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Kowalska JD, Wójcik G, Rutkowski J, Antonyak S, Siewaszewicz E. Rapid antiretroviral treatment start seems as vital and cost-effective strategy in Central and Eastern Europe. Przegl Epidemiol 2022; 76:304-313. [PMID: 36520041 DOI: 10.32394/pe.76.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND It is essential to deliver specialist human immunodeficiency virus (HIV) care with maximum effectiveness, but also minimum time delay. Therefore, we aimed to determine whether rapid linkage to care defined as starting combined antiretroviral therapy (cART) on the day of the first visit at the HIV clinic is a costeffective approach. METHODS In the analysis, Markov's lifetime model presented in our previous study was implemented. The inputs used in the model were updated in the terms of costs, life expectancy, and patient characteristics. For the analysis we used information from the previous model about the additional costs of treatment and qualityadjusted life years (QALYs) lost in the life horizon for people newly infected with HIV. The number of newly infected persons was estimated based on available data. RESULTS Input data was available for 344 men having sex with men (MSM) who registered in the HIV specialist care between 2016 and 2017. The estimated QALY loss due to lack of rapid treatment initiation, where the viral load is not (was) taken into account, equals 0·018 (0·022), 0·039 (0·047), 0·131 (0·158) respectively in low, medium and high risk transmission groups. Rapid cART initiation was dominant regardless of the chosen scenarios. CONCLUSIONS Cost-effectiveness analysis considering the HIV transmission indicates that the rapid initiation of HIV treatment is a cost-effective and potentially cost-saving approach to improve HIV care and reduce HIV transmission in Central and Eastern Europe.
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Affiliation(s)
- Justyna D Kowalska
- Department of Adults' Infectious Diseases, Medical University of Warsaw, Warsaw, Poland
- HIV Out-Patients Clinic, Hospital for Infectious Diseases in Warsaw, Warsaw, Poland
| | | | | | - Svitlana Antonyak
- HIV Department of Clinic of the Gromashevsky Institute of Epidemiology and Infectious Diseases, Kiev, Ukraine
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Silhol R, Boily MC, Dimitrov D, German D, Flynn C, Farley JE, Gelman M, Hughes JP, Donnell D, Adeyeye A, Remien RH, Beyrer C, Paz-Bailey G, Wejnert C, Mitchell KM. Understanding the HIV Epidemic Among MSM in Baltimore: A Modeling Study Estimating the Impact of Past HIV Interventions and Who Acquired and Contributed to Infections. J Acquir Immune Defic Syndr 2020; 84:253-62. [PMID: 32141958 DOI: 10.1097/QAI.0000000000002340] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Supplemental Digital Content is Available in the Text. Men who have sex with men (MSM) in the United States are disproportionately affected by HIV. We estimated the impact of past interventions and contribution of different population groups to incident MSM HIV infections.
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3
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McAllister S, van Asten H, Anglemyer A, Crengle S, Zeng J, Raymond N, Handy R, Giola M, Dickson N, Priest P. Cascade of care of people diagnosed with HIV in New Zealand between 2006 and 2017. HIV Med 2020; 22:122-130. [PMID: 33107188 DOI: 10.1111/hiv.12983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 08/24/2020] [Accepted: 09/17/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We estimated the proportion of people reported with HIV in New Zealand between 2006 and 2017, and alive in 2017-2019, who were on antiretroviral therapy (ART) and had a suppressed viral load (VL), and explored their associated characteristics. METHODS Data were anonymously linked to information on ART and VL within the data collection period (January 2017 to August 2019) using the National Health Index (NHI), Ministry of Health and laboratory datasets, as well as information from clinical specialists. Logistic regression was used to test for associations. Sensitivity analyses were undertaken to estimate the range for the key proportions. RESULTS Overall, 2355 people were reported with HIV, of whom 116 (5%) had died, 337 (14%) were overseas, and 1701 (72%) were alive in New Zealand; for the remaining 201 (9%) the outcome was unknown. Clinical data were available for 1490 people (87.6%): 1408 (94.5%) were on ART, 11 (< 1%) were not on ART, and for 71 (4.8%) this was unknown. Of those on ART, 1156 (82.1%) had a suppressed VL (< 200 copies/mL), 34 (2.4%) were unsuppressed, and for 218 (15.5%) this was unknown. The estimate of the proportion on ART ranged from 99% to 78%, and those with a suppressed VL ranged from 98% to 78%. CONCLUSIONS Among people with HIV in New Zealand who are under care, a high proportion were on ART and had suppressed VL. Increasing collection of NHIs and better linkage with laboratory information will reduce the number with unknown information and provide more complete VL results in the future.
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Affiliation(s)
- S McAllister
- AIDS Epidemiology Group, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - H van Asten
- AIDS Epidemiology Group, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - A Anglemyer
- AIDS Epidemiology Group, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - S Crengle
- Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - J Zeng
- Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - N Raymond
- Capital and Coast District Health Board, Wellington, New Zealand
| | - R Handy
- Auckland District Health Board, Auckland, New Zealand
| | - M Giola
- Bay of Plenty and Lakes District Health Board, Tauranga and Rotorua, New Zealand
| | - N Dickson
- AIDS Epidemiology Group, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - P Priest
- AIDS Epidemiology Group, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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4
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Croxford S, Tavoschi L, Sullivan AK, Combs L, Raben D, Delpech V, Jakobsen SF, Amato‐Gauci AJ, Desai S. HIV testing strategies outside of health care settings in the European Union (EU)/European Economic Area (EEA): a systematic review to inform European Centre for Disease Prevention and Control guidance. HIV Med 2020; 21:142-162. [PMID: 31682060 PMCID: PMC7065225 DOI: 10.1111/hiv.12807] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 09/05/2019] [Accepted: 09/16/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVES In recent years, new technologies and new approaches to scale up HIV testing have emerged. The objective of this paper was to synthesize the body of recent evidence on strategies aimed at increasing the uptake and coverage of HIV testing outside of health care settings in the European Union (EU)/European Economic Area (EEA). METHODS Systematic searches to identify studies describing effective HIV testing interventions and barriers to testing were run in five databases (2010-2017) with no language restrictions; the grey literature was searched for similar unpublished studies (2014-2017). Study selection, data extraction and critical appraisal were performed by two independent reviewers following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Eighty studies on HIV testing in non-health care settings were identified, the majority set in Northern Europe. Testing was implemented in 65 studies, with men who have sex with men the risk group most often targeted. Testing coverage and positivity/reactivity rates varied widely by setting and population group. However, testing in community and outreach settings was effective at reaching people who had never previously been tested and acceptability of HIV testing, particularly rapid testing, outside of health care settings was found to be high. Other interventions aimed to increase HIV testing identified were: campaigns (n = 8), communication technologies (n = 2), education (n = 3) and community networking (n = 1). CONCLUSIONS This review has identified several strategies with potential to achieve high HIV testing coverage outside of health care settings. However, the geographical spread of studies was limited, and few intervention studies reported before and after data, making it difficult to evaluate the impact of interventions on test coverage.
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Affiliation(s)
- S Croxford
- National Infection ServicePublic Health EnglandLondonUK
| | - L Tavoschi
- European Centre for Disease Prevention and ControlStockholmSweden
- University of PisaPisaItaly
| | - AK Sullivan
- National Infection ServicePublic Health EnglandLondonUK
- Directorate of HIV and Sexual HealthChelsea and Westminster Hospital NHS Foundation TrustLondonUK
| | - L Combs
- CHIPRigshospitalet ‐ University of CopenhagenCopenhagenDenmark
| | - D Raben
- CHIPRigshospitalet ‐ University of CopenhagenCopenhagenDenmark
| | - V Delpech
- National Infection ServicePublic Health EnglandLondonUK
| | - SF Jakobsen
- CHIPRigshospitalet ‐ University of CopenhagenCopenhagenDenmark
| | - AJ Amato‐Gauci
- European Centre for Disease Prevention and ControlStockholmSweden
| | - S Desai
- National Infection ServicePublic Health EnglandLondonUK
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5
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Kostaki EG, Frampton D, Paraskevis D, Pantavou K, Ferns B, Raffle J, Grant P, Kozlakidis Z, Hadjikou A, Pavlitina E, Williams LD, Hatzakis A, Friedman SR, Nastouli E, Nikolopoulos GK. Near Full-length Genomic Sequencing and Molecular Analysis of HIV-Infected Individuals in a Network-based Intervention (TRIP) in Athens, Greece: Evidence that Transmissions Occur More Frequently from those with High HIV-RNA. Curr HIV Res 2019; 16:345-353. [PMID: 30706819 PMCID: PMC6446520 DOI: 10.2174/1570162x17666190130120757] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 01/21/2019] [Accepted: 01/27/2019] [Indexed: 11/25/2022]
Abstract
Background: TRIP (Transmission Reduction Intervention Project) was a network-based, contact tracing approach to locate and link to care, mostly people who inject drugs (PWID) with recent HIV infection. Objective: We investigated whether sequences from HIV-infected participants with high viral load cluster together more frequently than what is expected by chance. Methods: Paired end reads were generated for 104 samples using Illumina MiSeq next-generation se-quencing. Results: 63 sequences belonged to previously identified local transmission networks of PWID (LTNs) of an HIV outbreak in Athens, Greece. For two HIV-RNA cut-offs (105 and 106 IU/mL), HIV transmissions were more likely between PWID with similar levels of HIV-RNA (p<0.001). 10 of the 14 sequences (71.4%) from PWID with HIV-RNA >106 IU/mL were clustered in 5 pairs. For 4 of these clusters (80%), there was in each one of them at least one sequence from a recently HIV-infected PWID. Conclusion: We showed that transmissions are more likely among PWID with high viremia.
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Affiliation(s)
- Evangelia-Georgia Kostaki
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Daniel Frampton
- Department of Infection and Immunity, UCL, London, United Kingdom
| | - Dimitrios Paraskevis
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Bridget Ferns
- NIHR Biomedical Research Centre, UCLH/UCL, London, United Kingdom
| | - Jade Raffle
- Department of Infection and Immunity, UCL, London, United Kingdom
| | - Paul Grant
- Department of Clinical Virology, UCLH, London, United Kingdom
| | - Zisis Kozlakidis
- Division of Infection and Immunity, Faculty of Medical Sciences, UCL and Farr Institute of Health Informatics Research, London, United Kingdom
| | - Andria Hadjikou
- Medical School, University of Cyprus, Nicosia, Cyprus.,European University Cyprus, Nicosia, Cyprus
| | - Eirini Pavlitina
- Transmission Reduction Intervention Project, Athens site, Athens, Greece
| | - Leslie D Williams
- National Development and Research Institutes, New York, United States
| | - Angelos Hatzakis
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Samuel R Friedman
- National Development and Research Institutes, New York, United States
| | - Eleni Nastouli
- NIHR Biomedical Research Centre, UCLH/UCL, London, United Kingdom.,Department of Population, Policy and Practice, UCL GOS Institute of Child Health, London, United Kingdom
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Teira R, Espinosa N, Gutiérrez MM, Montero M, Martínez E, González F, Lozano de León F, Téllez F, Galindo MJ, Peraire J, Deig E, Muñoz-Sánchez P; para el Grupo de estudio VACH. Losses to follow-up of HIV-infected people in the Spanish VACH cohort over the period between 2013 and 2014: The importance of sociodemographic factors. Enferm Infecc Microbiol Clin 2019; 37:361-6. [PMID: 30514587 DOI: 10.1016/j.eimc.2018.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 08/23/2018] [Accepted: 09/08/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To determine the proportion of people infected by HIV or AIDS under follow-up in the VACH Cohort in 2012 who were lost to follow-up from 2013 to 2014, and to establish the sociodemographic features relating to this loss. METHODS We considered subjects with less than one recorded consultation per year studied to be lost to follow-up. We built logistic regression models to calculate the odds ratios (OR) and their 95% confidence intervals (95% CI), of the variables relating to loss to follow-up. RESULTS The overall percentage of losses to follow-up was 15.5% (95% CI 14.9-16-1). The variables associated with loss to follow up were: not receiving antiretroviral treatment (ART) (OR: 1.948, 95% CI: 1.651 -2.298), being an immigrant (OR: 1.746; 95%CI: 1.494-2.040), intravenous drug consumption being the mechanism for HIV transmission (OR: 1.498, 95% CI: 1.312-1.711), being unemployed (OR: 1.331; 95% CI: 1.179-1.503), being without a partner (OR: 1.948, 95% CI: 1.651-1.298), belonging to a low socioeconomic class (OR: 1.279; 95% CI: 1.143-1.431), and being attended in a hospital with fewer than 1000 patients under follow-up (OR: 1.257, 95% CI: 1.121-1.457), as well as being under age and having spent less time under follow-up in the Cohort. CONCLUSIONS 15.5% of the patients were lost to follow-up over a period of 2years in the VACH Cohort. This was associated with a series of sociodemographic and epidemiological variables that it might be useful to identify to design initiatives targeting the populations most likely to abandon the circuits of care, and guide strategies towards achieving Objective 90-90-90.
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7
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Hibbert M, Crenna-Jennings W, Kirwan P, Benton L, Lut I, Okala S, Asboe D, Jeffries J, Kunda C, Mbewe R, Morris S, Morton J, Nelson M, Thorley L, Paterson H, Ross M, Reeves I, Sharp L, Sseruma W, Valiotis G, Wolton A, Jamal Z, Hudson A, Delpech V. The people living with HIV stigma survey UK 2015: HIV-related sexual rejection and other experiences of stigma and discrimination among gay and heterosexual men. AIDS Care 2018; 30:1189-1196. [PMID: 29806466 DOI: 10.1080/09540121.2018.1479027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
We aim to understand the difference in stigma and discrimination, in particular sexual rejection, experienced between gay and heterosexual men living with HIV in the UK. The People Living with HIV StigmaSurvey UK 2015 recruited a convenience sample of persons with HIV through over 120 cross sector community organisations and 46 HIV clinics to complete an online survey. 1162 men completed the survey, 969 (83%) gay men and 193 (17%) heterosexual men, 92% were on antiretroviral therapy. Compared to heterosexual men, gay men were significantly more likely to report worrying about workplace treatment in relation to their HIV (21% vs. 11%), worrying about HIV-related sexual rejection (42% vs 21%), avoiding sex because of their HIV status (37% vs. 23%), and experiencing HIV-related sexual rejection (27% vs. 9%) in the past 12 months. In a multivariate logistic regression controlling for other sociodemographic factors, being gay was a predictor of reporting HIV-related sexual rejection in the past 12 months (aOR 2.17, CI 1.16, 4.02). Both gay and heterosexual men living with HIV experienced stigma and discrimination in the past 12 months, and this was higher for gay men in terms of HIV-related sexual rejection. Due to the high proportion of men reporting sexual rejection, greater awareness and education of the low risk of transmission of HIV among people on effective treatment is needed to reduce stigma and sexual prejudice towards people living with HIV.
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Affiliation(s)
- M Hibbert
- a HIV & STI Department, Public Health England , London , UK
| | | | - P Kirwan
- a HIV & STI Department, Public Health England , London , UK
| | | | - I Lut
- b StigmaIndexUK , London , UK
| | - S Okala
- a HIV & STI Department, Public Health England , London , UK.,b StigmaIndexUK , London , UK
| | - D Asboe
- c British HIV Association , London , UK.,d Positively UK , London , UK
| | - J Jeffries
- a HIV & STI Department, Public Health England , London , UK
| | - C Kunda
- b StigmaIndexUK , London , UK
| | - R Mbewe
- b StigmaIndexUK , London , UK.,d Positively UK , London , UK
| | | | - J Morton
- b StigmaIndexUK , London , UK.,e Terrence Higgins Trust , London , UK
| | - M Nelson
- f Chelsea & Westminster Hospital , London , UK
| | | | | | - M Ross
- c British HIV Association , London , UK.,h CliniQ , London , UK
| | - I Reeves
- i Homerton University Hospital , London , UK
| | - L Sharp
- g University of Glasgow , Glasgow , UK
| | - W Sseruma
- b StigmaIndexUK , London , UK.,j NAZ, London , London , UK
| | - G Valiotis
- b StigmaIndexUK , London , UK.,k HIV Scotland , Edinburgh , UK
| | - A Wolton
- b StigmaIndexUK , London , UK.,f Chelsea & Westminster Hospital , London , UK.,h CliniQ , London , UK
| | | | | | - V Delpech
- a HIV & STI Department, Public Health England , London , UK
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8
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Lin A, Ong KJ, Hobbelen P, King E, Mesher D, Edmunds WJ, Sonnenberg P, Gilson R, Bains I, Choi YH, Tanton C, Soldan K, Jit M. Impact and Cost-effectiveness of Selective Human Papillomavirus Vaccination of Men Who Have Sex With Men. Clin Infect Dis 2017; 64:580-588. [PMID: 28011615 PMCID: PMC5404831 DOI: 10.1093/cid/ciw845] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 12/14/2016] [Indexed: 02/01/2023] Open
Abstract
Background. Men who have sex with men (MSM) have a high lifetime risk of anogenital warts and cancers related to infection with human papillomavirus (HPV). They also benefit less from herd protection than heterosexual males in settings with female-only HPV vaccination. Methods. We evaluated the potential health impact and cost-effectiveness of offering vaccination to MSM who visit genitourinary medicine (GUM) clinics. We used a mathematical model of HPV 6/11/16/18 sexual transmission within an MSM population in England, parameterized with sexual behaviour, GUM attendance, HPV prevalence, HIV prevalence, warts, and cancer incidence data. Interventions considered were offering HPV vaccination to either HIV-positive MSM or MSM regardless of HIV status, for age bands 16–25, 16–30, 16–35, and 16–40 years. Results. Substantial declines in anogenital warts and male HPV-related cancer incidence are projected to occur following an offer of vaccination to MSM. MSM not attending GUM clinics will partially benefit from herd protection. Offering vaccination to HIV-positive MSM up to age 40 is likely to be cost-effective if vaccine procurement and administration costs are below £96.50 a dose. At £48 a dose, offering vaccination to all MSM up to age 40 is likely to be cost-effective. Conclusions. Quadrivalent HPV vaccination of MSM via GUM clinics is likely to be an effective and cost-effective way of reducing the burden of HPV-related disease in MSM.
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Affiliation(s)
- Allen Lin
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.,Department of Systems Biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Koh J Ong
- National Infections Service-Colindale, Public Health England, London, UK
| | - Peter Hobbelen
- National Infections Service-Colindale, Public Health England, London, UK
| | - Eleanor King
- Research Department of Infection and Population Health, University College London, London, UK
| | - David Mesher
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.,National Infections Service-Colindale, Public Health England, London, UK
| | - W John Edmunds
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Pam Sonnenberg
- Research Department of Infection and Population Health, University College London, London, UK
| | - Richard Gilson
- Research Department of Infection and Population Health, University College London, London, UK
| | - Irenjeet Bains
- National Infections Service-Colindale, Public Health England, London, UK
| | - Yoon H Choi
- National Infections Service-Colindale, Public Health England, London, UK
| | - Clare Tanton
- Research Department of Infection and Population Health, University College London, London, UK
| | - Kate Soldan
- National Infections Service-Colindale, Public Health England, London, UK
| | - Mark Jit
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.,National Infections Service-Colindale, Public Health England, London, UK
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9
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Nachega JB, Adetokunboh O, Uthman OA, Knowlton AW, Altice FL, Schechter M, Galárraga O, Geng E, Peltzer K, Chang LW, Van Cutsem G, Jaffar SS, Ford N, Mellins CA, Remien RH, Mills EJ. Community-Based Interventions to Improve and Sustain Antiretroviral Therapy Adherence, Retention in HIV Care and Clinical Outcomes in Low- and Middle-Income Countries for Achieving the UNAIDS 90-90-90 Targets. Curr HIV/AIDS Rep 2017; 13:241-55. [PMID: 27475643 DOI: 10.1007/s11904-016-0325-9] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Little is known about the effect of community versus health facility-based interventions to improve and sustain antiretroviral therapy (ART) adherence, virologic suppression, and retention in care among HIV-infected individuals in low- and middle-income countries (LMICs). We systematically searched four electronic databases for all available randomized controlled trials (RCTs) and comparative cohort studies in LMICs comparing community versus health facility-based interventions. Relative risks (RRs) for pre-defined adherence, treatment engagement (linkage and retention in care), and relevant clinical outcomes were pooled using random effect models. Eleven cohort studies and eleven RCTs (N = 97,657) were included. Meta-analysis of the included RCTs comparing community- versus health facility-based interventions found comparable outcomes in terms of ART adherence (RR = 1.02, 95 % CI 0.99 to 1.04), virologic suppression (RR = 1.00, 95 % CI 0.98 to 1.03), and all-cause mortality (RR = 0.93, 95 % CI 0.73 to 1.18). The result of pooled analysis from the RCTs (RR = 1.03, 95 % CI 1.01 to 1.06) and cohort studies (RR = 1.09, 95 % CI 1.03 to 1.15) found that participants assigned to community-based interventions had statistically significantly higher rates of treatment engagement. Two studies found community-based ART delivery model either cost-saving or cost-effective. Community- versus facility-based models of ART delivery resulted in at least comparable outcomes for clinically stable HIV-infected patients on treatment in LMICs and are likely to be cost-effective.
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Affiliation(s)
- Jean B Nachega
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA.
- Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa.
- Johns Hopkins University, Baltimore, MD, USA.
| | - Olatunji Adetokunboh
- Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - Olalekan A Uthman
- Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
- Warwick Medical School, The University of Warwick, Coventry, UK
| | | | | | | | - Omar Galárraga
- Brown University School of Public Health, Providence, RI, USA
| | - Elvin Geng
- University of California, San Francisco, CA, USA
| | - Karl Peltzer
- Mahidol University, Salaya, Thailand
- University of Limpopo, Polokwane, South Africa
- Human Sciences Research Council, Pretoria, South Africa
| | | | | | | | - Nathan Ford
- World Health Organization, Geneva, Switzerland
| | - Claude A Mellins
- HIV Center for Clinical and Behavioral Studies, Columbia University, New York, NY, USA
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Abstract
Human immunodeficiency virus (HIV) infection continues to disproportionately affect vulnerable populations in Canada; particularly men who have sex with men (MSM). Novel HIV prevention strategies have recently expanded from the use of non-occupational post-exposure prophylaxis (nPEP) after high risk exposures to the use of pre-exposure prophylaxis (PrEP) in which individuals reduce risk of HIV infection through use of combination antiretrovirals taken prior to risk exposure. With approval of tenofovir/emtricitabine (TDF/FTC) for use as PrEP only in early 2016, and with limited public funding to date, uptake in Canada is in its preliminary stages. These biomedical prevention strategies have proven efficacy for MSM, and they may have potential for other at-risk populations. With generic formulations of TDF/FTC now available in Canada, there is an opportunity for widespread implementation. Expanding knowledge of health care providers across Canada on how best to assess, refer for or prescribe and monitor PrEP will contribute to the current efforts to reach the global goal of eliminating new HIV infections.
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11
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Stirratt MJ, Marks G, O'Daniels C, Cachay ER, Sullivan M, Mugavero MJ, Dhanireddy S, Rodriguez AE, Giordano TP. Characterising HIV transmission risk among US patients with HIV in care: a cross-sectional study of sexual risk behaviour among individuals with viral load above 1500 copies/mL. Sex Transm Infect 2017; 94:206-211. [PMID: 29097417 DOI: 10.1136/sextrans-2017-053178] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 09/20/2017] [Accepted: 10/08/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Viral load and sexual risk behaviour contribute to HIV transmission risk. High HIV viral loads present greater transmission risk than transient viral 'blips' above an undetectable level. This paper therefore characterises sexual risk behaviour among patients with HIV in care with viral loads>1500 copies/mL and associated demographic characteristics. METHODS This cross-sectional study was conducted at six HIV outpatient clinics in USA. The study sample comprises 1315 patients with HIV with a recent viral load >1500 copies/mL. This study sample was drawn from a larger sample of individuals with a recent viral load >1000 copies/mL who completed a computer-assisted self-interview (CASI) regarding sexual risk practices in the last 2 months. The study sample was 32% heterosexual men, 38% men who have sex with men (MSM) and 30% women. RESULTS Ninety per cent of the sample had their viral load assay within 60 days of the CASI. Thirty-seven per cent reported being sexually active (vaginal or anal intercourse) in the last 2 months. Most of the sexually active participants reported always using condoms (56.9%) or limiting condomless sex to seroconcordant partners (serosorting; 29.2% overall and 42.9% among MSM). Among sexually active participants who reported condomless anal or vaginal sex with an at-risk partner (14%), most had viral loads>10 000 copies/mL (62%). CONCLUSIONS A relatively small number of patients with HIV in care with viral loads above 1500 copies/mL reported concurrent sexual transmission risk behaviours. Most of the individuals in this small group had markedly elevated viral loads, increasing the probability of transmission. Directing interventions to patients in care with high viral loads and concurrent risk behaviour could strengthen HIV prevention and reduce HIV infections. TRIAL REGISTRATION NUMBER NCT02044484, completed.
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Affiliation(s)
- Michael J Stirratt
- Division of AIDS Research, National Institute of Mental Health, Bethesda, Maryland, USA
| | - Gary Marks
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Christine O'Daniels
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,Carter Consulting, Inc, Atlanta, Georgia, USA
| | - Edward R Cachay
- Division of Infectious Diseases, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Meg Sullivan
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Michael J Mugavero
- Division of Infectious Diseases, Department of Medicine, University of Alabama, Birmingham, Alabama, USA
| | | | - Allan E Rodriguez
- Division of Infectious Diseases, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Thomas P Giordano
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.,Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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Cambiano V, Miners A, Dunn D, McCormack S, Ong KJ, Gill ON, Nardone A, Desai M, Field N, Hart G, Delpech V, Cairns G, Rodger A, Phillips AN. Cost-effectiveness of pre-exposure prophylaxis for HIV prevention in men who have sex with men in the UK: a modelling study and health economic evaluation. Lancet Infect Dis 2017; 18:85-94. [PMID: 29054789 DOI: 10.1016/s1473-3099(17)30540-6] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 08/01/2017] [Accepted: 08/29/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND In the UK, HIV incidence among men who have sex with men (MSM) has remained high for several years, despite widespread use of antiretroviral therapy and high rates of virological suppression. Pre-exposure prophylaxis (PrEP) has been shown to be highly effective in preventing further infections in MSM, but its cost-effectiveness is uncertain. METHODS In this modelling study and economic evaluation, we calibrated a dynamic, individual-based stochastic model, the HIV Synthesis Model, to multiple data sources (surveillance data provided by Public Health England and data from a large, nationally representative survey, Natsal-3) on HIV among MSM in the UK. We did a probabilistic sensitivity analysis (sampling 22 key parameters) along with a range of univariate sensitivity analyses to evaluate the introduction of a PrEP programme with sexual event-based use of emtricitabine and tenofovir for MSM who had condomless anal sexual intercourse in the previous 3 months, a negative HIV test at baseline, and a negative HIV test in the preceding year. The main model outcomes were the number of HIV infections, quality-adjusted life-years (QALYs), and costs. FINDINGS Introduction of such a PrEP programme, with around 4000 MSM initiated on PrEP by the end of the first year and almost 40 000 by the end of the 15th year, would result in a total cost saving (£1·0 billion discounted), avert 25% of HIV infections (42% of which would be directly because of PrEP), and lead to a gain of 40 000 discounted QALYs over an 80-year time horizon. This result was particularly sensitive to the time horizon chosen, the cost of antiretroviral drugs (for treatment and PrEP), and the underlying trend in condomless sex. INTERPRETATION This analysis suggests that the introduction of a PrEP programme for MSM in the UK is cost-effective and possibly cost-saving in the long term. A reduction in the cost of antiretroviral drugs (including the drugs used for PrEP) would substantially shorten the time for cost savings to be realised. FUNDING National Institute for Health Research.
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Affiliation(s)
| | - Alec Miners
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - David Dunn
- MRC Clinical Trials Unit at UCL, London, UK
| | | | - Koh Jun Ong
- HIV and STI Department, Public Health England, London, UK
| | - O Noel Gill
- HIV and STI Department, Public Health England, London, UK
| | | | - Monica Desai
- HIV and STI Department, Public Health England, London, UK
| | - Nigel Field
- Institute for Global Health, University College London, London, UK
| | - Graham Hart
- Faculty of Population Health Sciences, University College London, London, UK
| | | | | | - Alison Rodger
- Institute for Global Health, University College London, London, UK
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13
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Miltz A, Phillips AN, Speakman A, Cambiano V, Rodger A, Lampe FC. Implications for a policy of initiating antiretroviral therapy in people diagnosed with human immunodeficiency virus: the CAPRA research programme. Programme Grants Appl Res 2017. [DOI: 10.3310/pgfar05180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BackgroundMore than 100,000 people in the UK are living with a human immunodeficiency virus (HIV) infection. There are currently estimated to be around 4000 people newly infected in the UK per year, mostly men who have sex with men (MSM). It has become increasingly clear that antiretroviral therapy (ART) used to treat people infected with HIV also has a profound effect on infectivity. At the initiation of the programme, it was the policy in the UK to initiate ART in people when their cluster of differentiation 4 (CD4) count was approaching 350/µl.ObjectivesTo assess what would be the effectiveness and cost-effectiveness of a policy of immediate initiation of ART at diagnosis among MSM, taking into account the potential reductions in new infections.DesignWe calibrated an individual-based model of HIV transmission, progression and the effect of ART in MSM, informed by a series of studies on sexual behaviour in relation to ART use and the transmission risk in people with viral suppression on ART, and by surveillance data collected by Public Health England.Setting, participants and interventionsThe series of studies used to inform the model included (1) the Antiretrovirals, Sexual Transmission Risk and Attitudes (ASTRA) study, a cross-sectional self-administered questionnaire study of people diagnosed with HIV attending eight HIV outpatient clinics in the UK (2011–12); (2) the Cognitive Impairment in People with HIV in the European Region (CIPHER) study, a study of levels of neurocognitive impairment in HIV-positive ASTRA participants and people from HIV clinics in Rome, Copenhagen and Minsk; (3) the Attitudes to, and Understanding of, Risk of Acquisition of HIV (AURAH) study, a cross-sectional self-administered questionnaire study of individuals who have not been diagnosed as HIV-positive attending 20 genitourinary medicine clinics across the UK (2013–14); (4) a substudy of sexual behaviour among individuals enrolled in an open-label multicentre international randomised trial (from 2013) of immediate versus deferred ART (to CD4 cell counts of 350/µl) in people with CD4 cell counts of > 500/µl [the Strategic Timing of Antiretroviral Therapy (START) trial]; and (5) Partners of People on ART: a new Evaluation of the Risks (PARTNER), an observational multicentre longitudinal study of HIV serodifferent heterosexual and MSM couples, in which the HIV-positive partner is on ART (2010–14).Main outcome measuresThe main outcome measures were the clinical effectiveness and cost-effectiveness of a policy of immediate initiation of ART at diagnosis.ResultsBased on data from studies (i)–(v), we estimated from our modelling work that increases in condomless sex (CLS) among MSM as a whole may explain the increase in HIV infection incidence in MSM epidemics over a time when ART coverage and viral suppression increased, demonstrating the limiting effects of non-condom use on the HIV epidemic among MSM. Accordingly, an increase in the overall proportion of MSM living with HIV who are virally suppressed on ART from the current level of < 60% to 90% without increases in CLS was required to achieve a reduction in the incidence of HIV among MSM to < 1 per 1000 person-years. The incremental cost-effectiveness ratio associated with the fourfold increase in levels of HIV testing and ART at diagnosis required to provide this increase from < 60% to 90% was £20,000 if we assumed continuation of current ART prices. However, this value falls to £3500 if we assume that ART prices will fall to 20% of their current cost as a result of the introduction of generic drugs. Therefore, our evaluation suggests that ART initiation at diagnosis is likely to be highly cost-effective in MSM at a population level, particularly accounting for future lower ART costs as generic drugs are used. The impact will be much greater if levels of HIV testing can be enhanced.LimitationsIt was necessary to make some assumptions beyond the available data in order to extrapolate cost-effectiveness through modelling.ConclusionsOur findings suggest that ART initiation at diagnosis is likely to be cost-effective in MSM. Of note, after this programme of work was completed, results from the main START trial demonstrated benefit in ART initiation even in people with CD4 cell counts of > 500/µl, supporting ART initiation in people diagnosed with a HIV infection.Future workThere is a need for future research into the means of increasing the frequency with which MSM test for HIV.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- Ada Miltz
- Research Department of Infection and Population Health, University College London, London, UK
| | - Andrew N Phillips
- Research Department of Infection and Population Health, University College London, London, UK
| | - Andrew Speakman
- Research Department of Infection and Population Health, University College London, London, UK
| | - Valentina Cambiano
- Research Department of Infection and Population Health, University College London, London, UK
| | - Alison Rodger
- Research Department of Infection and Population Health, University College London, London, UK
| | - Fiona C Lampe
- Research Department of Infection and Population Health, University College London, London, UK
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14
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Nakagawa F; Writing Group on HIV Epidemiologic Estimates in Countries With Migrant Populations From High Prevalence Areas. An epidemiological modelling study to estimate the composition of HIV-positive populations including migrants from endemic settings. AIDS 2017; 31:417-25. [PMID: 27831947 DOI: 10.1097/QAD.0000000000001329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Migrants account for a significant number of people living with HIV in Europe, and it is important to fully consider this population in national estimates. Using a novel approach with the UK as an example, we present key public health measures of the HIV epidemic, taking into account both in-country infections and infections likely to have been acquired abroad. DESIGN Mathematical model calibrated to extensive data sources. METHODS An individual-based stochastic simulation model is used to calibrate to routinely collected surveillance data in the UK. Data on number of new HIV diagnoses, number of deaths, CD4 cell count at diagnosis, as well as time of arrival into the UK for migrants and the annual number of people receiving care were used. RESULTS An estimated 106 400 (90% plausibility range: 88 700-124 600) people were living with HIV in the UK in 2013. Twenty-three percent of these people, 24 600 (15 000-36 200) were estimated to be undiagnosed; this number has remained stable over the last decade. An estimated 32% of the total undiagnosed population had CD4 cell count less than 350 cells/μl in 2013. Twenty-five and 23% of black African men and women heterosexuals living with HIV were undiagnosed respectively. CONCLUSION We have shown a working example to characterize the HIV population in a European context which incorporates migrants from countries with generalized epidemics. Despite all aspects of HIV care being free and widely available to anyone in need in the UK, there is still a substantial number of people who are not yet diagnosed and thus not in care.
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15
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Affiliation(s)
- Reuben Granich
- 1 International Association of Providers of AIDS Care, Washington, DC, USA
| | - José M Zuniga
- 1 International Association of Providers of AIDS Care, Washington, DC, USA
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16
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Gökengin D, Doroudi F, Tohme J, Collins B, Madani N. HIV/AIDS: trends in the Middle East and North Africa region. Int J Infect Dis 2016; 44:66-73. [PMID: 26948920 DOI: 10.1016/j.ijid.2015.11.008] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 11/08/2015] [Accepted: 11/09/2015] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To give an overview of the HIV epidemic in the Middle East and North Africa (MENA) region. METHODS Articles on the MENA region were reviewed. RESULTS The MENA region comprises a geographically defined group of countries including both high-income, well-developed nations and low- and middle-income countries. While the annual number of new HIV infections in Sub-Saharan Africa has declined by 33% since 2005, new HIV infections in the MENA region have increased by 31% since 2001, which is the highest increase among all regions in the world. Moreover, the number of AIDS-related deaths in 2013 was estimated to be 15000, representing a 66% increase since 2005. However, the current prevalence of 0.1% is still among the lowest rates globally. There is substantial heterogeneity in HIV epidemic dynamics across MENA, and different risk contexts are present throughout the region. Despite unfavorable conditions, many countries in the region have put significant effort into scaling up their response to this growing epidemic, while in others the response to HIV is proving slower due to denial, stigma, and reluctance to address sensitive issues. CONCLUSIONS The HIV epidemic in the MENA region is still at a controllable level, and this opportunity should not be missed.
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Affiliation(s)
- Deniz Gökengin
- Department of Clinical Microbiology and Infectious Diseases, Medical Faculty, Ege University, Bornova, Izmir, Turkey.
| | - Fardad Doroudi
- UNAIDS - The Joint United Nations Programme on HIV/AIDS (UNAIDS), Islamic Republic of Iran.
| | - Johnny Tohme
- M-Coalition, Yazbeck Center, Achrafieh, Beirut, Lebanon.
| | | | - Navid Madani
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.
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17
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Lampe FC. Sexual behaviour among people with HIV according to self-reported antiretroviral treatment and viral load status. AIDS 2016; 30:1745-59. [PMID: 27045375 PMCID: PMC4933581 DOI: 10.1097/qad.0000000000001104] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 03/13/2016] [Accepted: 03/14/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To assess, among people with HIV, the association of self-reported antiretroviral treatment (ART) and viral load status with condomless sex with an HIV-serodifferent partner (CLS-D). DESIGN Cross-sectional study of 3258 HIV-diagnosed adults in the United Kingdom, 2011-2012. METHODS CLS-D in the past 3 months and self-reported ART/viral load were ascertained by questionnaire. Clinic-recorded viral load was documented. HIV-transmission risk sex (CLS-D-HIV-risk) was defined as CLS-D together with either not on ART or clinic-recorded viral load more than 50 copies/ml. RESULTS Of 3178 participants diagnosed more than 3 months ago, 2746 (87.9%) were on ART, of whom self-reported viral load was '50 copies/ml/ or less/undetectable' for 78.4%; 'more than 50 copies/ml/detectable' for 8.3%; 'do not know/missing' for 13.3%. CLS-D prevalence was 14.9% (326/2189), 6.4% (23/360) and 10.7% (67/629) among men who have sex with men, heterosexual men and women, respectively. Among men who have sex with men, CLS-D prevalence was 18.8% among those not on ART; 15.2% among those on ART with undetectable self-reported viral load; 9.8% among those on ART without undetectable self-reported viral load. Compared with 'on ART with undetectable self-reported viral load', prevalence ratios (95% confidence interval) adjusted for demographic/HIV-related factors were: 0.66 (0.45, 0.95) for 'on ART without undetectable self-reported viral load', and 1.08 (0.78, 1.49) for 'not on ART' (global P = 0.021). Among heterosexual men and women (combined), ART/self-reported viral load was not associated with CLS-D [corresponding adjusted prevalence ratios: 1.14 (0.73, 1.79) for 'on ART without undetectable self-reported viral load'; 0.88 (0.44, 1.77) for 'not on ART', P = 0.77]. CLS-D-HIV-risk prevalence was 3.2% among all participants; 16.1% for 'not on ART'; 0.6% for 'on ART with undetectable self-reported viral load; 4.2% for 'on ART without undetectable self-reported viral load.' CONCLUSION Use of ART was not associated with increased prevalence of CLS-D, and was associated with greatly reduced prevalence of HIV-transmission risk sex.
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Affiliation(s)
- Fiona C Lampe
- Research Department of Infection and Population Health, University College London, London, UK
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18
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Sewell J, Speakman A, Phillips AN, Cambiano V, Lampe FC, Gilson R, Asboe D, Nwokolo N, Clarke A, Ogilvy A, Collins S, Rodger AJ. Attitudes to and Understanding of Risk of Acquisition of HIV Over Time: Design and Methods for an Internet-based Prospective Cohort Study Among UK Men Who Have Sex With Men (the AURAH2 Study). JMIR Res Protoc 2016; 5:e128. [PMID: 27307218 PMCID: PMC4927873 DOI: 10.2196/resprot.5582] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 02/29/2016] [Accepted: 03/16/2016] [Indexed: 11/18/2022] Open
Abstract
Background The annual number of new human immunodeficiency virus (HIV) infections among men who have sex with men (MSM) has risen in the United Kingdom and, of those who are HIV positive, the proportion undiagnosed is high. Objective The prospective AURAH2 study aims to assess factors associated with HIV acquisition among MSM in the United Kingdom and to investigate changes over time within individuals in sexual behavior and HIV-testing practices. Methods AURAH2 is a prospective study among MSM without diagnosed HIV, aiming to recruit up to 1000 sexually active MSM attending sexual health clinics in London and Brighton in the United Kingdom. Participants complete an initial paper-based questionnaire, followed by online follow-up questionnaires every 4 months collecting sociodemographic, health and behavioral data, including sexual behavior, recreational and other drug use, HIV testing practices, and pre-exposure prophylaxis use, over a planned 3-year period. Results The study is ongoing. Conclusions The results from AURAH2 study will provide important insight into established and emerging risk behaviors that may be associated with acquisition of HIV in MSM in the United Kingdom, changes over time within individuals in sexual behavior, and information on HIV testing practices. These data will be crucial to inform future HIV prevention strategies.
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Affiliation(s)
- Janey Sewell
- Department of Infection and Population Health, UCL, London, United Kingdom.
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19
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Phillips AN, Cambiano V, Miners A, Lampe FC, Rodger A, Nakagawa F, Brown A, Gill ON, De Angelis D, Elford J, Hart G, Johnson AM, Lundgren JD, Collins S, Delpech V. Potential impact on HIV incidence of higher HIV testing rates and earlier antiretroviral therapy initiation in MSM. AIDS 2015; 29:1855-62. [PMID: 26372391 DOI: 10.1097/QAD.0000000000000767] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Increased rates of testing, with early antiretroviral therapy (ART) initiation, represent a key potential HIV-prevention approach. Currently, in MSM in the United Kingdom, it is estimated that 36% are diagnosed by 1 year from infection, and the ART initiation threshold is at CD4 cell count 350/μl. We investigated what would be required to reduce HIV incidence in MSM to below 1 per 1000 person-years (i.e. <535 new infections per year) by 2030, and whether this is likely to be cost-effective. METHODS A dynamic, individual-based simulation model was calibrated to multiple data sources on HIV in MSM in the United Kingdom. Outcomes were projected according to future alternative HIV testing and ART initiation scenarios to 2030, considering also potential changes in levels of condomless sex. RESULTS For ART use to result in an incidence of close to 1/1000 person-years requires the proportion of all HIV-positive MSM with viral suppression to increase from below 60% currently to 90%, assuming no rise in levels of condomless sex. Substantial increases in HIV testing, such that over 90% of men are diagnosed within a year of infection, would increase the proportion of HIV-positive men with viral suppression to 80%, and it would be 90%, if ART is initiated at diagnosis. The scenarios required for such a policy to be cost-effective are presented. CONCLUSION This analysis provides targets for the proportion of all HIV-positive MSM with viral suppression required to achieve substantial reductions in HIV incidence.
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Abstract
Uptake of antiretroviral regimens with associated durable virologic suppression has been shown to reduce the risk of HIV transmission. Expanding antiretroviral therapy (ART) programs at a population level may serve as a vital strategy in the elimination of the AIDS epidemic. The global expansion of ART programs has greatly improved access to life-saving therapies and is likely to achieve the target of 15 million individuals on therapy set by UNAIDS. In addition to the incontrovertible gains in terms of life expectancy, growing evidence demonstrates that durable virologic suppression is associated with significant reductions in HIV transmission amongst heterosexual couples and men who have sex with men. Expansion of successful ART programs, best monitored by a program-level continuum of care cascade to assess progress in diagnosis, retention in care, and virologic suppression, is associated with reductions in HIV incidence at a population level. Expanding and sustaining successful ART delivery at a global level is a key component in a comprehensive approach to combating the HIV epidemic over the next two decades.
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Affiliation(s)
- Mark Hull
- BC Centre for Excellence in HIV/AIDS, Room 667, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
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22
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Desai M, Gafos M, Dolling D, McCormack S, Nardone A. Healthcare providers' knowledge of, attitudes to and practice of pre-exposure prophylaxis for HIV infection. HIV Med 2015; 17:133-42. [PMID: 26172217 DOI: 10.1111/hiv.12285] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Pre-exposure prophylaxis (PrEP) has proven biological efficacy in reducing the risk of sexual acquisition of HIV. Healthcare providers' (HCPs) knowledge of and attitudes to PrEP will be key to successful implementation. In England, PrEP is only available to men who have sex with men (MSM) through the open-label randomized PROUD pilot study of immediate or deferred use. METHODS In September 2013, a cross-sectional survey of UK HCPs distributed through sexual health clinics (219) and professional societies' email lists (2599) and at a conference (80) asked about knowledge of, attitudes to and practice of PrEP. RESULTS Overall, 328 of 2898 (11%) completed the survey, of whom 160 of 328 (49%) were doctors, 51 (16%) sexual health advisers (SHAs), 44 (14%) nurses and 73 (22%) unspecified. Over a quarter (83 of 311; 27%) were involved in PROUD. Most respondents (260 of 326; 80%) rated their knowledge of PrEP as medium or high. Over half of respondents (166 of 307; 54%) thought PrEP should be available outside of a clinical trial. The main barriers to supporting PrEP availability outside a clinical trial were concerns about current evidence (odds ratio [OR] 0.13), lack of UK-specific guidance (OR 0.35), concerns about adherence (OR 0.38) and risk of sexual or physical coercion for patients to have condomless or higher risk sex (OR 0.42 in multivariate regression). Just over half (147 of 277; 53%) had been asked about PrEP by patients in the past year, including almost half of those working in a clinic not involved in the PROUD study (86 of 202; 43%). CONCLUSIONS There is support for PrEP availability outside a clinical trial, but HCPs have residual concerns about its effectiveness and negative consequences, and the absence of UK-specific implementation guidance.
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Affiliation(s)
- M Desai
- Clinical Trials Unit, Medical Research Council, London, UK.,HIV/STI Department, Public Health England, London, UK
| | - M Gafos
- Clinical Trials Unit, Medical Research Council, London, UK
| | - D Dolling
- Clinical Trials Unit, Medical Research Council, London, UK
| | - S McCormack
- Clinical Trials Unit, Medical Research Council, London, UK
| | - A Nardone
- HIV/STI Department, Public Health England, London, UK
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Abstract
Despite significant efforts, the rate of new HIV infections worldwide remains unacceptably high, highlighting the need for new HIV prevention strategies. HIV pre-exposure prophylaxis (PrEP) is a new approach that involves the ongoing use of antiretroviral medications by HIV-negative individuals to reduce the risk of HIV infection. The use of daily tenofovir/emtricitabine as oral PrEP was found to be effective in multiple placebo-controlled clinical trials and approved by the United States Food and Drug Administration. In addition, the Centers for Disease Control and Prevention in the United States and the World Health Organization have both released guidelines recommending the offer of oral PrEP to high-risk populations. The scale-up of PrEP is underway, but several implementation questions remain unanswered. Demonstration projects and open-label extensions of placebo-controlled trials are ongoing and hope to contribute to our understanding of PrEP use and delivery outside the randomized controlled trial setting. Evidence is beginning to emerge from these open-label studies and will be critical for guiding PrEP scale-up. Outside of such studies, PrEP uptake has been slow and several client- and provider-related barriers are limiting uptake. Maximizing the public health impact of PrEP will require rollout to be combined with interventions to promote uptake, support adherence, and prevent increases in risk behavior. Additional PrEP strategies are currently under investigation in placebo-controlled clinical trials and may be available in the future.
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Affiliation(s)
- James Wilton
- Canadian AIDS Treatment Information Exchange (CATIE), University of Toronto, Toronto, ON, Canada
| | - Heather Senn
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Malika Sharma
- Wilson Centre for Research in Education, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Darrell Hs Tan
- Division of Infectious Diseases, St Michael's Hospital, University of Toronto, Toronto, ON, Canada ; Department of Medicine, University of Toronto, Toronto, ON, Canada
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Horwood J, Ingle SM, Burton D, Woodman-Bailey A, Horner P, Jeal N. Sexual health risks, service use, and views of rapid point-of-care testing among men who have sex with men attending saunas: a cross-sectional survey. Int J STD AIDS 2015; 27:273-80. [PMID: 25907347 PMCID: PMC4933927 DOI: 10.1177/0956462415580504] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 03/13/2015] [Indexed: 11/30/2022]
Abstract
Guidelines highlight the need to increase HIV testing among men who have sex with men (MSM) and novel point-of-care testing provides new possibilities for delivery of care. However, it is unclear how point-of-care testing should be used to best effect. This study aimed to increase understanding of sexual risk-taking behaviour, service use, and attitudes to point-of-care testing among MSM sauna clients. Data were collected within two saunas for MSM in south west England using a self-completion survey (n = 134). Though this sample of MSM sauna clients are at high risk of acquiring a sexually transmitted infection, the testing frequency among the majority of those reporting unprotected anal intercourse is not in keeping with national guidelines. For almost all participants the introduction of rapid point-of-care testing for both genital and blood-borne infection was likely to increase testing and for the majority NHS specialist services was the preferred setting.
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Affiliation(s)
- Jeremy Horwood
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Suzanne M Ingle
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - David Burton
- University of Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Paddy Horner
- School of Social and Community Medicine, University of Bristol, Bristol, UK Bristol Sexual Health Service, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Nikki Jeal
- School of Social and Community Medicine, University of Bristol, Bristol, UK Bristol Sexual Health Service, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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25
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Stromdahl S, Hickson F, Pharris A, Sabido M, Baral S, Thorson A. A systematic review of evidence to inform HIV prevention interventions among men who have sex with men in Europe. ACTA ACUST UNITED AC 2015; 20. [PMID: 25953133 DOI: 10.2807/1560-7917.es2015.20.15.21096] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
An estimated 42% of all newly diagnosed HIV cases in Europe in 2013 were transmitted during sex between men. This review was performed to identify and describe studies evaluating the efficacy and effectiveness of HIV prevention interventions among men who have sex with men (MSM), in relation to implementation data from European settings. A systematic search was performed individually for 24 interventions.Data were extracted from studies including efficacy or implementation data from European settings,appraised for efficacy, implementation and plausibility, and assigned a grade (1-4) according to the Highest Attainable Standard of Evidence (HASTE)framework. Four interventions (condom use, peer outreach,peer-led groups, and using universal coverage of antiretroviral treatment and treatment as prevention)were assigned the highest HASTE grade, 1. Another four interventions were assigned 2a for probable recommendation, including voluntary counseling and testing for HIV, using condom-compatible lubricant,using post-exposure prophylaxis, and individual counselling for MSM living with HIV. In addition, seven interventions were assigned a grade of 2b, for possible recommendation. Encouragingly, 15 interventions were graded to be strongly, probably or possibly recommended.In the relatively resource-rich European setting, there is an opportunity to provide global leadership with regard to the regional scale-up of comprehensive HIV prevention interventions for MSM.
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Affiliation(s)
- S Stromdahl
- Department of Public Health Sciences, Karolinska Institutet, Sweden
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26
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O’Brien KK, Ibáñez-Carrasco F, Solomon P, Harding R, Cattaneo J, Chegwidden W, Gahagan J, Baxter L, Worthington C, Gayle P, Merritt B, Baltzer-Turje R, Iku N, Zack E. Advancing research and practice in HIV and rehabilitation: a framework of research priorities in HIV, disability and rehabilitation. BMC Infect Dis 2014; 14:724. [PMID: 25551619 PMCID: PMC4304172 DOI: 10.1186/s12879-014-0724-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 12/17/2014] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND HIV increasingly is experienced as a complex chronic illness where individuals are living longer with a range of physical, cognitive, mental and social health-related challenges associated with HIV, comorbidities and aging, a concept that may be termed 'disability'. Rehabilitation such as physical therapy and occupational therapy can help address disability and has the potential to improve quality of life in people living with HIV. Hence, the role for rehabilitation in the context of HIV, aging and comorbidities is emerging. Our aim was to establish a framework of research priorities in HIV, disability and rehabilitation. METHODS We convened people living with HIV, clinicians, researchers, service providers, representatives from community-based organizations and policy and funding stakeholders to participate in the first International Forum on HIV and Rehabilitation Research. We conducted a multi-stakeholder consultation to identify current and emerging issues in HIV, disability and rehabilitation. Data were collated and analyzed using content analytical techniques. RESULTS Ninety-two participants attended the Forum from Canada, United Kingdom (UK), Ireland and the United States. Situated within three overarching themes (episodic health and disability across the life course; rehabilitation; and methodological advances), the Framework of Research Priorities in HIV, Disability and Rehabilitation includes six research priorities: 1) episodic health and disability; 2) aging with HIV across the life course; 3) concurrent health conditions; 4) access to rehabilitation and models of rehabilitation service provision; 5) effectiveness of rehabilitation interventions; and 6) enhancing outcome measurement in HIV and rehabilitation research. The Framework includes methodological considerations and environmental and personal contextual factors (or lenses) through which to approach research in the field. Knowledge translation should be implemented throughout the development and application of research knowledge to inform HIV clinical practice, programming and policy. CONCLUSIONS These priorities highlight the emerging priorities of living long-term with HIV and outline a plan for HIV and rehabilitation research in resource-rich countries such as the UK and Canada.
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Affiliation(s)
- Kelly K O’Brien
- />Department of Physical Therapy, University of Toronto, 500 University Avenue, Room 160, Toronto, ON Canada
- />Institute of Health Policy, Management and Evaluation, University of Toronto, 4th Floor, 155 College Street, Toronto, ON Canada
- />School of Rehabilitation Science, McMaster University, 1400 Main Street West, Room 403, Hamilton, ON Canada
| | | | - Patricia Solomon
- />School of Rehabilitation Science, McMaster University, 1400 Main Street West, Room 403, Hamilton, ON Canada
| | - Richard Harding
- />Cicely Saunders Institute, School of Medicine, King’s College London, Bessemer Road, London, United Kingdom
| | - Jessica Cattaneo
- />AIDS Committee of Toronto, 399 Church Street, 4th Floor, Toronto, ON Canada
| | - William Chegwidden
- />Barts and the London NHS Trust, London, United Kingdom
- />University College Hospitals NHS Foundation Trust, London, United Kingdom
| | - Jacqueline Gahagan
- />School of Health and Human Performance, Dalhousie University, Stairs House, 6230 South Street, Halifax, NS Canada
| | - Larry Baxter
- />Canadian Working Group on HIV and Rehabilitation, 600 Bay Street, Suite 600, Toronto, ON Canada
| | - Catherine Worthington
- />School of Public Health and Social Policy, University of Victoria, Human and Social Development Building, 3800 Finnerty Road, Victoria, BC Canada
| | | | - Brenda Merritt
- />School of Occupational Therapy, Dalhousie University, Forrest Building, Room 215, 5869 University Avenue, Halifax, NS Canada
| | | | - Nkem Iku
- />Department of Physical Therapy, University of Toronto, 500 University Avenue, Room 160, Toronto, ON Canada
| | - Elisse Zack
- />Canadian Working Group on HIV and Rehabilitation, 600 Bay Street, Suite 600, Toronto, ON Canada
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27
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Hoffmann CJ, Gallant JE. Rationale and evidence for human immunodeficiency virus treatment as prevention at the individual and population levels. Infect Dis Clin North Am 2014; 28:549-61. [PMID: 25287588 DOI: 10.1016/j.idc.2014.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Individual health benefits of antiretroviral therapy (ART) are becoming clearer. In resource-rich countries, side effects of current ART regimens are minimal. US guidelines recommend ART regardless of CD4 count or viral load. Maintaining an undetectable viral load with ART comes close to eliminating the risk of HIV transmission, leading the US guidelines to recommend universal ART to reduce HIV transmission. Achieving population-level control through treatment as prevention (TasP) may be feasible, but requires considerable investment of resources devoted to HIV testing, linkage to care, ART accessibility, and retention in care. Ongoing studies of TasP will provide insight into achieving meaningful ART coverage.
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Affiliation(s)
- Christopher J Hoffmann
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, 725 North Wolfe Street, Room 226, Baltimore, MD 21205, USA
| | - Joel E Gallant
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, 725 North Wolfe Street, Room 226, Baltimore, MD 21205, USA; Department of Specialty Services, Southwest CARE Center, 649 Harkle Road, Suite E, Sante Fe, NM 87505, USA.
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28
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Ankiersztejn-Bartczak M, Firląg-Burkacka E, Czeszko-Paprocka H, Kubicka J, Cybula A, Horban A, Kowalska JD. Factors responsible for incomplete linkage to care after HIV diagnosis: preliminary results from the Test and Keep in Care (TAK) project. HIV Med 2014; 16:88-94. [PMID: 25123958 DOI: 10.1111/hiv.12175] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2014] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Linkage to care after HIV diagnosis remains underinvestigated in Europe, yet delays in linkage to care are an important obstacle to controlling the HIV epidemic. The Test and Keep in Care (TAK) project aims to determine the prevalence of HIV-positive persons who are lost or late to care and factors associated with this. METHODS Data from community-based voluntary counselling and testing that occurred in 2010-2011 were linked with data from HIV clinics using unique test numbers. Persons not registered in HIV clinics were considered lost to care (LTC). For statistical analysis, nonparametric tests were used for comparison, and a multivariable logistic regression model was developed that included all variables with P<0.1 from the univariable models. RESULTS A total of 110 persons were diagnosed as HIV-positive: 91% lived in central Poland, 5% were female and 71% were men who have sex with men (MSM). Forty-seven (42%) persons were LTC, seven of whom did not collect their enzyme-linked immunosorbent assay (ELISA) test result. Of those who registered, 75% registered within 1 month from HIV diagnosis, and 54% were late presenters. LTC individuals were more likely to have heterosexual or bisexual orientation, to have >20 sexual partners, to not be in a relationship with an HIV-positive partner, to not use condoms, and to be taking their first HIV test. In a logistic regression model, after adjusting for these factors, using condoms in a stable relationship decreased the odds of LTC by 72% (odds ratio 0.28; confidence interval 0.11-0.67). CONCLUSIONS Integration into care after HIV diagnosis requires improvement. Our results suggest that broadening awareness and counselling about sexual risks may have a positive impact.
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29
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Nachega JB, Uthman OA, del Rio C, Mugavero MJ, Rees H, Mills EJ. Addressing the Achilles' heel in the HIV care continuum for the success of a test-and-treat strategy to achieve an AIDS-free generation. Clin Infect Dis 2014; 59 Suppl 1:S21-7. [PMID: 24926028 PMCID: PMC4141496 DOI: 10.1093/cid/ciu299] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Mathematical models and recent data from ecological, observational, and experimental studies show that antiretroviral therapy (ART) is effective for both treatment and prevention of HIV, validating the treatment as prevention (TasP) approach. Data from a variety of settings, including resource-rich and -limited sites, show that patient attrition occurs at each stage of the human immunodeficiency virus (HIV) treatment cascade, starting with the percent unaware of their HIV infection in a population and linkage to care after diagnosis, assessment of ART readiness, receipt of ART, and finally long-term virologic suppression. Therefore, in order to implement TasP, we must first define practical and effective linkage to care, acceptability of treatment, and adherence and retention monitoring strategies, as well as the cost-effectiveness of such strategies. Ending this pandemic will require the combination of political will, resources, and novel effective interventions that are not only feasible and cost effective but also likely to be used in combination across successive steps on the HIV treatment cascade.
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Affiliation(s)
- Jean B. Nachega
- Department of Epidemiology, Infectious Diseases Epidemiology Research Program, Pittsburgh University Graduate School of Public Health, Pennsylvania
- Departments of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Medicine and Centre for Infectious Diseases, Stellenbosch University, Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - Olalekan A. Uthman
- Warwick-Centre for Applied Health Research and Delivery, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, United Kingdom
- Liverpool School of Tropical Medicine, International Health Group, United Kingdom
| | - Carlos del Rio
- Departments of Global Health and Medicine, Emory University, Atlanta, Georgia
| | - Michael J. Mugavero
- Department of Medicine and Division of Infectious Diseases, University of Alabama at Birmingham, Alabama
| | - Helen Rees
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Edward J. Mills
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Humanities and Sciences, California
- Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
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30
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Abstract
HIV infection in Western Europe is mainly concentrated among men who have sex with men, heterosexuals who acquired HIV from sub-Saharan African countries, and in people who inject drugs. The rate of newly diagnosed cases of HIV has remained roughly stable since 2004 whereas the number of people living with HIV has slowly increased due to new infections and the success of antiretroviral therapy in prolonging life. An ageing population is gradually emerging that will require additional care. There are large differences across countries in HIV testing rates, proportions of people who present to care with low CD4+ cell counts, accessibility to treatment and care, and rates of retention once in care. Improved collection of HIV surveillance data will benefit countries and help to understand their epidemic better. However, social inequalities experienced by people with HIV still remain in some regions and urgently need to be addressed.
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Affiliation(s)
- Fumiyo Nakagawa
- Research Department of Infection and Population Health, UCL Royal Free Campus, Rowland Hill Street, London, NW3 2PF UK
| | - Andrew N. Phillips
- Research Department of Infection and Population Health, UCL Royal Free Campus, Rowland Hill Street, London, NW3 2PF UK
| | - Jens D. Lundgren
- Copenhagen HIV Programme (CHIP), Department of Infectious Disease (8632), Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
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31
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Long EF, Mandalia R, Mandalia S, Alistar SS, Beck EJ, Brandeau ML. Expanded HIV testing in low-prevalence, high-income countries: a cost-effectiveness analysis for the United Kingdom. PLoS One 2014; 9:e95735. [PMID: 24763373 DOI: 10.1371/journal.pone.0095735] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 03/30/2014] [Indexed: 02/07/2023] Open
Abstract
Objective In many high-income countries with low HIV prevalence, significant numbers of persons living with HIV (PLHIV) remain undiagnosed. Identification of PLHIV via HIV testing offers timely access to lifesaving antiretroviral therapy (ART) and decreases HIV transmission. We estimated the effectiveness and cost-effectiveness of HIV testing in the United Kingdom (UK), where 25% of PLHIV are estimated to be undiagnosed. Design We developed a dynamic compartmental model to analyze strategies to expand HIV testing and treatment in the UK, with particular focus on men who have sex with men (MSM), people who inject drugs (PWID), and individuals from HIV-endemic countries. Methods We estimated HIV prevalence, incidence, quality-adjusted life years (QALYs), and health care costs over 10 years, and cost-effectiveness. Results Annual HIV testing of all adults could avert 5% of new infections, even with no behavior change following HIV diagnosis because of earlier ART initiation, or up to 18% if risky behavior is halved. This strategy costs £67,000–£106,000/QALY gained. Providing annual testing only to MSM, PWID, and people from HIV-endemic countries, and one-time testing for all other adults, prevents 4–15% of infections, requires one-fourth as many tests to diagnose each PLHIV, and costs £17,500/QALY gained. Augmenting this program with increased ART access could add 145,000 QALYs to the population over 10 years, at £26,800/QALY gained. Conclusions Annual HIV testing of key populations in the UK is very cost-effective. Additional one-time testing of all other adults could identify the majority of undiagnosed PLHIV. These findings are potentially relevant to other low-prevalence, high-income countries.
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Brown AE, Nardone A, Delpech VC. WHO 'Treatment as Prevention' guidelines are unlikely to decrease HIV transmission in the UK unless undiagnosed HIV infections are reduced. AIDS 2014; 28:281-3. [PMID: 24361685 DOI: 10.1097/QAD.0000000000000137] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The WHO guidelines recommend antiretroviral therapy (ART) begins when CD4 cell counts reach less than 500 cells to reduce HIV transmission. In the UK, 96 000 people were living with HIV (PLWHIV) in 2011, ART coverage was 84% among the diagnosed population and 42% of PLWHIV had detectable viraemia. Using published methods, we estimate starting ART at below 500 CD4 cells could have reduced the proportion of PLWHIV with detectable viraemia from 42% to 38%, whereas halving the undiagnosed population could have led to a decrease to 28%. In the UK, it is unlikely early treatment will reduce HIV transmission unless the undiagnosed population is substantially reduced.
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33
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Affiliation(s)
- Helen Clark
- United Nations Development Programme, New York, NY 10017, USA.
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34
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Cambiano V, O'Connor J, Phillips AN, Rodger A, Lodwick R, Pharris A, Lampe F, Nakagawa F, Smith C, van de Laar MJ. Antiretroviral therapy for prevention of HIV transmission: implications for Europe. ACTA ACUST UNITED AC 2013; 18:20647. [PMID: 24308982 DOI: 10.2807/1560-7917.es2013.18.48.20647] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The aim of this review is to summarise the evidence on the population-level effect of antiretroviral therapy (ART) in preventing HIV infections, and to discuss potential implications in the European context of recommending starting ART when the CD4 count is above 350 cells/mm3. The ability of ART to reduce the risk of HIV transmission has been reported in observational studies and in a randomised controlled trial (HPTN 052), in which ART initiation reduced HIV transmission by 96% within serodiscordant couples. As yet, there is no direct evidence for such an effect among men having sex with men or people who inject drugs. HPTN 052 led international organisations to develop recommendations with a higher CD4 threshold for ART initiation. However, there remains a lack of strong evidence of clinical benefit for HIV-positive individuals starting ART with CD4 count above 350 cells/mm3. The main goal of ART provision should be to increase ART coverage for all those in need, based on the current guidelines, and the offer of ART to those who wish to reduce infectivity; increased HIV testing is therefore a key requirement. Other proven prevention means such as condom use and harm reduction for people who inject drugs remain critical.
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Affiliation(s)
- V Cambiano
- Research Department of Infection and Population Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
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35
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Affiliation(s)
- Anthony Nardone
- HIV and STI Department, Centre for Disease Surveillance and Control, Health Protection Directorate, London NW9 5EQ, UK.
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