia Correctional Service health-care workers in PrEP management using the national PrEP training package. People who were incarcerated and screened positive for substantial HIV risk by use of a standardised HIV risk assessment tool were offered voluntary HIV testing and counselling. Those who tested positive were linked to antiretroviral therapy, and those who tested negative and met national HIV prevention eligibility criteria were offered PrEP. We assessed PrEP uptake and used descriptive statistics to characterise programme beneficiaries and the cascade of PrEP services.

FINDINGS

During the study period, we reached 12 367 people older than 15 years with HIV risk assessment and counselling, including 11 794 (95·4%) men and 573 (4·6%) women. Of these, 2610 people received HIV testing, with 357 (13·7%) testing HIV positive; positivity was significantly higher in women (20·6%) than men (13·2%, p=0·011). 1276 people were identified as HIV negative and PrEP eligible. Of these, 1190 (93·3%) initiated PrEP. The age group with the highest proportion reached and initiated on PrEP was those aged 25-29 years, representing 19·2% (2377 of 12 367) of all people reached and 24·1% (287 of 1190) of those who initiated PrEP.

INTERPRETATION

Delivery of PrEP to people who are incarcerated is feasible with adequate resourcing and support to the criminal justice health system, and can result in high uptake among eligible individuals. Further assessment is needed of PrEP persistence and adherence, and the perceptions of people who are incarcerated regarding their HIV risk and preferences for combination HIV prevention services.

FUNDING

US President's Emergency Plan for AIDS Relief through the US Centers for Disease Control and Prevention.