1
|
Nakyanzi A, Naddunga F, Bulterys MA, Mujugira A, Wyatt MA, Kamusiime B, Nalumansi A, Kasiita V, Peacock S, Celum CL, Ware NC. " It Soothes Your Heart": A Multimethod Study Exploring Acceptability of Point-of-Care Viral Load Testing among Ugandan Pregnant and Postpartum Women Living with HIV. Diagnostics (Basel) 2023; 14:72. [PMID: 38201381 PMCID: PMC10795616 DOI: 10.3390/diagnostics14010072] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/16/2023] [Accepted: 11/24/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND High adherence to antiretroviral therapy (ART) is critical for achieving viral suppression and preventing onward HIV transmission. ART continuation can be challenging for pregnant women living with HIV (PWLHIV), which has critical implications for risk of vertical HIV transmission. Point-of-care viral load (POC VL) testing has been associated with improved treatment and retention outcomes. We sought to explore acceptability of POC VL testing among Ugandan PWLHIV during pregnancy and postpartum. METHODS This multimethod analysis drew on quantitative and qualitative data collected between February and December 2021. Quantitatively, we used an intent-to-treat analysis to assess whether randomization to clinic-based POC VL testing during pregnancy and infant testing at delivery was associated with improved viral suppression (≤50 copies/mL) by 3 months postpartum compared to standard-of-care (SOC) VL testing through a central laboratory, adjusting for factorial randomization for the male partner testing strategy. Additionally, a subset of 22 PWLHIV in the POC VL arm participated in in-depth qualitative interviews. We inductively analyzed transcripts to develop categories representing concepts that characterized women's perceptions of POC VL testing during pregnancy and at delivery and ways that POC VL testing may have impacted their ART adherence and viral suppression. Key themes around women's perceptions of POC VL testing were then organized into main categories. RESULTS Overall, 151 PWLHIV were enrolled into the study, 77 (51%) of whom were randomized to receive POC VL testing during pregnancy and at delivery. Women reported in qualitative interviews that POC VL testing had (1) motivated their ART adherence during pregnancy and postpartum and that they felt this testing method had (2) helped them protect their infants from acquiring HIV and (3) improved their emotional wellbeing. CONCLUSIONS POC VL testing was highly acceptable among Ugandan PWLHIV and was viewed as an important tool that women believed improved their ART adherence, gave them information necessary to protect their infants from vertical HIV acquisition, and improved their emotional wellbeing. These findings support the global scale-up of POC VL testing in settings with high HIV burden, especially for PWLHIV who may be at risk of treatment disruptions or loss to follow-up.
Collapse
Affiliation(s)
- Agnes Nakyanzi
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 7072, Uganda; (F.N.); (A.M.); (B.K.); (A.N.); (V.K.)
| | - Faith Naddunga
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 7072, Uganda; (F.N.); (A.M.); (B.K.); (A.N.); (V.K.)
| | - Michelle A. Bulterys
- Department of Global Health, University of Washington, Seattle, WA 98109, USA; (M.A.B.); (S.P.); (C.L.C.)
| | - Andrew Mujugira
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 7072, Uganda; (F.N.); (A.M.); (B.K.); (A.N.); (V.K.)
- Department of Global Health, University of Washington, Seattle, WA 98109, USA; (M.A.B.); (S.P.); (C.L.C.)
| | - Monique A. Wyatt
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA; (M.A.W.); (N.C.W.)
- Harvard Global, Cambridge, MA 02138, USA
| | - Brenda Kamusiime
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 7072, Uganda; (F.N.); (A.M.); (B.K.); (A.N.); (V.K.)
| | - Alisaati Nalumansi
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 7072, Uganda; (F.N.); (A.M.); (B.K.); (A.N.); (V.K.)
| | - Vicent Kasiita
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 7072, Uganda; (F.N.); (A.M.); (B.K.); (A.N.); (V.K.)
| | - Sue Peacock
- Department of Global Health, University of Washington, Seattle, WA 98109, USA; (M.A.B.); (S.P.); (C.L.C.)
| | - Connie L. Celum
- Department of Global Health, University of Washington, Seattle, WA 98109, USA; (M.A.B.); (S.P.); (C.L.C.)
- Departments of Medicine and Epidemiology, University of Washington, Seattle, WA 98109, USA
| | - Norma C. Ware
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA; (M.A.W.); (N.C.W.)
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
| |
Collapse
|
2
|
Cannon CA, Celum CL. Doxycycline postexposure prophylaxis for prevention of sexually transmitted infections. Top Antivir Med 2023; 31:566-575. [PMID: 38198668 PMCID: PMC10776032] [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] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
Doxycycline postexposure prophylaxis (doxy-PEP) is a novel strategy now demonstrated in several clinical trials to dramatically reduce incidence rates of gonorrhea, chlamydia, and syphilis in some key populations at high risk of sexually transmitted infections. Even so, much remains unknown about the long-term consequences of doxy-PEP, and several concerns, including the potential for the development of antibiotic resistance and disturbances to the microbiome, balance the benefits. This review highlights the history of antibiotic prophylaxis for sexually transmitted infections, and the rationale, current evidence, and future directions for doxy-PEP.
Collapse
Affiliation(s)
- Chase A. Cannon
- Write to Chase A. Cannon, MD, MPH, University of Washington, 325 9th Ave, Box 359777, Seattle, WA, 98104, or email
| | | |
Collapse
|
3
|
Moore M, Stansfield S, Donnell DJ, Boily MC, Mitchell KM, Anderson PL, Delany-Moretlwe S, Bekker LG, Mgodi NM, Celum CL, Dimitrov D. Efficacy estimates of oral pre-exposure prophylaxis for HIV prevention in cisgender women with partial adherence. Nat Med 2023; 29:2748-2752. [PMID: 37798438 DOI: 10.1038/s41591-023-02564-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/23/2023] [Indexed: 10/07/2023]
Abstract
Pre-exposure prophylaxis (PrEP) with tenofovir (TFV) disoproxil fumarate and emtricitabine administered orally daily is effective in preventing human immunodeficiency virus (HIV) acquisition in both men and women with sufficient adherence; however, the adherence-efficacy relationship in cisgender women has not been well established. We calculated the adherence-efficacy curve for cisgender women by using HIV incidence and plasma TFV concentration data from three trials (FEM-PrEP, VOICE and Partners PrEP). We imputed TFV diphosphate (TFV-DP) concentrations, a measure of long-term adherence, from TFV quantification by using data from the HIV Prevention Trials Network 082 study, which measured both TFV-DP and TFV concentrations. Two, four and seven pills per week reduced HIV incidence by 59.3% (95% credible interval (CrI) 29.9-95.8%), 83.8% (95% CI 51.7-99.8%) and 95.9% (95% CI 72.6-100%), respectively. Our adherence-efficacy curve can be validated and updated by HIV prevention studies that directly measure TFV-DP concentrations. The curve suggests that high adherence confers high protection in cisgender women. However, the lower efficacy with partial adherence highlights the need for new PrEP products and interventions to increase adherence.
Collapse
Affiliation(s)
- Mia Moore
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA.
- HPTN Modelling Centre, Imperial College London, London, UK.
| | - Sarah Stansfield
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- HPTN Modelling Centre, Imperial College London, London, UK
| | - Deborah J Donnell
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Marie-Claude Boily
- HPTN Modelling Centre, Imperial College London, London, UK
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Kate M Mitchell
- HPTN Modelling Centre, Imperial College London, London, UK
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Peter L Anderson
- Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | | | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Nyaradzo M Mgodi
- College of Health Sciences Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Connie L Celum
- Departments of Global Health, Medicine and Epidemiology, University of Washington, Seattle, WA, USA
| | - Dobromir Dimitrov
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- HPTN Modelling Centre, Imperial College London, London, UK
- Department of Applied Mathematics, University of Washington, Seattle, WA, USA
| |
Collapse
|
4
|
Peters RPH, McIntyre JA, Garrett N, Brink AJ, Celum CL, Bekker LG. Doxycycline post-exposure prophylaxis for sexually transmitted infections in South Africa. South Afr J HIV Med 2023; 24:1510. [PMID: 37795430 PMCID: PMC10546896 DOI: 10.4102/sajhivmed.v24i1.1510] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/20/2023] [Indexed: 10/06/2023] Open
Abstract
South Africa has a large burden of bacterial sexually transmitted infections (STIs) with high rates among men who have sex with men (MSM). Randomised controlled trials have recently demonstrated high effectiveness of doxycycline post-exposure prophylaxis (PEP) for prevention of bacterial STIs in MSM, with 70% - 85% reductions in Chlamydia trachomatis infection and syphilis, and approximately 50% reduction in Neisseria gonorrhoeae infection. Doxycycline PEP was not demonstrated to be effective in reducing C. trachomatis and N. gonorrhoeae infection among Kenyan cisgender women. Although no worrisome trends in antimicrobial resistance (AMR) were observed in the trials, important concerns remain about doxycycline PEP and AMR development in STIs, other pathogens, commensals, and the microbiome. Tetracycline resistance in N. gonorrhoeae is already widespread in South Africa, but emergence of AMR in other STIs would be concerning. Larger sample sizes of doxycycline PEP users with longer follow-up time are needed to understand the impact that doxycycline PEP may have on AMR at individual and population level. In this opinion article, we weigh the benefits of doxycycline PEP for prevention of bacterial STIs against the existing AMR concerns and data gaps in the South African context. Based on the current evidence, we conclude that it would be reasonable to offer doxycycline PEP to high-risk MSM on a case-by-case basis, provided that it is offered by experienced sexual health clinicians in settings that have access to diagnostic STI testing and ongoing AMR surveillance.
Collapse
Affiliation(s)
- Remco P H Peters
- Research Unit, Foundation for Professional Development, East London, South Africa
- Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - James A McIntyre
- Anova Health Institute, Johannesburg, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Adrian J Brink
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Services, Groote Schuur Hospital, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Connie L Celum
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, United States of America
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
5
|
Mujugira A, Nakyanzi A, Donnell D, Boyer J, Stein G, Bulterys M, Naddunga F, Kyomugisha J, Birungi JE, Ssendiwala P, Nsubuga R, Muwonge TR, Musinguzi J, Sharma M, Celum CL. Partner testing with HIV self-test distribution by Ugandan pregnant women living with HIV: a randomized trial. J Int AIDS Soc 2023; 26:e26156. [PMID: 37675834 PMCID: PMC10483500 DOI: 10.1002/jia2.26156] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 08/17/2023] [Indexed: 09/08/2023] Open
Abstract
INTRODUCTION Secondary distribution of HIV self-tests (HIVST) by HIV-negative pregnant women to male partners increases men's testing rates. We examined whether this strategy promotes male partner testing for pregnant women living with HIV (PWLHIV). METHODS We conducted an open-label individually randomized trial in Kampala, Uganda, in which PWLHIV ≥18 years who reported a partner of unknown HIV status were randomized 2:1 to secondary distribution of HIVST for male partner(s) or standard-of-care (SOC; invitation letter to male partner for fast-track testing). Women were followed until 12 months post-partum. Male partners were offered confirmatory HIV testing and facilitated linkage to antiretroviral treatment (ART) or oral pre-exposure prophylaxis (PrEP). Using intention-to-treat analysis, primary outcomes were male partner testing at the clinic and initiation on PrEP or ART evaluated through 12 months post-partum (ClinicalTrials.gov, NCT03484533). RESULTS From November 2018 to March 2020, 500 PWLHIV were enrolled with a median age of 27 years (interquartile range [IQR] 23-30); 332 were randomized to HIVST and 168 to SOC with 437 PWLHIV (87.4%) completing 12 months follow-up post-partum. Of 236 male partners who tested at the clinic and enrolled (47.2%), their median age was 31 years (IQR 27-36), 45 (88.3%) men with HIV started ART and 113 (61.1%) HIV-negative men started PrEP. There was no intervention effect on male partner testing (hazard ratio [HR] 1.04; 95% confidence interval [CI]: 0.79-1.37) or time to ART or PrEP initiation (HR 0.96; 95% CI: 0.69-1.33). Two male partners and two infants acquired HIV for an incidence of 0.99 per 100 person-years (95% CI: 0.12-3.58) and 1.46 per 100 person-years (95% CI: 0.18%-5.28%), respectively. Social harms related to study participation were experienced by six women (HIVST = 5, SOC = 1). CONCLUSIONS Almost half of the partners of Ugandan PWLHIV tested for HIV with similar HIV testing rates and linkage to ART or PrEP among the secondary distribution of HIVST and SOC arms. Although half of men became aware of their HIV serostatus and linked to services, additional strategies to reach male partners of women in antenatal care are needed to increase HIV testing and linkage to services among men.
Collapse
Affiliation(s)
- Andrew Mujugira
- Infectious Diseases InstituteMakerere UniversityKampalaUganda
| | - Agnes Nakyanzi
- Infectious Diseases InstituteMakerere UniversityKampalaUganda
| | | | - Jade Boyer
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Gabrielle Stein
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Michelle Bulterys
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Faith Naddunga
- Infectious Diseases InstituteMakerere UniversityKampalaUganda
| | | | | | - Paul Ssendiwala
- Infectious Diseases InstituteMakerere UniversityKampalaUganda
| | - Rogers Nsubuga
- Infectious Diseases InstituteMakerere UniversityKampalaUganda
| | | | | | - Monisha Sharma
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Connie L. Celum
- Departments of Global Health, Medicine, and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| |
Collapse
|
6
|
Bulterys MA, Mujugira A, Nakyanzi A, Wyatt MA, Kamusiime B, Kasiita V, Kakoola GN, Nalumansi A, Twesigye C, Pisarski EE, Sharma M, Boyer J, Naddunga F, Ware NC, Celum CL. "Him Leaving Me - That is My Fear Now": A Mixed Methods Analysis of Relationship Dissolution Between Ugandan Pregnant and Postpartum Women Living with HIV and Their Male Partners. AIDS Behav 2023; 27:1776-1792. [PMID: 36348192 PMCID: PMC10942742 DOI: 10.1007/s10461-022-03910-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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] [Accepted: 10/18/2022] [Indexed: 11/09/2022]
Abstract
High rates of relationship dissolution among pregnant women living with HIV (PWLHIV) and their male partners might increase mothers' and children's vulnerability to financial hardship and poor health outcomes. This mixed methods analysis identified factors associated with separation between PWLHIV and their male partners. We utilized data from a randomized controlled trial ( www.ClinicalTrials.gov NCT03484533) of 500 PWLHIV attending antenatal care in Uganda and 237 male partners between 2018 and 2020 and followed until 12 months postpartum. Multivariate regression models estimated the impact of relationship factors on the adjusted relative risk of separation during follow up, and we conducted in-depth interviews with 45 women and 45 men enrolled in the trial. Overall, 23% of PWLHIV reported separation during the study period. HIV serodifferent status, financial burdens and gender expectations were sources of relationship conflict. Significant factors associated with separation included unmarried, non-cohabitating, shorter, polygamous relationships, as well as HIV non-disclosure and verbal abuse. Participants discussed potential positive and negative consequences of separation, including impact on their mental health, treatment continuation, financial security, and safety. Addressing relationship dynamics is essential to improve counseling messaging and support PWLHIV who are experiencing relationship conflict.
Collapse
Affiliation(s)
- Michelle A Bulterys
- Department of Global Health, University of Washington, 325 Ninth Avenue, Seattle, WA, 98104, USA.
- Department of Epidemiology, University of Washington, Seattle, WA, USA.
| | - Andrew Mujugira
- Department of Global Health, University of Washington, 325 Ninth Avenue, Seattle, WA, 98104, USA
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Agnes Nakyanzi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Monique A Wyatt
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Harvard Global, Cambridge, MA, USA
| | - Brenda Kamusiime
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Vicent Kasiita
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | | | - Collins Twesigye
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Monisha Sharma
- Department of Global Health, University of Washington, 325 Ninth Avenue, Seattle, WA, 98104, USA
| | - Jade Boyer
- Department of Global Health, University of Washington, 325 Ninth Avenue, Seattle, WA, 98104, USA
| | - Faith Naddunga
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Norma C Ware
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Connie L Celum
- Department of Global Health, University of Washington, 325 Ninth Avenue, Seattle, WA, 98104, USA
| |
Collapse
|
7
|
Rousseau E, Wu L, Heffron R, Baeten JM, Celum CL, Travill D, Delany-Moretlwe S, Bekker LG, Bukusi E, Omollo V, van der Straten A, O’Malley G, Haberer JE, Morton JF, Johnson RE, Roberts ST. Association of sexual relationship power with PrEP persistence and other sexual health outcomes among adolescent and young women in Kenya and South Africa. Front Reprod Health 2023; 5:1073103. [PMID: 37325240 PMCID: PMC10266091 DOI: 10.3389/frph.2023.1073103] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 05/16/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction Gendered power inequalities impact adolescent girls' and young women's (AGYW) sexual and reproductive health (SRH) outcomes. We investigated the influence of sexual relationship power on AGYW's SRH outcomes, including HIV pre-exposure prophylaxis (PrEP) persistence. Methods The POWER study in Kisumu, Kenya, and Cape Town and Johannesburg, South Africa provided PrEP to 2,550 AGYW (aged 16-25). AGYW's perceived power in their primary sexual relationship was measured among the first 596 participants enrolled using the Sexual Relationship Power Scale's (SRPS) relationship control sub-scale. Multivariable regression was used to test for (1) key sociodemographic and relationship characteristics associated with relationship power; and (2) the association of relationship power with SRH outcomes including PrEP persistence. Results In this cohort, the mean SRPS score was 2.56 (0.49), 542 (90.9%) initiated PrEP; 192 (35.4%) persisted with PrEP at 1 month of which 46 (24.0% of 192) persisted at 6 months. SRPS were significantly lower among AGYW who cohabited with their sex partner (-0.14, 95% CI: -0.24 to -0.04, p = 0.01), or had ≥1 sex partner (-0.10, 95% CI: -0.19 to -0.00, p = 0.05). AGYW with lower SRPS were more likely to not know their partner's HIV status (aOR 2.05, 95% CI: 1.27 to 3.33, p < 0.01), but SRPS was not associated with PrEP persistence, STI infection, condom, or hormonal contraception use. Discussion AGYW's reasons for initiating PrEP and reasons for continuously using PrEP may be different. While low relationship power was associated with perceived HIV vulnerability, AGYW's PrEP persistence may be influenced by more than relationship power.
Collapse
Affiliation(s)
- Elzette Rousseau
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Linxuan Wu
- Departments of Global Health, Medicine and Epidemiology, University of Washington, Seattle, WA, United States
| | - Renee Heffron
- Departments of Global Health, Medicine and Epidemiology, University of Washington, Seattle, WA, United States
| | - Jared M. Baeten
- Departments of Global Health, Medicine and Epidemiology, University of Washington, Seattle, WA, United States
- Gilead Sciences, Inc., Seattle, WA, United States
| | - Connie L. Celum
- Departments of Global Health, Medicine and Epidemiology, University of Washington, Seattle, WA, United States
| | - Danielle Travill
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | | | | | - Ariane van der Straten
- Department of Medicine, Centre for AIDS Prevention Studies, University of California, San Francisco, San Francisco, CA, United States
- Astra Consulting, Kensington, CA, United States
| | - Gabrielle O’Malley
- Departments of Global Health, Medicine and Epidemiology, University of Washington, Seattle, WA, United States
| | - Jessica E. Haberer
- Harvard Medical School, Harvard University, Boston, MA, United States
- Centre for Global Health, Massachusetts General Hospital, Boston, MA, United States
| | - Jennifer F. Morton
- Departments of Global Health, Medicine and Epidemiology, University of Washington, Seattle, WA, United States
| | - Rachel E. Johnson
- Departments of Global Health, Medicine and Epidemiology, University of Washington, Seattle, WA, United States
| | - Sarah T. Roberts
- RTI International, Women’s Global Health Imperative (WGHI), Berkeley, CA, United States
| |
Collapse
|
8
|
Ware NC, Wyatt MA, Pisarski EE, Kamusiime B, Kasiita V, Nalukwago G, Nalumansi A, Twesigye C, Boyer J, Nakyanzi A, Naddunga F, Mujugira A, Celum CL. How pregnant women living with HIV and their male partners manage men's HIV self-testing: qualitative analysis of an HIVST secondary distribution process in Kampala, Uganda. J Int AIDS Soc 2023; 26:e26050. [PMID: 36659835 PMCID: PMC9852794 DOI: 10.1002/jia2.26050] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 11/30/2022] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Increased HIV testing by men in sub-Saharan Africa is key to meeting UNAIDS 2025 testing targets. Secondary distribution of HIV self-testing (HIVST) kits by pregnant women attending antenatal care to male partners has been shown to increase testing among African men. A detailed understanding of how women and male partners manage the distribution and use of HIVST and subsequent linkage to clinic-based follow-up can inform implementation and scale-up efforts. METHODS We use qualitative data from the Obumu Study, a randomized trial of secondary distribution of HIVST by pregnant women living with HIV to male partners in Kampala, Uganda, to unpack the HIVST delivery process. The protocol included a clinic visit by male partners to confirm HIVST results. Individual interviews eliciting data on experiences of delivering and using HIVST and of subsequent linkage to clinic-based testing were conducted with a purposefully selected sample of 45 women and 45 male partner Obumu Study participants from November 2018 to March 2021. Interview data from 59 participants (29 women and 30 men) in the HIVST arm were analysed through coding and category construction. RESULTS Women living with HIV were apprehensive about delivering HIVST to their partners, especially if they had not disclosed their HIV status. They invested effort in developing strategies for introducing HIVST. Male partners described a range of responses to receiving the self-testing kit, especially fear of a positive test result. Women reported leading the self-testing process, often conducting the test themselves. Most women confidently interpreted HIVST results. However, they tended to defer to healthcare workers rather than report positive results directly to partners. Women told their partners the testing process required a clinic follow-up visit, often without explaining the visit's purpose. Many partners delayed the visit as a result. Women again responded by strategizing to persuade their partners to link to follow-up care. CONCLUSIONS Secondary distribution of HIVST by pregnant women living with HIV to male partners can be challenging, especially when women have not disclosed their HIV status. Additional support may alleviate the burden; outreach to male partners may facilitate linkage to confirmatory testing and HIV care or prevention.
Collapse
Affiliation(s)
- Norma C. Ware
- Department of MedicineBrigham and Women's HospitalBostonMassachusettsUSA,Department of Global Health and Social MedicineHarvard Medical SchoolBostonMassachusettsUSA
| | - Monique A. Wyatt
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMassachusettsUSA,Harvard GlobalCambridgeMassachusettsUSA
| | - Emily E. Pisarski
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMassachusettsUSA
| | | | - Vicent Kasiita
- Infectious Diseases InstituteMakerere UniversityKampalaUganda
| | - Grace Nalukwago
- Infectious Diseases InstituteMakerere UniversityKampalaUganda
| | | | | | - Jade Boyer
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Agnes Nakyanzi
- Infectious Diseases InstituteMakerere UniversityKampalaUganda
| | - Faith Naddunga
- Infectious Diseases InstituteMakerere UniversityKampalaUganda
| | - Andrew Mujugira
- Infectious Diseases InstituteMakerere UniversityKampalaUganda,Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Connie L. Celum
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| |
Collapse
|
9
|
Garcia-Cremades M, Vučićević K, Hendrix CW, Jayachandran P, Jarlsberg L, Grant R, Celum CL, Martin M, Baeten JM, Marrazzo J, Anderson P, Choopanya K, Vanichseni S, Glidden DV, Savic RM. Characterizing HIV-Preventive, Plasma Tenofovir Concentrations-A Pooled Participant-level Data Analysis From Human Immunodeficiency Virus Preexposure Prophylaxis Clinical Trials. Clin Infect Dis 2022; 75:1873-1882. [PMID: 35474481 PMCID: PMC10139701 DOI: 10.1093/cid/ciac313] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 11/30/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Daily dosing of tenofovir disoproxil fumarate, with or without emtricitabine, has high efficacy in preventing human immunodeficiency virus (HIV) infection when individuals are adherent. The target protective plasma concentration of tenofovir (TFV), however, is not fully understood. The aim of this study is to estimate the protective TFV plasma concentration. METHODS Participant data from TFV-based daily oral and topical active arms of phase 3 trials (iPrEx, VOICE, and Partners PrEP) were pooled (n = 2950). Individual specific risk scores (low and high risk) of acquiring HIV, based on an earlier placebo analysis, were created. Longitudinal TFV pharmacokinetics (PK), HIV outcome, individual risk scores and the effect of sex at birth data were integrated and analyzed using non-linear mixed effects models. RESULTS Around 50% of the individuals were estimated to be adherent, which differed from self-reported adherence (∼90%) and large variation between longitudinal adherence patterns were identified. Following oral administration, the estimated protective TFV trough concentration was substantially higher in high-risk females (45.8 ng/mL) compared with high-risk males (16.1 ng/mL) and to low-risk individuals (∼7.5 ng/mL). Dosing simulations indicated that high-risk women require full adherence to maintain protective levels. CONCLUSIONS Using the largest PK-HIV outcome database to date, we developed a population adherence-PK-risk-outcome model. Our results indicate that high-risk females need higher levels of plasma TFV to achieve HIV protection compared with males. HIV protection exceeds 90% in all populations if daily adherence is achieved.
Collapse
Affiliation(s)
- Maria Garcia-Cremades
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Katarina Vučićević
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA.,Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade-Faculty of Pharmacy, Belgrade, Serbia
| | - Craig W Hendrix
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Priya Jayachandran
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Leah Jarlsberg
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Robert Grant
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Connie L Celum
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, Washington, USA
| | - Michael Martin
- Centers for Disease Control and Prevention, National Center For HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia, USA.,Thailand Ministry of Public Health-US CDC Collaboration, Nonthaburi, Thailand
| | - Jared M Baeten
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, Washington, USA
| | - Jeanne Marrazzo
- Division of Infectious Diseases, University of Alabama at Birmingham Medical Center, Birmingham, Alabama, USA
| | - Peter Anderson
- Department of Pharmaceutical Sciences, University of Colorado, Denver, Colorado, USA
| | | | | | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Radojka M Savic
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
10
|
Garcia-Cremades M, Hendrix CW, Jayachandran P, Strydom N, Jarlsberg L, Grant R, Celum CL, Martin M, Baeten JM, Marrazzo J, Anderson P, Choopanya K, Vanichseni S, Glidden DV, Savic RM. Modeling the Probability of HIV Infection over Time in High-Risk Seronegative Participants Receiving Placebo in Five Randomized Double-Blind Placebo-Controlled HIV Pre-Exposure Prophylaxis Trials: A Patient-Level Pooled Analysis. Pharmaceutics 2022; 14:pharmaceutics14091801. [PMID: 36145549 PMCID: PMC9504389 DOI: 10.3390/pharmaceutics14091801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/11/2022] [Accepted: 08/24/2022] [Indexed: 11/16/2022] Open
Abstract
The World Health Organization recommends pre-exposure prophylaxis (PrEP) for individuals at substantial risk of HIV infection. The aim of this analysis is to quantify the individual risk of HIV infection over time, using a large database of high-risk individuals (n = 5583). We used data from placebo recipients in five phase III PrEP trials: iPrEx, conducted in men who have sex with men and transgender women; VOICE, conducted in young women at high sexual risk; Partners PrEP, conducted in HIV serodiscordant heterosexual couples; TDF2, conducted in high-risk heterosexual men and women; and BTS, conducted in persons who inject drugs. The probability of HIV infection over time was estimated using NONMEM7.4. We identified predictors of HIV risk and found a substantial difference in the risk of infection among and within trial populations, with each study including a mix of low, moderate, and high-risk individuals (p < 0.05). Persons who were female at birth were at a higher risk of HIV infection than people who were male at birth. Final models were integrated in a tool that can assess person-specific risk and simulate cumulative HIV risk over time. These models can be used to optimize future PrEP clinical trials by identifying potential participants at highest risk.
Collapse
Affiliation(s)
- Maria Garcia-Cremades
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA 94143, USA
- Correspondence:
| | - Craig W. Hendrix
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Priya Jayachandran
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA 94143, USA
| | - Natasha Strydom
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA 94143, USA
| | - Leah Jarlsberg
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA 94143, USA
| | - Robert Grant
- Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA
| | - Connie L. Celum
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA 98104, USA
| | - Michael Martin
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Atlanta, GA 30333, USA
- Thailand Ministry of Public Health—US CDC Collaboration, Nonthaburi 11000, Thailand
| | - Jared M. Baeten
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA 98104, USA
| | - Jeanne Marrazzo
- Division of Infectious Diseases, University of Alabama at Birmingham Medical Center, Birmingham, AL 35294, USA
| | - Peter Anderson
- Department of Pharmaceutical Sciences, University of Colorado, Denver, CO 80045, USA
| | | | | | - David V. Glidden
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA 94143, USA
| | - Radojka M. Savic
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA 94143, USA
| |
Collapse
|
11
|
Celum CL, Bukusi EA, Bekker LG, Delany-Moretlwe S, Kidoguchi L, Omollo V, Rousseau E, Travill D, Morton JF, Mogaka F, O'Malley G, Barnabee G, van der Straten A, Donnell D, Parikh UM, Kudrick L, Anderson PL, Haberer JE, Wu L, Heffron R, Johnson R, Morrison S, Baeten JM. PrEP use and HIV seroconversion rates in adolescent girls and young women from Kenya and South Africa: the POWER demonstration project. J Int AIDS Soc 2022; 25:e25962. [PMID: 35822945 PMCID: PMC9278271 DOI: 10.1002/jia2.25962] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [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: 09/14/2021] [Accepted: 06/23/2022] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION HIV incidence remains high among African adolescent girls and young women (AGYW). The primary objective of this study is to assess pre-exposure prophylaxis (PrEP) initiation, use, persistence and HIV acquisition among African AGYW offered PrEP in order to inform PrEP scale-up. METHODS POWER was a prospective implementation science evaluation of PrEP delivery for sexually active HIV-negative AGYW ages 16-25 in family planning clinics in Kisumu, Kenya and youth and primary healthcare clinics in Cape Town and Johannesburg, South Africa. Follow-up visits occurred at month 1 and quarterly for up to 36 months. PrEP users were defined based on the month 1 refill. PrEP persistence through month 6 was assessed using Kaplan-Meier survival analysis among AGYW with a month 1 visit, defining non-persistence as an ≥15 day gap in PrEP availability for daily dosing. PrEP execution was evaluated in a subset with PrEP supply from the prior visit sufficient for daily dosing by measuring blood tenofovir diphosphate (TFV-DP) levels. RESULTS From June 2017 to September 2020, 2550 AGYW were enrolled (1000 in Kisumu, 787 in Cape Town and 763 in Johannesburg). Median age was 21 years, 66% had a sexual partner of unknown HIV status, and 29% had chlamydia and 10% gonorrhoea. Overall, 2397 (94%) initiated PrEP and 749 (31%) had a refill at 1 month. Of AGYW who could reach 6 months of post-PrEP initiation follow-up, 128/646 (20%) persisted with PrEP for 6 months and an additional 92/646 (14%) had a gap and restarted PrEP. TFV-DP levels indicated that 47% (91/193) took an average of ≥4 doses/week. Sixteen HIV seroconversions were observed (incidence 2.2 per 100 person-years, 95% CI 1.2, 3.5); 13 (81%) seroconverters either did not have PrEP dispensed in the study interval prior to seroconversion or TFV-DP levels indicated <4 doses/week in the prior 6 weeks. CONCLUSIONS In this study of PrEP integration with primary care and reproductive health services for African AGYW, demand for PrEP was high. Although PrEP use decreased in the first months, an important fraction used PrEP through 6 months. Strategies are needed to simplify PrEP delivery, support adherence and offer long-acting PrEP options to improve persistence and HIV protection.
Collapse
Affiliation(s)
- Connie L Celum
- Department of Global Health, University of Washington, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA.,Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Elizabeth A Bukusi
- Department of Global Health, University of Washington, Seattle, Washington, USA.,Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA.,Center for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | | | | | - Lara Kidoguchi
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Victor Omollo
- Center for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Danielle Travill
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Jennifer F Morton
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Felix Mogaka
- Center for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Gabrielle O'Malley
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Gena Barnabee
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Ariane van der Straten
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Deborah Donnell
- Department of Global Health, University of Washington, Seattle, Washington, USA.,Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Urvi M Parikh
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Peter L Anderson
- University of Colorado-Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Linxuan Wu
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, Washington, USA.,Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Rachel Johnson
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Susan Morrison
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA.,Department of Epidemiology, University of Washington, Seattle, Washington, USA.,Gilead Sciences, Foster City, California, USA
| | | |
Collapse
|
12
|
Medina‐Marino A, Bezuidenhout D, Ngwepe P, Bezuidenhout C, Facente SN, Mabandla S, Hosek S, Little F, Celum CL, Bekker L. Acceptability and feasibility of leveraging community-based HIV counselling and testing platforms for same-day oral PrEP initiation among adolescent girls and young women in Eastern Cape, South Africa. J Int AIDS Soc 2022; 25:e25968. [PMID: 35872602 PMCID: PMC9309460 DOI: 10.1002/jia2.25968] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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: 01/07/2022] [Accepted: 07/06/2022] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Community-based delivery of HIV pre-exposure prophylaxis (PrEP) to South African adolescent girls and young women's (AGYW) could increase access but needs evaluation. We integrated PrEP services via home-based services and pop-up tents into existing community-based HIV testing services (CB-HTS) in Eastern Cape Province, South Africa. METHODS After accessing CB-HTS via a "pop-up" tent or home-based services, HIV-negative AGYW aged 16-25 years were invited to complete a baseline questionnaire and referred for PrEP services at a community-based PrEP site co-located with pop-up HTS tents. A 30-day supply of PrEP was dispensed. PrEP uptake, time-to-initiation, cohort characteristics and first medication refill within 90 days were measured using descriptive statistics. RESULTS Of the 1164 AGYW who tested for HIV, 825 (74.3%) completed a questionnaire and 806 (97.7%) were referred for community-based PrEP. Of those, 624 (77.4%) presented for PrEP (482/483 [99.8%] from pop-up HTS and 142/323 [44.0%] from home-based HTS), of which 603 (96.6%) initiated PrEP. Of those initiating PrEP following home-based HTS, 59.1% initiated within 0-3 days, 25.6% within 4-14 days and 15.3% took ≥15 days to initiate; 100% of AGYW who used pop-up HTS initiated PrEP the same day. Among AGWY initiating PrEP, 37.5% had a detectable sexually transmitted infection (STI). Although AGYW reported a low self-perception of HIV risk, post-hoc application of HIV risk assessment measures to available data classified most study participants as high risk for HIV acquisition. Cumulatively, 329 (54.6%) AGYW presented for a first medication refill within 90 days of accepting their first bottle of PrEP. CONCLUSIONS Leveraging CB-HTS platforms to provide same-day PrEP initiation and refill services was acceptable to AGYW. A higher proportion of AGYW initiated PrEP when co-located with CB-HTS sites compared to those referred following home-based HTS, suggesting that proximity of CB-HTS and PrEP services facilitates PrEP uptake among AGYW. The high prevalence of STIs among those initiating PrEP necessitates the integration of STI and HIV prevention programs for AGYW. Eligibility for PrEP initiation should not be required among AHYW in high HIV burden communities. Community-based service delivery will be crucial to maintaining access to PrEP services during the COVID-19 pandemic and future health and humanitarian emergencies.
Collapse
Affiliation(s)
- Andrew Medina‐Marino
- Desmond Tutu HIV CentreUniversity of Cape TownCape TownSouth Africa
- Research UnitFoundation for Professional Development, Buffalo City MetroEastern Cape ProvinceSouth Africa
- Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Dana Bezuidenhout
- Research UnitFoundation for Professional Development, Buffalo City MetroEastern Cape ProvinceSouth Africa
- Department of EpidemiologyMailman School of Public HealthColumbia UniversityNew York CityNew YorkUSA
| | - Phuti Ngwepe
- Research UnitFoundation for Professional Development, Buffalo City MetroEastern Cape ProvinceSouth Africa
- Department of Statistical SciencesUniversity of Cape TownCape TownSouth Africa
| | - Charl Bezuidenhout
- Research UnitFoundation for Professional Development, Buffalo City MetroEastern Cape ProvinceSouth Africa
- School of Public HealthBoston UniversityBostonMassachusettsUSA
| | | | - Selly Mabandla
- HIV/AIDSSTIs and TB ProgramBuffalo City Metro Health DistrictEastern Cape Province Department of HealthBhishoSouth Africa
| | - Sybil Hosek
- Departments of Psychiatry and Infectious DiseaseStroger Hospital of Cook CountyChicagoIllinoisUSA
| | - Francesca Little
- Department of Statistical SciencesUniversity of Cape TownCape TownSouth Africa
| | - Connie L. Celum
- Department of Global Health, Medicine and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | | |
Collapse
|
13
|
Bershteyn A, Dahl AM, Dong TQ, Deming ME, Celum CL, Chu HY, Kottkamp AC, Greninger AL, Hoffman RM, Jerome KR, Johnston CM, Kissinger PJ, Landovitz RJ, Laufer MK, Luk A, Neuzil KM, Paasche-Orlow MK, Pitts RA, Schwartz MD, Stankiewicz Karita HC, Thorpe LE, Wald A, Zheng CY, Wener MH, Barnabas RV, Brown ER. Self-Assessed Severity as a Determinant of Coronavirus Disease 2019 Symptom Specificity: A Longitudinal Cohort Study. Clin Infect Dis 2022; 75:e1180-e1183. [PMID: 35152299 PMCID: PMC8903379 DOI: 10.1093/cid/ciac129] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Indexed: 01/19/2023] Open
Abstract
Coronavirus disease 2019 symptom definitions rarely include symptom severity. We collected daily nasal swab samples and symptom diaries from contacts of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) case patients. Requiring ≥1 moderate or severe symptom reduced sensitivity to predict SARS-CoV-2 shedding from 60.0% (95% confidence interval [CI], 52.9%-66.7%) to 31.5% (95% CI, 25.7%- 38.0%) but increased specificity from 77.5% (95% CI, 75.3%-79.5%) to 93.8% (95% CI, 92.7%-94.8%).
Collapse
Affiliation(s)
- Anna Bershteyn
- Correspondence: A. Bershteyn, Department of Population Health, New York University Grossman School of Medicine, 227 E 30th St, New York, NY 10016 ()
| | | | - Tracy Q Dong
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Meagan E Deming
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Connie L Celum
- International Clinical Research Center and Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Helen Y Chu
- Department of Medicine and Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Angelica C Kottkamp
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Alexander L Greninger
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA,Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Risa M Hoffman
- Department of Medicine and Division of Infectious Diseases, University of California, Los Angeles, California, USA
| | - Keith R Jerome
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA,Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Christine M Johnston
- Department of Medicine and Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Patricia J Kissinger
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
| | - Raphael J Landovitz
- Center for Clinical AIDS Research & Education, University of California, Los Angeles, California, USA
| | - Miriam K Laufer
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Alfred Luk
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Kathleen M Neuzil
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Michael K Paasche-Orlow
- Department of Medicine and Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Robert A Pitts
- Department of Medicine and Division of Infectious Diseases, NYC Health & Hospitals/Bellevue, New York, New York, USA
| | - Mark D Schwartz
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | | | - Lorna E Thorpe
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Anna Wald
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA,Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA,Department of Medicine, Department of Epidemiology, Seattle, Washington, USA
| | - Crystal Y Zheng
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Mark H Wener
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Ruanne V Barnabas
- Department of Global Health and Department of Medicine, University of Washington, Seattle, Washington, USA,Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USAand
| | - Elizabeth R Brown
- Department of Biostatistics, University of Washington, Seattle, Washington, USA,Vaccine and Infectious Disease Division and Public Health Sciences Division, Fred Hutchinson Cancer Research Center, USA
| |
Collapse
|
14
|
Liu G, Mugo NR, Brown ER, Mgodi NM, Chirenje ZM, Marrazzo JM, Winer RL, Mansoor L, Palanee-Phillips T, Siva SS, Naidoo L, Jeenarain N, Gaffoor Z, Nair GL, Selepe P, Nakabiito C, Mkhize B, Mirembe BG, Taljaard M, Panchia R, Baeten JM, Balkus JE, Hladik F, Celum CL, Barnabas RV. Prevalent human papillomavirus infection increases the risk of HIV acquisition in African women: advancing the argument for human papillomavirus immunization. AIDS 2022; 36:257-265. [PMID: 34172672 PMCID: PMC8702475 DOI: 10.1097/qad.0000000000003004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 12/16/2022]
Abstract
OBJECTIVE Vaccine-preventable human papillomavirus (HPV) infection is common, especially in sub-Saharan Africa where HIV risk is also high. However, unlike other sexually transmitted infections (STIs), HPV's role in HIV acquisition is unclear. We evaluated this relationship using data from MTN-003, a clinical trial of HIV chemoprophylaxis among cisgender women in sub-Saharan Africa. DESIGN A case-control study. METHODS We matched 138 women who acquired HIV (cases) to 412 HIV-negative controls. Cervicovaginal swabs collected within 6 months before HIV seroconversion were tested for HPV DNA. We estimated the associations between carcinogenic (high-risk) and low-risk HPV types and types targeted by HPV vaccines and HIV acquisition, using conditional logistic regression models adjusted for time-varying sexual behaviors and other STIs. RESULTS Mean age was 23 (±4) years. Any, high-risk and low-risk HPV was detected in 84, 74 and 66% of cases, and 65, 55 and 48% of controls. Infection with at least two HPV types was common in cases (67%) and controls (49%), as was infection with nonavalent vaccine-targeted types (60 and 42%). HIV acquisition increased with any [adjusted odds ratio (aOR) 2.5, 95% confidence interval (95% CI) 1.3-4.7], high-risk (aOR 2.6, 95% CI 1.5-4.6) and low-risk (aOR 1.8, 95% CI 1.1-2.9) HPV. Each additional type detected increased HIV risk by 20% (aOR 1.2, 95% CI 1.1-1.4). HIV acquisition was associated with HPV types targeted by the nonavalent (aOR 2.1, 95% CI 1.3-3.6) and quadrivalent vaccines (aOR 1.9, 95% CI 1.1-3.2). CONCLUSION HPV infection is associated with HIV acquisition in sub-Saharan African women. In addition to preventing HPV-associated cancers, increasing HPV vaccination coverage could potentially reduce HIV incidence.
Collapse
Affiliation(s)
- Gui Liu
- Department of Epidemiology, University of Washington,
Seattle, USA
- Department of Global Health, University of Washington,
Seattle, USA
| | - Nelly R. Mugo
- Department of Global Health, University of Washington,
Seattle, USA
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth R. Brown
- Vaccine and Infectious Disease Division, Fred Hutchinson
Cancer Research Center, Seattle, USA
- Department of Biostatistics, University of Washington,
Seattle, USA
| | - Nyaradzo M. Mgodi
- Clinical Trials Research Centre, University of Zimbabwe,
Harare, Zimbabwe
| | | | - Jeanne M. Marrazzo
- Department of Medicine/Division of Infectious Diseases,
University of Alabama at Birmingham, Alabama, USA
| | - Rachel L. Winer
- Department of Epidemiology, University of Washington,
Seattle, USA
- Kaiser Permanente Washington Health Research Institute,
Seattle, USA
| | - Leila Mansoor
- Centre for the AIDS Programme of Research in South Africa,
University of KwaZulu-Natal, Durban, South Africa
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute in
Johannesburg, South Africa
- Faculty of Health Sciences, University of Witwatersrand,
Johannesburg, South Africa
| | | | | | | | - Zakir Gaffoor
- South Africa Medical Research Council, Durban, South
Africa
| | - Gonasagrie L. Nair
- Desmond Tutu HIV Centre, University of Cape Town, Cape
Town, South Africa
| | | | | | - Baningi Mkhize
- Faculty of Health Sciences, University of Witwatersrand,
Johannesburg, South Africa
| | | | | | - Ravindre Panchia
- Perinatal HIV Research Unit, Chris Hani Baragwanath
Hospital, Soweto, South Africa
| | - Jared M. Baeten
- Department of Epidemiology, University of Washington,
Seattle, USA
- Department of Global Health, University of Washington,
Seattle, USA
- Division of Allergy and Infectious Diseases, Department of
Medicine, University of Washington, Seattle, USA
| | - Jennifer E. Balkus
- Department of Epidemiology, University of Washington,
Seattle, USA
- Department of Global Health, University of Washington,
Seattle, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson
Cancer Research Center, Seattle, USA
| | - Floriand Hladik
- Division of Allergy and Infectious Diseases, Department of
Medicine, University of Washington, Seattle, USA
- Department of Obstetrics and Gynecology, University of
Washington, Seattle, USA
| | - Connie L. Celum
- Department of Global Health, University of Washington,
Seattle, USA
| | - Ruanne V. Barnabas
- Department of Epidemiology, University of Washington,
Seattle, USA
- Department of Global Health, University of Washington,
Seattle, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson
Cancer Research Center, Seattle, USA
- Division of Allergy and Infectious Diseases, Department of
Medicine, University of Washington, Seattle, USA
| |
Collapse
|
15
|
Gilbert HN, Wyatt MA, Pisarski EE, Asiimwe S, van Rooyen H, Seeley J, Shahmanesh M, Turyamureeba B, van Heerden A, Adeagbo O, Celum CL, Barnabas RV, Ware NC. How community ART delivery may improve HIV treatment outcomes: Qualitative inquiry into mechanisms of effect in a randomized trial of community-based ART initiation, monitoring and re-supply (DO ART) in South Africa and Uganda. J Int AIDS Soc 2021; 24:e25821. [PMID: 34624173 PMCID: PMC8500674 DOI: 10.1002/jia2.25821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/03/2021] [Indexed: 02/05/2023] Open
Abstract
Introduction UNAIDS fast track targets for ending the AIDS epidemic by 2030 call for viral suppression in 95% of people using antiretroviral therapy (ART) to treat HIV infection. Difficulties in linking to care following a positive HIV test have impeded progress towards meeting treatment targets. Community‐based HIV services may reduce linkage barriers and have been associated with high retention and favourable clinical outcomes. We use qualitative data from The Delivery Optimization of Antiretroviral Therapy (DO ART) Study, a three‐arm randomized trial of community ART initiation, monitoring and re‐supply conducted in western Uganda and KwaZulu‐Natal South Africa, to identify mechanisms through which community ART delivery may improve treatment outcomes, defined as viral suppression in people living with HIV (PLHIV). Methods We conducted open‐ended interviews with a purposeful sample of 150 DO ART participants across study arms and study sites, from October 2016 to November 2019. Interviews covered experiences of: (1) HIV testing; (2) initiating and refilling ART; and (3) participating in the DO ART Study. A combined inductive content analytic and thematic approach was used to characterize mechanisms through which community delivery of ART may have contributed to viral suppression in the DO ART trial. Results The analysis yielded four potential mechanisms drawn from qualitative data representing the perspectives and priorities of DO ART participants. Empowering participants to schedule, re‐schedule and select the locations of community‐based visits via easy phone contact with clinical staff is characterized as flexibility. Integration refers to combining the components of clinic‐based visits into single interaction with a healthcare provider. Providers” willingness to talk at length with participants during visits, addressing non‐HIV as well as HIV‐related concerns, is termed “a slower pace”. Finally, increased efficiency denotes the time savings and increased income‐generating opportunities for participants brought about by delivering services in the community. Conclusions Understanding the mechanisms through which HIV service delivery innovations produce an effect is key to transferability and potential scale‐up. The perspectives and priorities of PLHIV can indicate actionable changes for HIV care programs that may increase engagement in care and improve treatment outcomes.
Collapse
Affiliation(s)
- Hannah N Gilbert
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Monique A Wyatt
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Harvard Global, Cambridge, Massachusetts, USA
| | - Emily E Pisarski
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephen Asiimwe
- Mbarara University of Science and Technology, Mbarara, Uganda.,Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA.,Integrated Community-based Initiatives, Kabwohe, Uganda
| | - Heidi van Rooyen
- Human Sciences Research Council, KwaZulu-Natal, South Africa.,SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Janet Seeley
- London School of Hygiene and Tropical Medicine, London, UK.,Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Maryam Shahmanesh
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,Institute for Global Health, University College London, London, UK
| | | | - Alastair van Heerden
- Human Sciences Research Council, KwaZulu-Natal, South Africa.,SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Connie L Celum
- Departments of Global Health and Medicine, University of Washington, Seattle, Washington, USA
| | - Ruanne V Barnabas
- Departments of Global Health and Medicine, University of Washington, Seattle, Washington, USA
| | - Norma C Ware
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | -
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
16
|
Medina-Marino A, Bezuidenhout D, Hosek S, Barnabas RV, Atujuna M, Bezuidenhout C, Ngwepe P, Peters RPH, Little F, Celum CL, Daniels J, Bekker LG. The Community PrEP Study: a randomized control trial leveraging community-based platforms to improve access and adherence to pre-exposure prophylaxis to prevent HIV among adolescent girls and young women in South Africa-study protocol. Trials 2021; 22:489. [PMID: 34311754 PMCID: PMC8314507 DOI: 10.1186/s13063-021-05402-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 02/15/2021] [Accepted: 06/26/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND HIV incidence among South African adolescent girls and young women (AGYW) remains high, but could be reduced by highly effective pre-exposure prophylaxis (PrEP). Unfortunately, AGYW report significant barriers to clinic-based sexual and reproductive health services. Even when AGYW access PrEP as an HIV prevention method, poor prevention-effective use was a serious barrier to achieving its optimal HIV prevention benefits. Determining the acceptability and feasibility of community-based platforms to increase AGYW's access to PrEP, and evaluating behavioural interventions to improve prevention-effective use of PrEP are needed. METHODS We propose a mixed-methods study among AGYW aged 16-25 years in Eastern Cape Province, South Africa. In the first component, a cross-sectional study will assess the acceptability and feasibility of leveraging community-based HIV counselling and testing (CBCT) platforms to refer HIV-negative, at-risk AGYW to non-clinic-based, same-day PrEP initiation services. In the second component, we will enrol 480 AGYW initiating PrEP via our CBCT platforms into a three-armed (1:1:1) randomized control trial (RCT) that will evaluate the effectiveness of adherence support interventions to improve the prevention-effective use of PrEP. Adherence will be measured over 24 months via tenofovir-diphosphate blood concentration levels. Qualitative investigations will explore participant, staff, and community experiences associated with community-based PrEP services, adherence support activities, study implementation, and community awareness. Costs and scalability of service platforms and interventions will be evaluated. DISCUSSION This will be the first study to assess the acceptability and feasibility of leveraging CBCT platforms to identify and refer at-risk AGYW to community-based, same-day PrEP initiation services. It will also provide quantitative and qualitative results to inform adherence support activities and services that promote the prevention-effective use of PrEP among AGYW. By applying principles of implementation science, behavioural science, and health economics research, we aim to inform strategies to improve access to and prevention-effective use of PrEP by AGYW. TRIAL REGISTRATION ClinicalTrials.gov NCT03977181 . Registered on 6 June 2019-retrospectively registered.
Collapse
Affiliation(s)
- Andrew Medina-Marino
- Research Unit, Foundation for Professional Development, 10 Rochester Rd, Vincent, East London, Buffalo City Metro, Eastern Cape Province, South Africa.
- The Desmond Tutu HIV Centre, University of Cape Town, Anzio Road, Observatory, Cape Town, South Africa.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Dana Bezuidenhout
- Research Unit, Foundation for Professional Development, 10 Rochester Rd, Vincent, East London, Buffalo City Metro, Eastern Cape Province, South Africa
| | - Sybil Hosek
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Stroger Hospital of Cook County, Chicago, IL, USA
| | - Ruanne V Barnabas
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Millicent Atujuna
- The Desmond Tutu HIV Centre, University of Cape Town, Anzio Road, Observatory, Cape Town, South Africa
| | - Charl Bezuidenhout
- Research Unit, Foundation for Professional Development, 10 Rochester Rd, Vincent, East London, Buffalo City Metro, Eastern Cape Province, South Africa
| | - Phuti Ngwepe
- Research Unit, Foundation for Professional Development, 10 Rochester Rd, Vincent, East London, Buffalo City Metro, Eastern Cape Province, South Africa
| | - Remco P H Peters
- Research Unit, Foundation for Professional Development, 10 Rochester Rd, Vincent, East London, Buffalo City Metro, Eastern Cape Province, South Africa
| | - Francesca Little
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Connie L Celum
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Joseph Daniels
- Department of Psychiatry and Human Behaviors, Charles R. Drew University of Medicine and Science, Los Angeles, USA
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Anzio Road, Observatory, Cape Town, South Africa.
| |
Collapse
|
17
|
O’Rourke S, Hartmann M, Myers L, Lawrence N, Gill K, Morton JF, Celum CL, Bekker LG, van der Straten A. The PrEP Journey: Understanding How Internal Drivers and External Circumstances Impact The PrEP Trajectory of Adolescent Girls and Young Women in Cape Town, South Africa. AIDS Behav 2021; 25:2154-2165. [PMID: 33521908 DOI: 10.1007/s10461-020-03145-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 10/22/2022]
Abstract
Despite high risk for HIV, South African adolescent girls and young women (AGYW) experience numerous challenges with adherence to PrEP. To better understand AGYW's motivations for PrEP and factors that impact PrEP adherence, we conducted serial in-depth interviews with 22 South African AGYW during a 12 month prospective study. Interviews explored motivations and initial experiences of PrEP use, patterns of adherence, social support, and reasons for stopping or persisting with PrEP. We also assessed drug levels as a biomarker of adherence; dried blood spots were collected at months 1, 2, 3, 6, and 12 to assess intracellular tenofovir diphosphate levels. An end-user journey analytical approach revealed themes related to behavioral and emotional aspects of use, including multilevel factors leading to divergent PrEP adherence trajectories. Our findings highlight how internal versus external motivations drive PrEP use, as well as how positive identity formation and challenges are handled, which are essential to understand AGYW in their PrEP journeys.
Collapse
|
18
|
O'Malley G, Beima-Sofie KM, Roche SD, Rousseau E, Travill D, Omollo V, Delany-Moretlwe S, Bekker LG, Bukusi EA, Kinuthia J, Barnabee G, Dettinger JC, Wagner AD, Pintye J, Morton JF, Johnson RE, Baeten JM, John-Stewart G, Celum CL. Health Care Providers as Agents of Change: Integrating PrEP With Other Sexual and Reproductive Health Services for Adolescent Girls and Young Women. Front Reprod Health 2021; 3:668672. [PMID: 36303982 PMCID: PMC9580786 DOI: 10.3389/frph.2021.668672] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 02/16/2021] [Accepted: 04/22/2021] [Indexed: 10/07/2023] Open
Abstract
Background: Successful integration of pre-exposure prophylaxis (PrEP) with existing reproductive health services will require iterative learning and adaptation. The interaction between the problem-solving required to implement new interventions and health worker motivation has been well-described in the public health literature. This study describes structural and motivational challenges faced by health care providers delivering PrEP to adolescent girls and young women (AGYW) alongside other SRH services, and the strategies used to overcome them. Methods: We conducted in-depth interviews (IDIs) and focus group discussions (FGDs) with HCWs from two demonstration projects delivering PrEP to AGYW alongside other SRH services. The Prevention Options for the Women Evaluation Research (POWER) is an open label PrEP study with a focus on learning about PrEP delivery in Kenyan and South African family planning, youth mobile services, and public clinics at six facilities. PrIYA focused on PrEP delivery to AGYW via maternal and child health (MCH) and family planning (FP) clinics in Kenya across 37 facilities. IDIs and FGDs were transcribed verbatim and analyzed using a combination of inductive and deductive methods. Results: We conducted IDIs with 36 participants and 8 FGDs with 50 participants. HCW described a dynamic process of operationalizing PrEP delivery to better respond to patient needs, including modifying patient flow, pill packaging, and counseling. HCWs believed the biggest challenge to sustained integration and scaling of PrEP for AGYW would be lack of health care worker motivation, primarily due to a misalignment of personal and professional values and expectations. HCWs frequently described concerns of PrEP provision being seen as condoning or promoting unprotected sex among young unmarried, sexually active women. Persuasive techniques used to overcome these reservations included emphasizing the social realities of HIV risk, health care worker professional identities, and vocational commitments to keeping young women healthy. Conclusion: Sustained scale-up of PrEP will require HCWs to value and prioritize its incorporation into daily practice. As with the provision of other SRH services, HCWs may have moral reservations about providing PrEP to AGYW. Strategies that strengthen alignment of HCW personal values with professional goals will be important for strengthening motivation to overcome delivery challenges.
Collapse
Affiliation(s)
- Gabrielle O'Malley
- Department of Global Health, University of Washington, Seattle, WA, United States
| | | | - Stephanie D. Roche
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Elzette Rousseau
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Danielle Travill
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Victor Omollo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Sinead Delany-Moretlwe
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Elizabeth A. Bukusi
- Department of Global Health, University of Washington, Seattle, WA, United States
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Departments of Obstetrics and Gynecology, University of Washington, Seattle, WA, United States
| | - John Kinuthia
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Gena Barnabee
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Julie C. Dettinger
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Anjuli D. Wagner
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Jillian Pintye
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Jennifer F. Morton
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Rachel E. Johnson
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Washington, Seattle, WA, United States
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Connie L. Celum
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| |
Collapse
|
19
|
Celum CL, Gill K, Morton JF, Stein G, Myers L, Thomas KK, McConnell M, van der Straten A, Baeten JM, Duyver M, Mendel E, Naidoo K, Dallimore J, Wiesner L, Bekker LG. Incentives conditioned on tenofovir levels to support PrEP adherence among young South African women: a randomized trial. J Int AIDS Soc 2021; 23:e25636. [PMID: 33247553 PMCID: PMC7695999 DOI: 10.1002/jia2.25636] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [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: 05/14/2020] [Revised: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 12/13/2022] Open
Abstract
Introduction HIV incidence remains high among African adolescent girls and young women (AGYW), who would benefit from pre‐exposure prophylaxis (PrEP). Strategies to increase PrEP adherence and persistence need to be evaluated in African AGY, including incentives conditional on high adherence. Methods The 3Ps for Prevention Study was a 12‐month prospective cohort of 200 women ages 16 to 25 initiating PrEP in South Africa from 2017 to 2018. Participants received retrospective feedback about drug levels at Months 1, 2 and 3; half was randomized to receive a 200 Rand shopping voucher ($13 US) at Months 2, 3 and 4, conditioned on high intracellular tenofovir diphosphate (TFV‐DP) levels in dried blood spots (≥500 fmol/punch at Month 1, ≥700 fmol/punch at Months 2 and 3). The primary analysis was intention‐to‐treat, comparing the proportion with high PrEP adherence (≥700 fmol/punch) at Month 3 by randomized group, based on 100% efficacy among men who have sex with men. Results Median age of the 200 women was 19 years (interquartile range [IQR] 17, 21); 86% had a primary sexual partner. At Month 3, the mean TFV‐DP level was 822 fmol/punch (SD 522) in the incentive group and 689 fmol/punch (SD 546) in the control group (p = 0.11). Forty‐five (56%) of 85 women in the incentive group and 35 (41%) of 85 women in the control group had TFV‐DP levels ≥700 fmol/punch (RR 1.35; 95% CI 0.98, 1.86; p = 0.067), which declined to 8% and 5% in the incentive and control groups at Month 12 (no significant difference by arm). 44% refilled PrEP without gaps, 14% had a gap of ≥3 weeks in coverage subsequently restarted PrEP and 54% accepted at the final dispensing visit at Month 9. No new HIV infections were observed after PrEP initiation. Conclusions Among South African AGYW initiating PrEP, drug levels indicated high PrEP adherence in almost half of women at Month 3, with a non‐statistically significant higher proportion with high adherence among those in the incentive group. Over half persisted with the 12‐month PrEP programme although high adherence declined after Month 3. Strategies to support PrEP adherence and persistence and longer‐acting PrEP formulations are needed.
Collapse
Affiliation(s)
- Connie L Celum
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Katherine Gill
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Jennifer F Morton
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Gabrielle Stein
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Laura Myers
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | | | | | - Ariane van der Straten
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA.,Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Menna Duyver
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Eve Mendel
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Keshani Naidoo
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Jacqui Dallimore
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Department of Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
20
|
Giovenco D, Gill K, Fynn L, Duyver M, O’Rourke S, van der Straten A, Morton JF, Celum CL, Bekker LG. Experiences of oral pre-exposure prophylaxis (PrEP) use disclosure among South African adolescent girls and young women and its perceived impact on adherence. PLoS One 2021; 16:e0248307. [PMID: 33667264 PMCID: PMC7935254 DOI: 10.1371/journal.pone.0248307] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/23/2021] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION There is limited understanding of how social dynamics impact pre-exposure prophylaxis (PrEP) adherence among adolescent girls and young women (AGYW) in generalized HIV-epidemic settings. We examined experiences of oral PrEP use disclosure to various social groups with the goal of identifying supportive relationships that can be leveraged to promote adherence. METHODS We used qualitative methods to explore experiences disclosing PrEP use and the perceived impact of disclosure on adherence among 22 South African AGYW (16-25 years) taking daily oral PrEP. Serial in-depth-interviews (IDIs) were conducted 1-, 3-, and 12-months post-PrEP initiation. Respondents also self-reported their disclosures separately for various social groups and adherence was assessed using intracellular tenofovir-diphosphate levels. RESULTS Qualitative respondents had a median age of 20.5 years and reported disclosing their PrEP use to friends (n = 36 total disclosures), partners, siblings, other family members (n = 24 disclosures each), and parents (n = 19 disclosures). IDI data revealed that parents and partners provided the most support to respondents and a lack of support from these groups was most often perceived as negatively affecting PrEP use. AGYW described difficulties explaining PrEP to their mothers, who believed PrEP was HIV treatment or would lead to HIV infection. Disclosure to household members was notably meaningful for AGYW (both positively and negatively). Respondents reported leveraging supportive relationships for pill reminders. For respondents who perceived a household member would be unsupportive, however, non-disclosure was less feasible and PrEP use was often stigmatized. To avoid stigma, several respondents hid or discontinued PrEP. CONCLUSIONS While supportive relationships may facilitate PrEP use, disclosure can also lead to stigma. Counselors should support AGYW in disclosing to key people in their social networks and provide AGYW with materials that lend credibility to explanations of PrEP. Community education is necessary to alleviate PrEP-related stigma and facilitate disclosure.
Collapse
Affiliation(s)
- Danielle Giovenco
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Katherine Gill
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Lauren Fynn
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Menna Duyver
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Shannon O’Rourke
- RTI International, Women’s Global Health Imperative, Berkeley, CA, United States of America
| | - Ariane van der Straten
- RTI International, Women’s Global Health Imperative, Berkeley, CA, United States of America
- Center for AIDS Prevention Studies, Department of Medicine, UCSF, San Francisco, CA, United States of America
| | - Jennifer F. Morton
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Connie L. Celum
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Departments of Medicine and Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
21
|
Musinguzi N, Kidoguchi L, Mugo NR, Ngure K, Katabira E, Celum CL, Baeten JM, Heffron R, Haberer JE. Adherence to recommendations for ART and targeted PrEP use among HIV serodiscordant couples in East Africa: the "PrEP as a bridge to ART" strategy. BMC Public Health 2020; 20:1621. [PMID: 33115478 PMCID: PMC7594426 DOI: 10.1186/s12889-020-09712-3] [Citation(s) in RCA: 5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 10/15/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND PrEP use should be aligned with periods of risk for HIV acquisition. For HIV serodiscordant couples, PrEP can be used as a bridge until the partner living with HIV takes antiretroviral therapy (ART) long enough to achieve viral suppression (the "PrEP as a Bridge to ART" strategy). However, adherence to this strategy is unknown. METHODS In a demonstration project in Kenya and Uganda, HIV-uninfected partners of serodiscordant couples were advised to take PrEP until the partner living with HIV took ART for ≥ 6 months. PrEP discontinuation was then recommended unless there were concerns about ART adherence, immediate fertility intentions, or outside partners with unknown HIV/ART status. Electronic adherence monitoring and socio-behavioral questionnaire data were used in logistic regression models to explore completion of this strategy and continuation of PrEP beyond recommendations to stop its use. RESULTS Among 833 serodiscordant couples, 436 (52%) HIV-uninfected partners completed ≥ 6 months of PrEP as a bridge to ART. Strategy completion was associated with older age (aOR per 5 years = 1.1; p = 0.008) and having fewer children (aOR = 0.9; p = 0.019). Of the 230 participants encouraged to stop PrEP according to strategy recommendations, 170 (74%) did so. PrEP continuation among the remaining 60 participants was associated with more education (aOR = 1.1; p = 0.029), a preference for PrEP over ART (aOR = 3.6; p = 0.026), comfort with managing their serodiscordant relationship (aOR = 0.6; p = 0.046), and believing PrEP makes sex safe (aOR = 0.5; p = 0.026). CONCLUSION Half of participants completed the PrEP as a bridge to ART strategy and the majority stopped PrEP as recommended. These findings suggest that targeting PrEP to periods of risk is a promising approach; however, tailoring counseling around aligning PrEP use and HIV risk will be important for optimal strategy implementation.
Collapse
Affiliation(s)
- Nicholas Musinguzi
- grid.33440.300000 0001 0232 6272Global Health Collaborative, Mbarara University of Science and Technology, P. O Box 434, Mbarara, Uganda
| | - Lara Kidoguchi
- grid.34477.330000000122986657Department of Medicine, University of Washington, Seattle, USA
| | - Nelly R. Mugo
- grid.33058.3d0000 0001 0155 5938Centres for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya ,grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, USA
| | - Kenneth Ngure
- grid.411943.a0000 0000 9146 7108School of Public Health, Jomo Kenyatta University of Agriculture and Technology Nairobi, Nairobi, Kenya
| | - Elly Katabira
- grid.11194.3c0000 0004 0620 0548Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Connie L. Celum
- grid.34477.330000000122986657Department of Medicine, University of Washington, Seattle, USA ,grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, USA ,grid.34477.330000000122986657Department of Epidemiology, University of Washington, Seattle, USA
| | - Jared M. Baeten
- grid.34477.330000000122986657Department of Medicine, University of Washington, Seattle, USA ,grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, USA ,grid.34477.330000000122986657Department of Epidemiology, University of Washington, Seattle, USA
| | - Renee Heffron
- grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, USA ,grid.34477.330000000122986657Department of Epidemiology, University of Washington, Seattle, USA
| | - Jessica E. Haberer
- grid.32224.350000 0004 0386 9924Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | | |
Collapse
|
22
|
Shapiro AE, van Heerden A, Krows M, Sausi K, Sithole N, Schaafsma TT, Koole O, van Rooyen H, Celum CL, Barnabas RV. An implementation study of oral and blood-based HIV self-testing and linkage to care among men in rural and peri-urban KwaZulu-Natal, South Africa. J Int AIDS Soc 2020; 23 Suppl 2:e25514. [PMID: 32589337 PMCID: PMC7319114 DOI: 10.1002/jia2.25514] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [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: 09/27/2019] [Revised: 04/02/2020] [Accepted: 04/22/2020] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION In South Africa, HIV-infected men are less likely than women to test and know their status (the first UNAIDS "90-90-90" target), and men have worse outcomes across the HIV care cascade. HIV self-testing (HIVST) may address this testing disparity but questions remain over the most effective distribution strategy and linkage following a positive test result. We implemented a men-focused HIVST distribution programme to evaluate components contributing to participation and retention. METHODS We conducted an implementation study of multi-venue HIVST kit distribution in rural and peri-urban KwaZulu-Natal (KZN), South Africa. We distributed HIVST kits at community points, workplaces and social venues for on site or take-home use. Clients could choose blood-based or oral-fluid-based HIVST kits and elect to watch an in-person or video demonstration. We provided a USD2 incentive to facilitate reporting test results by phone or SMS. Persons with reactive HIVST results were provided immediate confirmatory tests (if used HIVST on site) or were referred for confirmatory testing (if took HIVST off site) and linkage to care for ART initiation. We describe the testing and linkage cascade in this sample and describe predictors of reactive HIVST results and linkage. RESULTS Between July and November 2018, we distributed 4496 HIVST kits in two regions of KZN (96% to men, median age 28 (IQR 23 to 35). Most participants (58%) chose blood-based HIVST and 42% chose oral-swab kits. 11% of men were testing for the first time. A total of 3902 (83%) of testers reported their test result to the study team, with 314 (8%) screening positive for HIV. Among 274 men with reactive HIVST results, 68% linked to ART; no significant predictors of linkage were identified. 10% of kit users reported they would prefer a different type (oral vs. blood) of kit for repeat testing than the type they used. CONCLUSIONS HIVST is acceptable to men and rapid distribution with optional testing support is feasible in rural and peri-urban settings. HIVST kits successfully reached younger men and identified undetected infections. Both oral and blood-based HIVST were selected. Scaling up HIVST distribution and guidance may increase the number of first-time testers among men and help achieve the first UNAIDS "90" for men in South Africa.
Collapse
Affiliation(s)
- Adrienne E Shapiro
- Department of Global HealthUniversity of WashingtonSeattleUSA
- Department of MedicineDivision of Infectious DiseasesUniversity of WashingtonSeattleUSA
| | - Alastair van Heerden
- Human Sciences Research CouncilSweetwatersSouth Africa
- MRC/Wits Developmental Pathways for Health Research Unit (DPHRU)University of the WitwatersrandJohannesburg‐BraamfonteinSouth Africa
| | - Meighan Krows
- Department of Global HealthUniversity of WashingtonSeattleUSA
| | - Kombi Sausi
- MRC/Wits Developmental Pathways for Health Research Unit (DPHRU)University of the WitwatersrandJohannesburg‐BraamfonteinSouth Africa
| | - Nsika Sithole
- Africa Health Research InstituteMtubatubaSouth Africa
| | | | - Olivier Koole
- Africa Health Research InstituteMtubatubaSouth Africa
- London School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Heidi van Rooyen
- Human Sciences Research CouncilSweetwatersSouth Africa
- MRC/Wits Developmental Pathways for Health Research Unit (DPHRU)University of the WitwatersrandJohannesburg‐BraamfonteinSouth Africa
| | - Connie L Celum
- Department of Global HealthUniversity of WashingtonSeattleUSA
- Department of MedicineDivision of Infectious DiseasesUniversity of WashingtonSeattleUSA
| | - Ruanne V Barnabas
- Department of Global HealthUniversity of WashingtonSeattleUSA
- Department of MedicineDivision of Infectious DiseasesUniversity of WashingtonSeattleUSA
| |
Collapse
|
23
|
Barnabas RV, van Heerden A, McConnell M, Szpiro AA, Krows ML, Schaafsma TT, Ngubane T, Nxele RB, Joseph P, Baeten JM, Celum CL, van Rooyen H. Lottery incentives have short-term impact on ART initiation among men: results from a randomized pilot study. J Int AIDS Soc 2020; 23 Suppl 2:e25519. [PMID: 32589342 PMCID: PMC7319109 DOI: 10.1002/jia2.25519] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 09/27/2019] [Revised: 04/22/2020] [Accepted: 04/23/2020] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Among people living with HIV in South Africa, viral suppression is lower among men than women. The study aim was to test the impact of lottery incentives, which reward positive health choice (e.g. antiretroviral therapy (ART) linkage) with a chance to win a prize, on strengthening the HIV care continuum including ART initiation and viral suppression for men. METHODS We conducted a randomized, prospective trial of lottery incentives in the context of HIV testing and linkage to ART in rural KwaZulu-Natal, South Africa. Men living with HIV were randomly allocated to: lottery incentives and motivational text messages or motivational text messages only. Lottery prize eligibility was conditional on clinic registration, ART initiation, or viral suppression by one, three and six months respectively. After completing each continuum step, participants in the lottery group were notified whether they had won and were encouraged to continue in care. Lottery prizes were either a mobile phone, data or a gift card (valued at R1000/$100). Kaplan-Meier curves were plotted to determine time to ART initiation by study group. The primary outcome was viral suppression at six months. RESULTS Between November 2017 and December 2018, we tested 740 men for HIV and enrolled 131 HIV-positive men who reported not being on ART. At baseline, 100 (76%) participants were 30 years and older, 95 (73%) were unemployed and the median CD4 count was 472 cells/μL. At study exit, 84% (110/131) of participants had visited a clinic and 62% (81/131) were virally suppressed. Compared to motivational text messages, lottery incentives decreased the median time to ART initiation from 126 to 66 days (p = 0.0043, age-adjusted Cox regression) among all participants, and, from 134 days to 20 days (p = 0.0077) among participants who were not virally suppressed at baseline. Lottery incentives had an inconclusive effect on clinic registration (RR = 1.21, 95% CI: 0.83 to 1.76) and on viral suppression at six months (RR = 1.13, 95% CI: 0.73 to 1.75) compared to motivational text messages. CONCLUSIONS Conditional lottery incentives shortened the time to ART initiation among South African men. Behavioural economics strategies strengthen linkage to ART, but the study power was limited to see an impact on viral suppression. CLINICAL TRIAL NUMBER NCT03808194.
Collapse
Affiliation(s)
- Ruanne V Barnabas
- Department of Global Health and Division of Allergy and Infectious DiseasesUniversity of WashingtonSeattleWAUSA
- Vaccine and Infectious Diseases DivisionFred Hutchinson Cancer Research CenterSeattleWAUSA
| | - Alastair van Heerden
- Human Sciences Research CouncilSweetwatersKwaZulu‐NatalSouth Africa
- MRC/Wits Developmental Pathways for Health Research UnitUniversity of the WitwatersrandJohannesburg‐BraamfonteinSouth Africa
| | | | - Adam A Szpiro
- Department of BiostatisticsUniversity of WashingtonSeattleWAUSA
| | - Meighan L Krows
- Department of Global Health and Division of Allergy and Infectious DiseasesUniversity of WashingtonSeattleWAUSA
| | - Torin T Schaafsma
- Department of Global Health and Division of Allergy and Infectious DiseasesUniversity of WashingtonSeattleWAUSA
| | - Thulani Ngubane
- Human Sciences Research CouncilSweetwatersKwaZulu‐NatalSouth Africa
| | - Rose B Nxele
- Human Sciences Research CouncilSweetwatersKwaZulu‐NatalSouth Africa
| | - Philip Joseph
- Human Sciences Research CouncilSweetwatersKwaZulu‐NatalSouth Africa
| | - Jared M Baeten
- Department of Global Health and Division of Allergy and Infectious DiseasesUniversity of WashingtonSeattleWAUSA
| | - Connie L Celum
- Department of Global Health and Division of Allergy and Infectious DiseasesUniversity of WashingtonSeattleWAUSA
| | - Heidi van Rooyen
- Human Sciences Research CouncilSweetwatersKwaZulu‐NatalSouth Africa
- MRC/Wits Developmental Pathways for Health Research UnitUniversity of the WitwatersrandJohannesburg‐BraamfonteinSouth Africa
| |
Collapse
|
24
|
Celum CL, Delany‐Moretlwe S, Baeten JM, van der Straten A, Hosek S, Bukusi EA, McConnell M, Barnabas RV, Bekker L. HIV pre-exposure prophylaxis for adolescent girls and young women in Africa: from efficacy trials to delivery. J Int AIDS Soc 2019; 22 Suppl 4:e25298. [PMID: 31328444 PMCID: PMC6643076 DOI: 10.1002/jia2.25298] [Citation(s) in RCA: 107] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 05/10/2019] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Adolescent girls and young women (AGYW) in Africa have high HIV incidence despite scale-up of HIV testing and HIV treatment. Placebo-controlled trials of tenofovir-based pre-exposure prophylaxi (PrEP) in diverse populations demonstrated that PrEP works with close to 100% effectiveness if taken with high, but not perfect, adherence. Divergent efficacy estimates among African AGYW led to demonstration and implementation projects to better understand motivations for HIV prevention, uptake, adherence and persistence to PrEP. To inform PrEP programmes, the design and initial findings from PrEP demonstration projects for AGYW are reviewed. DISCUSSION Early lessons from PrEP implementation projects among young African women include: (1) awareness and demand creation with positive messaging about the benefits of PrEP are critical to motivate AGYW to consider this novel prevention technology and to foster awareness among peers, partners, parents and guardians to support AGYW's effective PrEP use; (2) PrEP initiation is high in projects that are integrating PrEP into youth-friendly clinics, family planning clinics and mobile clinics; (3) young African women at risk are initiating PrEP, based on behavioural characteristics, history of intimate partner violence, depression and 30% prevalence of chlamydia and/or gonorrhoea; (4) provision of youth-friendly PrEP delivery programmes that integrate reproductive health services, including contraception and the diagnosis and treatment of sexually transmitted infections, increase health impact; (5) messages that emphasize the necessity for high adherence while at potential risk of HIV exposure and support strategies that addresses AGYW's adherence challenges are essential; and, (6) a substantial proportion of AGYW do not persist with PrEP, and strategies are needed to help AGYW assess their ongoing need, motivation and challenges with persisting with PrEP. CONCLUSIONS PrEP is feasible to implement in integrated reproductive health service delivery models to reach African AGYW. While PrEP demonstration projects indicate that women with behavioural risks and high rates of sexually transmitted diseases are initiating PrEP; effective strategies to support AGYW's adherence and persistence with PrEP are needed. Lessons learned from oral PrEP delivery, a novel first generation HIV prevention product, are relevant to longer-acting and less adherence-dependent strategies which are currently in clinical trials.
Collapse
Affiliation(s)
- Connie L Celum
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | - Sinead Delany‐Moretlwe
- Wits Reproductive Health and HIV InstituteUniversity of WitswatersrandJohannesburgSouth Africa
| | - Jared M Baeten
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | | | - Sybil Hosek
- Department of PsychiatryStroger HospitalChicagoILUSA
| | - Elizabeth A Bukusi
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Kenya Medical Research InstituteNairobiKenya
- Departments of Obstetrics‐GynecologyUniversity of WashingtonSeattleWAUSA
| | - Margaret McConnell
- Department of Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonMAUSA
| | - Ruanne V Barnabas
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | | |
Collapse
|
25
|
Sugarman J, Celum CL, Donnell D, Mayer KH. Ethical considerations for new HIV prevention trials. Lancet HIV 2019; 6:e489-e491. [PMID: 31221591 DOI: 10.1016/s2352-3018(19)30184-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/10/2019] [Accepted: 05/21/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Jeremy Sugarman
- Berman Institute of Bioethics, School of Medicine, and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA.
| | - Connie L Celum
- Global Health, Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Deborah Donnell
- Vaccine and Infectious Disease Division, Fred Hutchison Cancer Research Center, Seattle, WA, USA
| | - Kenneth H Mayer
- Beth Israel Deaconess Medical Center, Harvard Medical School and Fenway Health, Boston, MA, USA
| |
Collapse
|
26
|
Shapiro AE, van Heerden A, Schaafsma TT, Hughes JP, Baeten JM, van Rooyen H, Tumwesigye E, Celum CL, Barnabas RV. Completion of the tuberculosis care cascade in a community-based HIV linkage-to-care study in South Africa and Uganda. J Int AIDS Soc 2019; 21. [PMID: 29381257 PMCID: PMC5810338 DOI: 10.1002/jia2.25065] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 07/28/2017] [Accepted: 12/28/2017] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Tuberculosis (TB) is the leading cause of HIV-associated mortality in Africa. As HIV testing, linkage to care and antiretroviral treatment initiation intensify to meet UNAIDS targets, it is not known what effect these efforts will have on TB detection and prevention. We aimed to characterize the TB care cascade of screening, diagnostic testing, treatment and provision of isoniazid preventive therapy (IPT) in a study of community-based HIV screening and linkage to care and determine whether symptom screening results affected progress along the cascade. METHODS Between June 2013 and March 2015, HIV-infected adults enrolled in the Linkages study, a multi-site, community-based, randomized HIV screening and linkage-to-care study in South Africa and Uganda. All participants were screened for TB symptoms at entry after testing positive for HIV and referred to local clinics for care. During the 9 month follow-up, participants were periodically surveyed about clinic linkage and initiation of HIV care as well as subsequent TB testing, treatment, or IPT. We compared outcomes between persons with and without a positive symptom screen at baseline using descriptive statistics and Poisson regression to calculate relative risks of outcomes along the care cascade. RESULTS AND DISCUSSION Of the 1,325 HIV-infected adults enrolled, 26% reported at least one TB symptom at the time of HIV diagnosis. Loss of appetite and fever were the most commonly reported symptoms on a TB symptom screen. Despite 92% HIV linkage success, corresponding TB linkage was incomplete. Baseline TB symptoms were associated with an increased risk of a TB diagnosis (relative risk 3.23, 95% CI 1.51 to 6.91), but only 34% of symptomatic persons had sputum TB testing. Fifty-five percent of participants diagnosed with TB started TB treatment. In South Africa, only 18% of asymptomatic participants initiated IPT after linkage to HIV care, and presence of symptoms was not associated with IPT initiation (relative risk 0.86 95% CI 0.6 to 1.23). CONCLUSIONS HIV linkage to care interventions provide an opportunity to improve completion of the TB care cascade, but will require additional support to realize full benefits.
Collapse
Affiliation(s)
- Adrienne E Shapiro
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | | | - Torin T Schaafsma
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - James P Hughes
- Department of Biostatistics, University of Washington, Seattle, WA, USA.,Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Heidi van Rooyen
- Human Services Research Council, Sweetwaters, South Africa.,School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Connie L Celum
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Ruanne V Barnabas
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA.,Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| |
Collapse
|
27
|
Nakku‐Joloba E, Pisarski EE, Wyatt MA, Muwonge TR, Asiimwe S, Celum CL, Baeten JM, Katabira ET, Ware NC. Beyond HIV prevention: everyday life priorities and demand for PrEP among Ugandan HIV serodiscordant couples. J Int AIDS Soc 2019; 22:e25225. [PMID: 30657642 PMCID: PMC6338102 DOI: 10.1002/jia2.25225] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 12/05/2018] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Pre-exposure prophylaxis (PrEP) to prevent HIV infection is being rolled out in Africa. The uptake of PrEP to date has varied across populations and locations. We seek to understand the drivers of demand for PrEP through analysis of qualitative data collected in conjunction with a PrEP demonstration project involving East African HIV serodiscordant couples. Our goal was to inform demand creation by understanding what PrEP means - beyond HIV prevention - for the lives of users. METHODS The Partners Demonstration Project evaluated an integrated strategy of PrEP and antiretroviral therapy (ART) delivery in which time-limited PrEP served as a "bridge" to long-term ART. Uninfected partners in HIV serodiscordant couples were offered PrEP at baseline and encouraged to discontinue once infected partners had taken ART for six months. We conducted 274 open-ended interviews with 93 couples at two Ugandan research sites. Interviews took place one month after enrolment and at later points in the follow-up period. Topics included are as follows: (1) discovery of serodiscordance; (2) decisions to accept/decline PrEP and/or ART; (3) PrEP and ART initiation; (4) experiences of using PrEP and ART; (5) PrEP discontinuation; (6) impact of PrEP and ART on the partnered relationship. Interviews were audio-recorded and transcribed. We used an inductive, content analytic approach to characterize meanings of PrEP stemming from its effectiveness for HIV prevention. Relevant content was represented as descriptive categories. RESULTS Discovery of HIV serodiscordance resulted in fear of HIV transmission for couples, which led to loss of sexual intimacy in committed relationships, and to abandonment of plans for children. As a result, partners became alienated from each other. PrEP countered the threat to the relationship by reducing fear and reinstating hopes of having children together. Condom use worked against the re-establishment of intimacy and closeness. By increasing couples' sense of protection against HIV infection and raising the prospect of a return to "live sex" (sex without condoms), PrEP was perceived by couples as solving the problem of serodiscordance and preserving committed relationships. CONCLUSIONS The most effective demand creation strategies for PrEP may be those that address the everyday life priorities of potential users in addition to HIV prevention. CLINICAL TRIAL NUMBER NCT02775929.
Collapse
Affiliation(s)
- Edith Nakku‐Joloba
- Department of Epidemiology and BiostatisticsMakerere University College of Health SciencesKampalaUganda
- STD Clinic/Ward 12Mulago HospitalKampalaUganda
| | - Emily E Pisarski
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMAUSA
| | - Monique A Wyatt
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMAUSA
- Harvard GlobalCambridgeMAUSA
| | | | | | - Connie L Celum
- Departments of Global Health, Medicine, and EpidemiologySchool of Medicine and School of Public HealthUniversity of WashingtonSeattleWAUSA
| | - Jared M Baeten
- Departments of Global Health, Medicine, and EpidemiologySchool of Medicine and School of Public HealthUniversity of WashingtonSeattleWAUSA
| | | | - Norma C Ware
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMAUSA
- Department of MedicineBrigham & Women's HospitalBostonMAUSA
| |
Collapse
|
28
|
Gilbert HN, Wyatt MA, Asiimwe S, Turyamureeba B, Tumwesigye E, Van Rooyen H, Barnabas RV, Celum CL, Ware NC. Messaging Circumstances and Economic Pressures as Influences on Linkage to Medical Male Circumcision following Community-Based HIV Testing for Men in Rural Southwest Uganda: A Qualitative Study. AIDS Res Treat 2018; 2018:8387436. [PMID: 29854445 PMCID: PMC5960566 DOI: 10.1155/2018/8387436] [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] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/26/2018] [Indexed: 12/03/2022] Open
Abstract
Voluntary medical male circumcision (MMC) reduces risk of HIV infection, but uptake remains suboptimal among certain age groups and locations in sub-Saharan Africa. We analysed qualitative data as part of the Linkages Study, a randomized controlled trial to evaluate community-based HIV testing and follow-up as interventions promoting linkage to HIV treatment and prevention in Uganda and South Africa. Fifty-two HIV-negative uncircumcised men participated in the qualitative study. They participated in semistructured individual interviews exploring (a) home HTC experience; (b) responses to test results; (c) efforts to access circumcision services; (d) outcomes of efforts; (e) experiences of follow-up support; and (f) local HIV education and support. Interviews were audio-recorded, translated, transcribed, and summarized into "linkage summaries." Summaries were analysed inductively to identify the following three thematic experiences shaping men's circumcision choices: (1) intense relief upon receipt of an unanticipated seronegative diagnosis, (2) the role of peer support in overcoming fear, and (3) anticipation of missed economic productivity. Increased attention to the timing of demand creation activities, to who delivers information about the HIV prevention benefits of MMC, and to the importance of missed income during recovery as a barrier to uptake promises to strengthen and sharpen future MMC demand creation strategies.
Collapse
Affiliation(s)
- Hannah N. Gilbert
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Monique A. Wyatt
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Harvard Global, Cambridge, MA, USA
| | | | | | | | - Heidi Van Rooyen
- Human Sciences Research Council, Durban, South Africa
- School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ruanne V. Barnabas
- Department of Global Health, School of Medicine and School of Public Health, University of Washington, Seattle, WA, USA
| | - Connie L. Celum
- Department of Global Health, School of Medicine and School of Public Health, University of Washington, Seattle, WA, USA
| | - Norma C. Ware
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
29
|
Ware NC, Pisarski EE, Nakku‐Joloba E, Wyatt MA, Muwonge TR, Turyameeba B, Asiimwe SB, Heffron RA, Baeten JM, Celum CL, Katabira ET. Integrated delivery of antiretroviral treatment and pre-exposure prophylaxis to HIV-1 serodiscordant couples in East Africa: a qualitative evaluation study in Uganda. J Int AIDS Soc 2018; 21:e25113. [PMID: 29851436 PMCID: PMC5980503 DOI: 10.1002/jia2.25113] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [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: 08/31/2017] [Accepted: 05/04/2018] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Serodiscordant couples are a priority population for delivery of new HIV prevention interventions in Africa. An integrated strategy of delivering time-limited, oral pre-exposure prophylaxis (PrEP) to uninfected partners in serodiscordant couples as a bridge to long-term antiretroviral treatment (ART) for infected partners has been implemented in East Africa, nearly eliminating new infections. We conducted a qualitative evaluation of the integrated strategy in Uganda, to better understand its success. METHODS Data collection consisted of 274 in-depth interviews with 93 participating couples, and 55 observations of clinical encounters between couples and healthcare providers. An inductive content analytic approach aimed at understanding and interpreting couples' experiences of the integrated strategy was used to examine the data. Analysis sought to characterize: (1) key aspects of services provided; (2) what the services meant to recipients; and (3) how couples managed the integrated strategy. Themes were identified in each domain, and represented as descriptive categories. Categories were grouped inductively into more general propositions based on shared content. Propositions were linked and interpreted to explain "why the integrated strategy worked." RESULTS Couples found "couples-focused" services provided through the integrated strategy strengthened partnered relationships threatened by the discovery of serodiscordance. They saw in services hope for "getting help" to stay together, turned joint visits to clinic into opportunities for mutual support, and experienced counselling as bringing them closer together. Couples adopted a "couples orientation" to the integrated strategy, considering the health of partners as they made decisions about initiating ART or accepting PrEP, and devising joint approaches to adherence. A couples orientation to services, grounded in strengthened partnerships, may have translated to greater success in using antiretrovirals to prevent HIV transmission. CONCLUSIONS Various strategies for delivering antiretrovirals for HIV prevention are being evaluated. Understanding how and why these strategies work will improve evaluation processes and strengthen implementation platforms. We highlight the role of service organization in shaping couples' experiences of and responses to ART and PrEP in the context of the integrated strategy. Organizing services to promote positive care experiences will strengthen delivery and contribute to positive outcomes as antiretrovirals for prevention are rolled out.
Collapse
Affiliation(s)
- Norma C Ware
- Department of MedicineBrigham and Women's HospitalBostonMAUSA
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMAUSA
| | - Emily E Pisarski
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMAUSA
| | - Edith Nakku‐Joloba
- Department of Epidemiology and BiostatisticsMakerere University College of Health SciencesKampalaUganda
- STD Clinic/Ward 12Mulago HospitalKampalaUganda
| | - Monique A Wyatt
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMAUSA
- Harvard GlobalCambridgeMAUSA
| | | | | | | | - Renee A Heffron
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Jared M Baeten
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Connie L Celum
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | | |
Collapse
|
30
|
Ross JM, Ying R, Celum CL, Baeten JM, Thomas KK, Murnane PM, van Rooyen H, Hughes JP, Barnabas RV. Modeling HIV disease progression and transmission at population-level: The potential impact of modifying disease progression in HIV treatment programs. Epidemics 2017; 23:34-41. [PMID: 29223580 DOI: 10.1016/j.epidem.2017.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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] [Received: 01/31/2017] [Revised: 09/15/2017] [Accepted: 12/01/2017] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Mathematical models that incorporate HIV disease progression dynamics can estimate the potential impact of strategies that delay HIV disease progression and reduce infectiousness for persons not on antiretroviral therapy (ART). Suppressive treatment of HIV-positive persons co-infected with herpes simplex virus-2 (HSV-2) with valacyclovir, an HSV-2 antiviral, can lower HIV viral load, but the impact of partially-suppressive valacyclovir relative to fully-suppressive ART on population HIV transmission has not been estimated. METHODS We modeled HIV disease progression as a function of changes in viral load and CD4 count over time among ART naïve persons. The disease progression Markov model was nested within a dynamic model of HIV transmission at population level. We assumed that valacyclovir reduced HIV viral load by 1.23 log copies/μL, and that persons treated with valacyclovir initiated ART more rapidly when their CD4 fell below 500 due to retention in HIV care. We estimated the potential impact of valacyclovir on onward transmission of HIV in three scenarios of different ART and valacyclovir population coverage. RESULTS The average duration of HIV infection was 9.5 years. The duration of disease before reaching CD4 200cells/μL was 2.53 years longer for females than males. Relative to a baseline of ART initiation at CD4≤500cells/μL, the valacyclovir scenario resulted in 167,000 fewer HIV infections over ten years, with an incremental cost-effectiveness ratio (ICER) of $5276 per HIV infection averted. A Test and Treat scenario with 70% ART coverage and no valacyclovir resulted in 350,000 fewer HIV infections at an ICER of $2822 and $812 per HIV infection averted and QALY gained, respectively. CONCLUSION Even when compared with valacyclovir suppression, a drug that reduces HIV viral load, universal treatment for HIV is the optimal strategy for averting new infections and increasing public health benefit. Universal HIV treatment would most effectively and efficiently reduce the HIV burden.
Collapse
Affiliation(s)
- Jennifer M Ross
- Department of Medicine, University of Washington, Seattle, WA, USA; Division of Allergy and Infectious Disease, University of Washington, 1959 NE Pacific St., Box 356423, Seattle, WA 98195, USA.
| | - Roger Ying
- Weill Cornell Medical College, Cornell University, 420 E 70th St., 12J-3, New York, NY 10021, USA.
| | - Connie L Celum
- Department of Medicine, University of Washington, Seattle, WA, USA; Department of Global Health, University of Washington, 325 9th Ave., Box 359927, Seattle, WA 98104-2420, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Division of Allergy and Infectious Disease, University of Washington, 1959 NE Pacific St., Box 356423, Seattle, WA 98195, USA.
| | - Jared M Baeten
- Department of Medicine, University of Washington, Seattle, WA, USA; Department of Global Health, University of Washington, 325 9th Ave., Box 359927, Seattle, WA 98104-2420, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Division of Allergy and Infectious Disease, University of Washington, 1959 NE Pacific St., Box 356423, Seattle, WA 98195, USA.
| | - Katherine K Thomas
- Department of Global Health, University of Washington, 325 9th Ave., Box 359927, Seattle, WA 98104-2420, USA.
| | - Pamela M Murnane
- Department of Global Health, University of Washington, 325 9th Ave., Box 359927, Seattle, WA 98104-2420, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco.
| | | | - James P Hughes
- Department of Biostatistics, University of Washington, 1959 NE Pacific St., Box 357232, Seattle, WA 98195, USA; Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
| | - Ruanne V Barnabas
- Department of Medicine, University of Washington, Seattle, WA, USA; Department of Global Health, University of Washington, 325 9th Ave., Box 359927, Seattle, WA 98104-2420, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Division of Allergy and Infectious Disease, University of Washington, 1959 NE Pacific St., Box 356423, Seattle, WA 98195, USA.
| |
Collapse
|
31
|
Buttolph J, Inwani I, Agot K, Cleland CM, Cherutich P, Kiarie JN, Osoti A, Celum CL, Baeten JM, Nduati R, Kinuthia J, Hallett TB, Alsallaq R, Kurth AE. Gender-Specific Combination HIV Prevention for Youth in High-Burden Settings: The MP3 Youth Observational Pilot Study Protocol. JMIR Res Protoc 2017; 6:e22. [PMID: 28274904 PMCID: PMC5434770 DOI: 10.2196/resprot.5833] [Citation(s) in RCA: 6] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 11/04/2016] [Accepted: 01/21/2017] [Indexed: 11/21/2022] Open
Abstract
Background Nearly three decades into the epidemic, sub-Saharan Africa (SSA) remains the region most heavily affected by human immunodeficiency virus (HIV), with nearly 70% of the 34 million people living with HIV globally residing in the region. In SSA, female and male youth (15 to 24 years) are at a disproportionately high risk of HIV infection compared to adults. As such, there is a need to target HIV prevention strategies to youth and to tailor them to a gender-specific context. This protocol describes the process for the multi-staged approach in the design of the MP3 Youth pilot study, a gender-specific, combination, HIV prevention intervention for youth in Kenya. Objective The objective of this multi-method protocol is to outline a rigorous and replicable methodology for a gender-specific combination HIV prevention pilot study for youth in high-burden settings, illustrating the triangulated methods undertaken to ensure that age, sex, and context are integral in the design of the intervention. Methods The mixed-methods, cross-sectional, longitudinal cohort pilot study protocol was developed by first conducting a systematic review of the literature, which shaped focus group discussions around prevention package and delivery options, and that also informed age- and sex- stratified mathematical modeling. The review, qualitative data, and mathematical modeling created a triangulated evidence base of interventions to be included in the pilot study protocol. To design the pilot study protocol, we convened an expert panel to select HIV prevention interventions effective for youth in SSA, which will be offered in a mobile health setting. The goal of the pilot study implementation and evaluation is to apply lessons learned to more effective HIV prevention evidence and programming. Results The combination HIV prevention package in this protocol includes (1) offering HIV testing and counseling for all youth; (2) voluntary medical circumcision and condoms for males; (3) pre-exposure prophylaxis (PrEP), conditional cash transfer (CCT), and contraceptives for females; and (4) referrals for HIV care among those identified as HIV-positive. The combination package platform selected is mobile health teams in an integrated services delivery model. A cross-sectional analysis will be conducted to determine the uptake of the interventions. To determine long-term impact, the protocol outlines enrolling selected participants in mutually exclusive longitudinal cohorts (HIV-positive, PrEP, CCT, and HIV-negative) followed by using mobile phone text messages (short message service, SMS) and in-person surveys to prospectively assess prevention method uptake, adherence, and risk compensation behaviors. Cross-sectional and sub-cohort analyses will be conducted to determine intervention packages uptake. Conclusions The literature review, focus groups, and modeling indicate that offering age- and gender- specific combination HIV prevention interventions that include biomedical, behavioral, and structural interventions can have an impact on HIV risk reduction. Implementing this protocol will show the feasibility of delivering these services at scale. The MP3 Youth study is one of the few combination HIV prevention intervention protocols incorporating youth- and gender-specific interventions in one delivery setting. Lessons learned from the design of the protocol can be incorporated into the national guidance for combination HIV prevention for youth in Kenya and other high-burden SSA settings. Trial Registration ClinicalTrials.gov NCT01571128; http://clinicaltrials.gov/ct2/show/NCT01571128?term=MP3+youth&rank=1 (Archived by WebCite at http://www.webcitation.org/6nmioPd54)
Collapse
Affiliation(s)
- Jasmine Buttolph
- New York University, College of Nursing Global, New York, NY, United States
| | - Irene Inwani
- University of Nairobi, Kenyatta National Hospital, Nairobi, Kenya
| | - Kawango Agot
- Impact Research & Development Organization (IRDO), Kisumu, Kenya
| | - Charles M Cleland
- New York University, College of Nursing Global, New York, NY, United States
| | - Peter Cherutich
- Kenya Ministry of Health, National AIDS & STI Control Program (NASCOP), Nairobi, Kenya
| | - James N Kiarie
- University of Nairobi, Kenyatta National Hospital, Nairobi, Kenya
| | - Alfred Osoti
- Department of Obstetrics and Gynecology, Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - Connie L Celum
- University of Washington, School of Public Health, Seattle, WA, United States
| | - Jared M Baeten
- University of Washington, School of Public Health, Seattle, WA, United States
| | - Ruth Nduati
- University of Nairobi, Kenyatta National Hospital, Nairobi, Kenya
| | - John Kinuthia
- University of Nairobi, Kenyatta National Hospital, Nairobi, Kenya
| | - Timothy B Hallett
- Imperial College London, Department of Infectious Disease Epidemiology, London, United Kingdom
| | - Ramzi Alsallaq
- New York University, College of Nursing Global, New York, NY, United States
| | - Ann E Kurth
- New York University, College of Nursing Global, New York, NY, and Yale School of Nursing, New Haven, CT, United States
| |
Collapse
|
32
|
Kirkpatrick AR, Patel EU, Celum CL, Moore RD, Blankson JN, Mehta SH, Kirk GD, Margolick JB, Quinn TC, Eshleman SH, Laeyendecker O. Development and Evaluation of a Modified Fourth-Generation Human Immunodeficiency Virus Enzyme Immunoassay for Cross-Sectional Incidence Estimation in Clade B Populations. AIDS Res Hum Retroviruses 2016; 32:756-62. [PMID: 26988426 DOI: 10.1089/aid.2015.0198] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Accurate methods for cross-sectional incidence estimation are needed for HIV surveillance and prevention research. We developed an avidity assay based on the fourth-generation Genetic Systems HIV Combo Ag/Ab EIA (Bio-Rad Combo assay) and evaluated its performance. MATERIALS AND METHODS The Bio-Rad Combo assay was modified incubating samples with and without 0.025 M diethylamine (DEA). The avidity index (AI) was calculated as the ratio of the DEA-treated to untreated result for a specific sample. We analyzed 2,140 samples from 808 individuals from the United States with known duration of HIV infection. The mean duration of recent infection (MDRI) and the false-recent rate (FRR, fraction of samples from individuals known to be infected >2 years misclassified as recent) were calculated for AI cutoffs of 20%-90% for the avidity assay alone and in combination with a viral load assay (VL, limit of detection 400 copies/ml). Factors associated with misclassification of samples collected ≥2 years after infections were also evaluated. RESULTS The MDRI for the Bio-Rad Combo Avidity assay ranged from 50 days using an AI cutoff of 20% to 276 days using an AI cutoff of 90%; the FRR ranged from 0% to 9%. When samples with a VL <400 copies/ml were classified as nonrecent, the FRRs were reduced approximately twofold and the MDRI estimates were reduced by ∼20%. An AI cutoff of 50% provided an MDRI of 135 days with an FRR of 2.1%. All samples from elite suppressors had an AI >80%. In adjusted analysis, viral suppression and low CD4 cell count were significantly associated with misclassification among individuals infected >2 years. CONCLUSIONS This modified Bio-Rad Combo Avidity assay may be a useful tool for cross-sectional HIV incidence estimation. Further research is needed to evaluate use of this assay in combination with other assays to accurately estimate population-level HIV incidence.
Collapse
Affiliation(s)
- Allison R. Kirkpatrick
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Baltimore, Maryland
| | - Eshan U. Patel
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Baltimore, Maryland
| | - Connie L. Celum
- Department of Medicine, University of Washington, Seattle, Washington
| | - Richard D. Moore
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joel N. Blankson
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shruti H. Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Gregory D. Kirk
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Joseph B. Margolick
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Thomas C. Quinn
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Baltimore, Maryland
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Susan H. Eshleman
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Oliver Laeyendecker
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Baltimore, Maryland
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
33
|
Abstract
PURPOSE OF REVIEW Despite tremendous promise as a female-controlled HIV prevention strategy, implementation of preexposure prophylaxis (PrEP) among women has been limited, in part because of disparate efficacy results from randomized trials in this population. This review synthesizes existing evidence regarding PrEP efficacy for preventing HIV infection in women and considerations for delivering PrEP to women. RECENT FINDINGS In three efficacy trials, conducted among men and women, tenofovir-based oral PrEP reduced HIV acquisition in subgroups of women by 49-79% in intent-to-treat analyses, and by >85% when accounting for PrEP adherence. Two trials did not demonstrate an HIV prevention benefit from PrEP in women, but substantial evidence indicates those results were compromised by very low adherence to the study medication. Qualitative research has identified risk perception, stigma, and aspects of clinical trial participation as influencing adherence to study medication. Pharmacokinetic studies provide supporting evidence that PrEP offers HIV protection in women who are adherent to the medication. SUMMARY Tenofovir-based daily oral PrEP prevents HIV acquisition in women. Offering PrEP as an HIV prevention option for women at high risk of HIV acquisition is a public health imperative and opportunities to evaluate implementation strategies for PrEP for women are needed.
Collapse
Affiliation(s)
- Kerry A. Thomson
- Department of Global Health, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Nelly R. Mugo
- Department of Global Health, University of Washington, Seattle, USA
- Sexual Reproductive Adolescent and Child Health Program, Kenya Medical Research Institute, Nairobi, Kenya
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Connie L. Celum
- Department of Global Health, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
| |
Collapse
|
34
|
Ying R, Sharma M, Heffron R, Celum CL, Baeten JM, Katabira E, Bulya N, Barnabas RV. Cost-effectiveness of pre-exposure prophylaxis targeted to high-risk serodiscordant couples as a bridge to sustained ART use in Kampala, Uganda. J Int AIDS Soc 2015; 18:20013. [PMID: 26198348 PMCID: PMC4509901 DOI: 10.7448/ias.18.4.20013] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [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: 01/16/2015] [Revised: 03/24/2015] [Accepted: 04/15/2015] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Despite scale-up of antiretroviral therapy (ART) for treating HIV-positive persons, HIV incidence remains elevated among those at high risk such as persons in serodiscordant partnerships. Antiretrovirals taken by HIV-negative persons as pre-exposure prophylaxis (PrEP) has the potential to avert infections in individuals in serodiscordant partnerships. Evaluating the cost-effectiveness of implementing time-limited PrEP as a short-term bridge during the first six months of ART for the HIV-positive partner to prevent HIV transmission compared to increasing ART coverage is crucial to informing policy-makers considering PrEP implementation. METHODS To estimate the real world delivery costs of PrEP, we conducted micro-costing and time and motion analyses in an open-label prospective study of PrEP and ART delivery targeted to high-risk serodiscordant couples in Uganda (the Partners Demonstration Project). The cost (in USD, in 2012) of PrEP and ART for serodiscordant couples was assessed, with and without research components, in the study setting. Using Ministry of Health costs, the cost of PrEP and ART provision within a government programme was estimated, as was the cost of providing PrEP in addition to ART. We parameterized an HIV transmission model to estimate the health and economic impacts of 1) PrEP and ART targeted to high-risk serodiscordant couples in the context of current ART use and 2) increasing ART coverage to 55% of HIV-positive persons with CD4 ≤500 cells/µL without PrEP. The incremental cost-effectiveness ratios (ICERs) per HIV infection and disability-adjusted life year (DALY) averted were calculated over 10 years. RESULTS The annual cost of PrEP and ART delivery for serodiscordant couples was $1058 per couple in the study setting and $453 in the government setting. The portion of the programme cost due to PrEP was $408 and $92 per couple per year in the study and government settings, respectively. Over 10 years, a programme of PrEP and ART for high-risk serodiscordant couples was projected to avert 43% of HIV infections compared to current practice with an ICER of $1340 per infection averted. This was comparable to ART expansion alone, which would avert 37% of infections with an ICER of $1452. CONCLUSIONS Using Uganda's gross domestic product per capita of $1681 as a threshold, PrEP and ART for high-risk persons have the potential for synergistic action and are cost-effective in preventing HIV infections in high prevalence settings. The annual cost of PrEP in this programme is less than $100 per serodiscordant couple if implemented in public clinics.
Collapse
Affiliation(s)
- Roger Ying
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Connie L Celum
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Elly Katabira
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Nulu Bulya
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Ruanne V Barnabas
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA;
| |
Collapse
|
35
|
Celum CL, Delany-Moretlwe S, McConnell M, van Rooyen H, Bekker LG, Kurth A, Bukusi E, Desmond C, Morton J, Baeten JM. Rethinking HIV prevention to prepare for oral PrEP implementation for young African women. J Int AIDS Soc 2015; 18:20227. [PMID: 26198350 PMCID: PMC4509892 DOI: 10.7448/ias.18.4.20227] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 05/13/2015] [Accepted: 05/21/2015] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION HIV incidence remains high among young women in sub-Saharan Africa in spite of scale-up of HIV testing, behavioural interventions, antiretroviral treatment and medical male circumcision. There is a critical need to critique past approaches and learn about the most effective implementation of evidence-based HIV prevention strategies, particularly emerging interventions such as pre-exposure prophylaxis (PrEP). DISCUSSION Women in sub-Saharan Africa are at increased risk of HIV during adolescence and into their 20s, in part due to contextual factors including gender norms and relationship dynamics, and limited access to reproductive and sexual health services. We reviewed behavioural, behavioural economic and biomedical approaches to HIV prevention for young African women, with a particular focus on the barriers, opportunities and implications for implementing PrEP in this group. Behavioural interventions have had limited impact in part due to not effectively addressing the context, broader sexual norms and expectations, and structural factors that increase risk and vulnerability. Of biomedical HIV prevention strategies that have been tested, daily oral PrEP has the greatest evidence for protection, although adherence was low in two placebo-controlled trials in young African women. Given high efficacy and effectiveness in other populations, demonstration projects of open-label PrEP in young African women are needed to determine the most effective delivery models and whether women at substantial risk are motivated and able to use oral PrEP with sufficient adherence to achieve HIV prevention benefits. CONCLUSIONS Social marketing, adherence support and behavioural economic interventions should be evaluated as part of PrEP demonstration projects among young African women in terms of their effectiveness in increasing demand and optimizing uptake and effective use of PrEP. Lessons learned through evaluations of implementation strategies for delivering oral PrEP, a first-generation biomedical HIV prevention product, will inform development of new and less user-dependent PrEP formulations and delivery of an expanding choice of prevention options in HIV prevention programmes for young African women.
Collapse
Affiliation(s)
- Connie L Celum
- Department of Global Health, University of Washington Seattle, WA, USA
- Department of Medicine, University of Washington Seattle, WA, USA
- Department of Epidemiology, University of Washington Seattle, WA, USA;
| | - Sinead Delany-Moretlwe
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Margaret McConnell
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health Boston, MA, USA
| | | | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Ann Kurth
- College of Nursing, New York University New York, NY, USA
| | | | - Chris Desmond
- Human Sciences Research Council, Durban, South Africa
| | - Jennifer Morton
- Department of Global Health, University of Washington Seattle, WA, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington Seattle, WA, USA
- Department of Medicine, University of Washington Seattle, WA, USA
- Department of Epidemiology, University of Washington Seattle, WA, USA
| |
Collapse
|
36
|
Alsallaq RA, Baeten JM, Celum CL, Hughes JP, Abu-Raddad LJ, Barnabas RV, Hallett TB. Understanding the potential impact of a combination HIV prevention intervention in a hyper-endemic community. PLoS One 2013; 8:e54575. [PMID: 23372738 PMCID: PMC3553021 DOI: 10.1371/journal.pone.0054575] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Accepted: 12/13/2012] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES Despite demonstrating only partial efficacy in preventing new infections, available HIV prevention interventions could offer a powerful strategy when combined. In anticipation of combination HIV prevention programs and research studies we estimated the population-level impact of combining effective scalable interventions at high population coverage, determined the factors that influence this impact, and estimated the synergy between the components. METHODS We used a mathematical model to investigate the effect on HIV incidence of a combination HIV prevention intervention comprised of high coverage of HIV testing and counselling, risk reduction following HIV diagnosis, male circumcision for HIV-uninfected men, and antiretroviral therapy (ART) for HIV-infected persons. The model was calibrated to data for KwaZulu-Natal, South Africa, where adult HIV prevalence is approximately 23%. RESULTS Compared to current levels of HIV testing, circumcision, and ART, the combined intervention with ART initiation according to current guidelines could reduce HIV incidence by 47%, from 2.3 new infections per 100 person-years (pyar) to 1.2 per 100 pyar within 4 years and by almost 60%, to 1 per 100 pyar, after 25 years. Short-term impact is driven primarily by uptake of testing and reductions in risk behaviour following testing while long-term effects are driven by periodic HIV testing and retention in ART programs. If the combination prevention program incorporated HIV treatment upon diagnosis, incidence could be reduced by 63% after 4 years and by 76% (to about 0.5 per 100 pyar) after 15 years. The full impact of the combination interventions accrues over 10-15 years. Synergy is demonstrated between the intervention components. CONCLUSION High coverage combination of evidence-based strategies could generate substantial reductions in population HIV incidence in an African generalized HIV epidemic setting. The full impact could be underestimated by the short assessment duration of typical evaluations.
Collapse
Affiliation(s)
- Ramzi A Alsallaq
- Global Health, University of Washington, Seattle, Washington, United States of America.
| | | | | | | | | | | | | |
Collapse
|
37
|
Celum CL. HIV preexposure prophylaxis: new data and potential use. Top Antivir Med 2011; 19:181-185. [PMID: 22298887 PMCID: PMC6148898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
HIV preexposure prophylaxis (PrEP) has demonstrated efficacy in 4 studies: 1) the CAPRISA 004 trial of pericoital administration of 1% tenofovir gel showed moderate (39%) efficacy in reducing risk of HIV acquisition in young women; 2) the iPrEx trial of daily oral emtricitabine/tenofovir had moderate (44%) efficacy in reducing risk of HIV acquisition among high-risk men who have sex with men (MSM); 3) the Partners PrEP Study in African HIV-serodiscordant couples, in which the HIV-seronegative partner received daily oral tenofovir or emtricitabine/tenofovir, showed high efficacy (62% and 73%, respectively); and 4) the TDF2 trial in young heterosexual men and women in Botswana demonstrated 62% efficacy of daily oral emtricitabine/tenofovir. Greater adherence to PrEP is associated with greater efficacy. Resistance to tenofovir and emtricitabine have been rare and were primarily observed during PrEP initiation in those with acute HIV infection. PrEP has been found to be safe and well tolerated. The FEM-PrEP trial of oral emtricitabine/tenofovir and the VOICE trials of daily 1% tenofovir gel and oral tenofovir (both studies conducted in African women) did not show protective benefit, for reasons that currently remain unknown. The Bangkok Tenofovir Study of oral tenofovir in injection drug users, and the emtricitabine/tenofovir study arm of the VOICE trial, are ongoing. Establishing PrEP programs will be a great challenge and a great opportunity. This article summarizes a presentation by Connie L. Celum, MD, MPH, at the IAS-USA live continuing education course held in Chicago in June 2011, and includes updates on PrEP trial results reported since July 2011.
Collapse
|
38
|
Celum CL. Sexually transmitted infections and HIV: epidemiology and interventions. Top HIV Med 2010; 18:138-142. [PMID: 21107013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Although the association of HIV and sexually transmitted infections (STIs) has been well known for 25 years, there is insufficient attention to STIs by many HIV providers, in part because patients are asymptomatic or have nonspecific symptoms and because of provider demands and focus. Optimal patient care requires frequent testing for STIs as well as obtaining an accurate medical history, which requires building trust with patients and asking direct but open-ended questions about risks and symptoms. Increased vigilance will also help practitioners avoid missing these infections. Herpes simplex virus type 2 infection has highly variable clinical manifestations, and diagnosis is needed before considering episodic or suppressive treatment. However, suppressive treatment of herpes simplex virus type 2 infection has not been shown to reduce risk of HIV acquisition. The increase in syphilis rates continues; screening is inexpensive and treatment is highly effective. Quinolone resistance rates in gonorrhea are increasing, complicating treatment in some locales. Cases of proctitis caused by chlamydial infection with lymphogranuloma venereum strains have been observed in the United States and Europe.
Collapse
Affiliation(s)
- Connie L Celum
- Department of Global Health, University of Washington, Seattle, WA, USA
| |
Collapse
|
39
|
Jameson DR, Celum CL, Manhart L, Menza TW, Golden MR. The association between lack of circumcision and HIV, HSV-2, and other sexually transmitted infections among men who have sex with men. Sex Transm Dis 2010; 37:147-52. [PMID: 19901865 PMCID: PMC10938871 DOI: 10.1097/olq.0b013e3181bd0ff0] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Observational studies evaluating the association of circumcision and HIV infection among men who have sex with men (MSM) have yielded mixed results. We examined the relationship between circumcision and HIV, herpes simplex virus type-2 (HSV-2), syphilis, urethral gonorrhea, and urethral chlamydia among MSM stratified by anal sexual role. METHODS Between October 2001 and May 2006, 4749 MSM who reported anal intercourse in the previous 12 months attended the Public Health-Seattle and King County STD clinic for 8337 evaluations. Clinicians determined circumcision status by examination and anal sexual role in the previous year by interview. Blood samples were used to test HIV, syphilis, and HSV-2 serostatus. Urethral gonorrhea and chlamydia were tested by culture or nucleic acid amplification. We used generalized estimating equations to evaluate the association between circumcision and specific diagnoses, adjusted for race/ethnicity and age. RESULTS Among the 3828 men whose circumcision status was assessed, 3241 (85%) were circumcised and 587 (15%) were not. The proportion of men newly testing HIV-positive or with previously diagnosed HIV did not differ by circumcision status when stratified by men's anal sexual role in the preceding year, even when limited to men who reported only insertive anal intercourse in the preceding 12 months (OR = 1.45; 95% CI: 0.30, 7.12). Similarly, we did not observe a significant association between circumcision status and the other sexually transmitted infections (STI). CONCLUSIONS Our findings suggest that male circumcision would not be likely to have a significant impact on HIV or sexually transmitted infections acquisition among MSM in Seattle.
Collapse
Affiliation(s)
- Damon R Jameson
- Department of Epidemiology, University of Washington, 404 E. Harrison St. 301, Seattle, WA 98102, USA.
| | | | | | | | | |
Collapse
|
40
|
Lama JR, Lucchetti A, Suarez L, Laguna-Torres VA, Guanira JV, Pun M, Montano SM, Celum CL, Carr JK, Sanchez J, Bautista CT, Sanchez JL. Association of herpes simplex virus type 2 infection and syphilis with human immunodeficiency virus infection among men who have sex with men in Peru. J Infect Dis 2006; 194:1459-66. [PMID: 17054077 DOI: 10.1086/508548] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2006] [Accepted: 07/22/2006] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND We evaluated associations between human immunodeficiency virus (HIV) infection, herpes simplex virus type 2 (HSV-2) infection, and syphilis among men who have sex with men (MSM) in Peru. METHODS A surveillance survey of 3280 MSM was conducted; sexual behavior was assessed with a structured computer-assisted self-interview, and serum antibody testing was performed for HIV, HSV-2, and Treponema pallidum. RESULTS HIV, HSV-2, and syphilis seroprevalences of 13.9%, 46.3%, and 13.4% were detected, respectively. HSV-2 seroprevalence was twice as high in HIV-infected subjects (80.5%) than it was in HIV-uninfected subjects (40.8%) (P < .01), and HSV-2 seropositivity (adjusted odds ratio [AOR], 5.66) was found to be strongly associated with HIV infection. In addition, homosexual self-definition (AOR, 3.12), exchange of sex for money (AOR, 1.61), unprotected sex (no condom) (AOR, 2.81), history of sex work (AOR, 1.89), oral receptive sex (AOR, 1.43), and cocaine use before/during sex (AOR, 2.53) within the preceding 6 months, as well as such sexually transmitted infections (STIs) and STI syndromes as proctitis (AOR, 2.80), genital ulcer disease (GUD) (AOR, 2.06), prior syphilis (AOR, 2.64), genital warts (AOR, 1.70), and self-reported STIs within the preceding 6 months (AOR, 1.61), were also found to be significant predictors of HIV infection. CONCLUSIONS We found a strong association between HSV-2 seropositivity and HIV infection. Intervention measures against GUD due to HSV-2 infection and syphilis, such as routine testing, early detection, HSV-2 suppressive treatment, and condom distribution, need to be enhanced as part of STI prevention strategies at a national level to effectively reduce HIV infection among MSM in Peru.
Collapse
Affiliation(s)
- Javier R Lama
- Asociacion Civil Impacta Salud y Educacion, Ministry of Health of Peru, Lima, Peru
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Whittington WLH, Morris M, Buchbinder SP, McKirnan DJ, Mayer KH, Para MF, Bartholow BN, Celum CL. Partner-Specific Sexual Behavioral Differences Between Phase 3 HIV Vaccine Efficacy Trial Participants and Controls. J Acquir Immune Defic Syndr 2006; 43:234-8. [PMID: 16951646 DOI: 10.1097/01.qai.0000230296.06829.14] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess and compare sexual behaviors using partner-specific data between HIV-negative men who have sex with men (MSM) recruited for an HIV vaccine efficacy trial and a control group. METHODS HIV-negative MSM from an HIV vaccine trial (n = 525) and controls (n = 732) were recruited by similar strategies and interviewed about behaviors with the 3 most recent partners in the past 6 months, obtained by audio computer-assisted self-interview (A-CASI). RESULTS Vaccine trial participants were more likely than controls to report an HIV-positive partner (24.7% and 14.1%, respectively) or an HIV-positive primary partner (16.1% and 6.8%, respectively) and were less likely to report occasional or single-time partners of unknown HIV status (51.6% and 63.2%, respectively; P < 0.05 for each comparison). Vaccine trial participants more often reported receptive unprotected anal intercourse (UAI) during their last sexual encounter with an HIV-positive partner (adjusted odds ratio [OR] = 2.7, 95% confidence interval [CI]: 1.0 to 7.9). Most believed their HIV-positive partners were receiving antiretroviral treatment (ART), however, and after adjustment for perceived ART use, the association between vaccine study participation and receptive UAI with an HIV-positive partner was not significant. CONCLUSIONS High-risk sexual behavior was reported by many VAX004 participants and controls. Differences between vaccine trial and control participants in the highest risk per contact behavior, receptive UAI with HIV-positive partners, was partly accounted for by perceived ART use. Partner level data are useful in refining risk assessment, which is important in the evaluation of HIV vaccine and other prevention trials.
Collapse
|
42
|
Kim HN, Tabet SR, Corey L, Celum CL. Antiretroviral therapy for HIV-1 vaccine efficacy trial participants who seroconvert. Vaccine 2005; 24:532-9. [PMID: 16242816 DOI: 10.1016/j.vaccine.2005.05.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2004] [Accepted: 05/16/2005] [Indexed: 10/25/2022]
Abstract
Instead of preventing infection, most HIV-1 vaccines in clinical trials are directed at inducing cytotoxic HIV-1-specific T cell (CTL) responses which may control viral replication and subsequently modify the clinical course of HIV-1 infection. Thus, vaccine efficacy trial designs must follow participants who become HIV-infected and monitor the course of HIV-1 infection, in order to assess the effect of vaccination on HIV-1 disease progression. This post-infection evaluation will assess time to reach specific CD4 and viral load thresholds as well as time to initiation of antiretroviral therapy. This paper discusses current literature and guidelines on the initiation of highly active antiretroviral therapy (HAART) for persons who become HIV-infected during HIV-1 vaccine trials, focusing both on acute and early HIV-1 infection, since participants in HIV-1 vaccine and other prevention trials will typically be identified within 3-6 months after HIV-1 acquisition. A standardized HAART protocol for HIV-1 vaccine efficacy trial participants who become HIV-infected is essential to the evaluation of CTL-based HIV-1 vaccines on the natural history of HIV-1 infection.
Collapse
Affiliation(s)
- H Nina Kim
- Departments of Medicine, University of Washington, Seattle, WA, USA
| | | | | | | |
Collapse
|
43
|
Corey L, Wald A, Celum CL, Quinn TC. The effects of herpes simplex virus-2 on HIV-1 acquisition and transmission: a review of two overlapping epidemics. J Acquir Immune Defic Syndr 2005; 35:435-45. [PMID: 15021308 DOI: 10.1097/00126334-200404150-00001] [Citation(s) in RCA: 415] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Increasing evidence demonstrates a substantial link between the epidemics of sexually transmitted HIV-1 and herpes simplex virus (HSV)-2 infection. More than 30 epidemiologic studies have demonstrated that prevalent HSV-2 is associated with a 2- to 4-fold increased risk of HIV-1 acquisition. Per-sexual contact transmission rates among couples from Rakai, Uganda indicate that at all levels of plasma HIV-1 RNA in the source partner, HSV-2-seropositive HIV-1-susceptible persons have a 5-fold greater risk of acquiring HIV-1 compared with HSV-2-negative persons. In vitro and in vivo studies suggest that mucosal HIV-1 shedding is more frequent and in greater amounts during mucocutaneous HSV-2 replication, including subclinical mucosal reactivations. Most HIV-1-infected persons are coinfected with HSV-2, and most experience frequent subclinical and clinical reactivations of HSV-2. Subclinical HSV reactivation elevates serum HIV-1 RNA levels, and daily therapy with acyclovir appears to reduce plasma HIV-1 RNA. These data show that greater attention to the diagnosis and treatment of HSV-2 among HIV-1-infected persons is warranted, especially those who continue to be sexually active, those not on antiretroviral therapy, or those whose disease is not well suppressed by antiretrovirals.
Collapse
Affiliation(s)
- Lawrence Corey
- Department of Medicine, University of Washington Program in Infectious Diseases, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA.
| | | | | | | |
Collapse
|
44
|
Buchbinder SP, Vittinghoff E, Heagerty PJ, Celum CL, Seage GR, Judson FN, McKirnan D, Mayer KH, Koblin BA. Sexual Risk, Nitrite Inhalant Use, and Lack of Circumcision Associated With HIV Seroconversion in Men Who Have Sex With Men in the United States. J Acquir Immune Defic Syndr 2005; 39:82-9. [PMID: 15851918 DOI: 10.1097/01.qai.0000134740.41585.f4] [Citation(s) in RCA: 171] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Men who have sex with men (MSM) continue to account for the largest number of new HIV infections in the United States, but limited data exist on independent risk factors for infection beyond the early 1990s. The HIV Network for Prevention Trials Vaccine Preparedness Study enrolled 3257 MSM in 6 US cities from 1995 to 1997. HIV seroincidence was 1.55 per 100 person-years (95% confidence interval: 1.23-1.95) over 18 months of follow-up. On multi-variable analysis using time-dependent covariates, independent risk factors for HIV seroconversion were increased number of reported HIV-negative male sex partners (adjusted odds ratio (AOR) = 1.14 per partner, population attributable risk (PAR) = 28%), nitrite inhalant use (AOR = 2.2, PAR = 28%), unprotected receptive anal sex with an HIV unknown serostatus partner (AOR = 2.7, PAR = 15%) or HIV-positive partner (AOR = 3.4, PAR = 12%), protected receptive anal sex with an HIV-positive partner (AOR = 2.2, PAR = 11%), lack of circumcision (AOR = 2.0, PAR = 10%), and receptive oral sex to ejaculation with an HIV-positive partner (AOR = 3.8, PAR = 7%). Having a large number of male sex partners, nitrite inhalant use, and engaging in receptive anal sex explained the majority of infections in this cohort and should be targeted in prevention strategies for MSM.
Collapse
Affiliation(s)
- Susan P Buchbinder
- AIDS Office, San Francisco Department of Public Health, San Francisco, CA, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Celum CL, Robinson NJ, Cohen MS. Potential effect of HIV type 1 antiretroviral and herpes simplex virus type 2 antiviral therapy on transmission and acquisition of HIV type 1 infection. J Infect Dis 2005; 191 Suppl 1:S107-14. [PMID: 15627220 DOI: 10.1086/425272] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Biological strategies for interrupting transmission of human immunodeficiency virus (HIV) type 1 should be directed at reducing infectiousness of and susceptibility to HIV-1. Potential antiretroviral interventions include reducing the likelihood of transmission of HIV-1 by reducing HIV-1 load in the blood and genital tract of HIV-1--infected person, prophylaxis after high-risk exposure, and pre-exposure prophylaxis for very high risk populations. Antiviral treatment of herpes simplex virus (HSV) type 2, the most common cause of genital ulcers, should be evaluated as a strategy for HIV-1 infection prevention by reducing infectiousness of and susceptibility to HIV-1, on the basis of biological and epidemiological data indicating that HSV-2 facilitates transmission and acquisition of HIV-1. The rationale for antiretroviral and HSV-2-specific interventions and studies to test these strategies are described.
Collapse
Affiliation(s)
- Connie L Celum
- Department of Medicine, University of Washington, Seattle, WA 98104, USA.
| | | | | |
Collapse
|
46
|
Lee D, Graham BS, Chiu YL, Gilbert PB, McElrath MJ, Belshe RB, Buchbinder SP, Sheppard HW, Koblin BA, Mayer KH, Keefer MC, Mulligan MJ, Celum CL. Breakthrough infections during phase 1 and 2 prime-boost HIV-1 vaccine trials with canarypox vectors (ALVAC) and booster dose of recombinant gp120 or gp160. J Infect Dis 2004; 190:903-7. [PMID: 15295694 DOI: 10.1086/423284] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2003] [Accepted: 03/25/2004] [Indexed: 11/04/2022] Open
Abstract
Candidate human immunodeficiency virus (HIV)-1 vaccines that elicit cytotoxic T lymphocytes may modulate HIV infection, requiring a prototype evaluation to assess participants who become infected with HIV. Of 1497 participants in canarypox HIV-1 vaccine prime-boost trials, 28 (1.9%) acquired HIV-1 infection after vaccination. Median plasma HIV-1 RNA levels (vaccinees, 4.78 log10 copies/mL; placebo recipients, 4.27 log10 copies/mL) and CD4 cell counts (vaccinees, 552 cells/mm3; placebo recipients, 657 cells/mm3) before administration of antiretroviral therapy (ART) and time to a composite end point (plasma HIV-1 RNA level >55,000 copies/mL, CD4 cell count <350 cells/mm3, or initiation of ART) did not differ significantly between vaccinees and placebo recipients (P =.4, P =.1, and P =.7, respectively). Persons who acquire HIV-1 infection while enrolled in HIV-1 vaccine trials can be successfully followed after infection, to determine whether vaccines alter the course of HIV-1 infection.
Collapse
Affiliation(s)
- Deborah Lee
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Zuckerman RA, Whittington WLH, Celum CL, Collis TK, Lucchetti AJ, Sanchez JL, Hughes JP, Sanchez JL, Coombs RW. Higher concentration of HIV RNA in rectal mucosa secretions than in blood and seminal plasma, among men who have sex with men, independent of antiretroviral therapy. J Infect Dis 2004; 190:156-61. [PMID: 15195255 DOI: 10.1086/421246] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2003] [Accepted: 12/20/2003] [Indexed: 11/03/2022] Open
Abstract
High levels of human immunodeficiency virus (HIV) in rectal secretions and semen likely increase the risk of HIV transmission. HIV-infected men who have sex with men made 2-3 study visits, over 4 weeks, to assess rectal, seminal, and plasma levels of HIV RNA. Mixed-effects models estimated the effect of factors on HIV shedding. Twenty-seven (42%) of 64 men were receiving antiretroviral therapy (ART); regardless of ART use, median HIV RNA levels were higher in rectal secretions (4.96 log(10) copies/mL) than in blood plasma (4.24 log(10) copies/mL) or seminal plasma (3.55 log(10) copies/mL; P<.05, each comparison). ART was associated with a 1.3-log(10) reduction in rectal HIV RNA in a model without plasma HIV RNA; with and without plasma RNA in models, ART accounted for a >1-log(10) decrease in seminal HIV RNA levels. Thus, controlling for plasma HIV RNA, ART had an independent effect on seminal, but not rectal, HIV levels.
Collapse
|
48
|
Celum CL. The interaction between herpes simplex virus and human immunodeficiency virus. Herpes 2004; 11 Suppl 1:36A-45A. [PMID: 15115628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/06/2003] [Accepted: 09/19/2003] [Indexed: 04/29/2023]
Abstract
Many studies indicate that herpes simplex virus (HSV) seropositivity increases the risk of acquiring HIV, with fewer studies also indicating that HSV-2 infection increases the risk of transmitting HIV. In a recent meta-analysis, HSV-2 infection increased the risk of HIV-acquisition two-fold. This increased risk may occur by HSV-2 reactivation disrupting the epithelial barrier and recruiting activated CD4 cells, which are target cells for HIV infection, into the lesion. In vivo and in vitro studies assessing the effect of HSV-2 on HIV transmission demonstrate that HIV-infected CD4 cells are recruited to HSV-infected lesions and that HSV regulatory proteins (ICP0, ICP4, VP16) may upregulate HIV replication, thus increasing the frequency and titre of mucosal HIV shedding. This may occur during both clinical and asymptomatic HSV reactivation. Plausibly, antiherpetic therapy could reduce HIV transmission by decreasing HIV plasma load and/or mucosal HIV shedding, but a proof-of-concept trial is needed to demonstrate this. It also appears that individuals co-infected with HIV and HSV-2 have more frequent HSV recurrences than individuals infected with HSV-2 alone. There is a strong correlation between decreasing CD4 count and increasing rates of HSV reactivation, suggesting that reactivation is linked to immunosuppression. The IHMF recommends that individuals with HIV should be serologically tested for HSV-2. HSV-2 infection should be targeted as a modifiable risk factor for HIV acquisition by testing, counselling and preventing acquisition through behavioural interventions, treatment and antiviral suppression.
Collapse
|
49
|
Zuckerman RA, Whittington WLH, Celum CL, Collis T, Lucchetti A, Sanchez JL, Hughes JP, Sanchez JL, Coombs RW. Factors associated with oropharyngeal human immunodeficiency virus shedding. J Infect Dis 2003; 188:142-5. [PMID: 12825183 DOI: 10.1086/375741] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2002] [Accepted: 02/10/2003] [Indexed: 11/03/2022] Open
Abstract
Orogenital transmission of human immunodeficiency virus (HIV) is considered to be inefficient, and infectious HIV is rarely detected in saliva. To evaluate the posterior oropharynx as a source of HIV shedding, we studied 64 HIV-infected men who have sex with men in Seattle, Washington, and Lima, Peru. In multivariate analysis, receipt of antiretroviral therapy, higher CD4 cell count, and history of tonsillectomy were predictors of lower pharyngeal HIV RNA levels.
Collapse
Affiliation(s)
- Richard A Zuckerman
- Department of Medicine, University of Washington, Seattle, Washington 98104, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Chesney MA, Koblin BA, Barresi PJ, Husnik MJ, Celum CL, Colfax G, Mayer K, McKirnan D, Judson FN, Huang Y, Coates TJ. An individually tailored intervention for HIV prevention: baseline data from the EXPLORE Study. Am J Public Health 2003; 93:933-8. [PMID: 12773358 PMCID: PMC1447873 DOI: 10.2105/ajph.93.6.933] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We describe the intervention tested in EXPLORE, an HIV prevention trial aimed at men who have sex with men (MSM), and test the empirical basis of the individually tailored intervention. METHODS Data on participants' self-efficacy, communication skills, social norms, and enjoyment of unprotected anal intercourse were examined in relation to sexual risk. Combinations of these factors, together with alcohol use and noninjection drug use, were also examined. RESULTS The individual factors examined were associated with sexual risk behavior. The cohort was shown to be heterogeneous in regard to the presence of combinations of these risk-related factors. CONCLUSIONS Baseline data from the EXPLORE study support the efficacy of the individually tailored intervention used.
Collapse
|