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Marquez C, Atukunda M, Nugent J, Charlebois ED, Chamie G, Mwangwa F, Ssemmondo E, Kironde J, Kabami J, Owaraganise A, Kakande E, Ssekaynzi B, Abbott R, Ayieko J, Ruel T, Kwariisima D, Kamya M, Petersen M, Havlir DV, Balzer LB. Community-Wide Universal Human Immunodeficiency Virus (HIV) Test and Treat Intervention Reduces Tuberculosis Transmission in Rural Uganda: A Cluster-Randomized Trial. Clin Infect Dis 2024:ciad776. [PMID: 38226445 DOI: 10.1093/cid/ciad776] [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: 07/14/2023] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV) treatment reduces tuberculosis (TB) disease and mortality; however, the population-level impact of universal HIV-test-and-treat interventions on TB infection and transmission remain unclear. METHODS In a sub-study nested in the SEARCH trial, a community cluster-randomized trial (NCT01864603), we assessed whether a universal HIV-test-and-treat intervention reduced population-level incident TB infection in rural Uganda. Intervention communities received annual, population-level HIV testing and patient-centered linkage. Control communities received population-level HIV testing at baseline and endline. We compared estimated incident TB infection by arms, defined by tuberculin skin test conversion in a cohort of persons aged 5 and older, adjusting for participation and predictors of infection, and accounting for clustering. RESULTS Of the 32 trial communities, 9 were included, comprising 90 801 participants (43 127 intervention and 47 674 control). One-year cumulative incidence of TB infection was 16% in the intervention and 22% in the control; SEARCH reduced the population-level risk of incident TB infection by 27% (adjusted risk ratio = 0.73; 95% confidence interval [CI]: .57-.92, P = .005). In pre-specified analyses, the effect was largest among children aged 5-11 years and males. CONCLUSIONS A universal HIV-test-and-treat intervention reduced incident TB infection, a marker of population-level TB transmission. Investments in community-level HIV interventions have broader population-level benefits, including TB reductions.
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Affiliation(s)
- Carina Marquez
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, California, USA
| | | | - Joshua Nugent
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Edwin D Charlebois
- Center for AIDS Prevention Studies (CAPS), University of California, San Francisco, California, USA
| | - Gabriel Chamie
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, California, USA
| | | | | | - Joel Kironde
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Elijah Kakande
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Bob Ssekaynzi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Rachel Abbott
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, California, USA
| | - James Ayieko
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Theodore Ruel
- Department of Pediatrics, University of California, San Francisco, California, USA
| | | | - Moses Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- School of Medicine, Makerere University, Kampala, Uganda
| | - Maya Petersen
- Division of Biostatistics, School of Public Health University of California, Berkeley, California, USA
| | - Diane V Havlir
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, California, USA
| | - Laura B Balzer
- Division of Biostatistics, School of Public Health University of California, Berkeley, California, USA
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Ayieko J, Balzer LB, Inviolata C, Kakande E, Opel F, Wafula EM, Kabami J, Owaraganise A, Mwangwa F, Nakato H, Bukusi EA, Camlin CS, Charlebois ED, Bacon MC, Petersen ML, Kamya MR, Havlir DV, Chamie G. Randomized Trial of a "Dynamic Choice" Patient-Centered Care Intervention for Mobile Persons With HIV in East Africa. J Acquir Immune Defic Syndr 2024; 95:74-81. [PMID: 38054932 PMCID: PMC10695335 DOI: 10.1097/qai.0000000000003311] [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: 03/15/2023] [Accepted: 08/04/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND Persons with HIV (PWH) with high mobility face obstacles to HIV care engagement and viral suppression. We sought to understand whether a patient-centered intervention for mobile PWH would improve viral suppression and retention in care, and if so, which subgroups would benefit most. METHODS In a randomized trial, we evaluated the effect of an intervention designed to address barriers to care among mobile (≥2 weeks out of community in previous year) PWH with viral nonsuppression or recent missed visits in Kenya and Uganda (NCT04810650). The intervention included dynamic choice of a "travel pack" (emergency antiretroviral therapy [ART] supply, discrete ART packaging, and travel checklist), multimonth and offsite refills, facilitated transfer to out-of-community clinics, and hotline access to a mobility coordinator. The primary outcome was viral suppression (<400 copies/mL) at 48 weeks. Secondary outcomes included retention in care and ART possession. RESULTS From April 2021 to July 2022, 201 participants were enrolled and randomized (102 intervention, 99 control): 109 (54%) were female participants and 101 (50%) from Kenya; median age was 37 years (interquartile range: 29-43). At 48 weeks, there was no significant difference in viral suppression in intervention (85%) vs. control (86%). The intervention improved retention in care (risk ratio: 1.06[1.02-1.1]; P < 0.001) and ART possession (risk ratio: 1.07[1.03-1.11]; P < 0.001), with larger effect sizes among persons with baseline nonsuppression and high mobility (≥2 weeks out of community in previous 3 months). CONCLUSIONS Mobile PWH-centered care should be considered for high-risk mobile populations, including nonsuppressed and highly mobile PWH, to improve retention in care and sustain viral suppression over time. TRIAL REGISTRATION NCT04810650.
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Affiliation(s)
| | | | | | - Elijah Kakande
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Fred Opel
- Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | - Hellen Nakato
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | | | - Melanie C. Bacon
- National Institute of Allergy and Infectious Diseases, Bethesda, MD; and
| | | | - Moses R. Kamya
- Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Gabriel Chamie
- University of California San Francisco, San Francisco, CA
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Ayieko J, Charlebois ED, Maeri I, Owino L, Thorp M, Bukusi EA, Petersen ML, Kamya MR, Havlir DV, Camlin CS. Improving care engagement for mobile people living with HIV in rural western Kenya. PLoS One 2023; 18:e0288087. [PMID: 37992063 PMCID: PMC10664942 DOI: 10.1371/journal.pone.0288087] [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: 10/04/2022] [Accepted: 06/20/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) assures major gains in health outcomes among people living with HIV, however, this benefit may not be realized by all due to care interruptions. Mobile populations comprise a subgroup that is likely to have sub-optimal care engagement, resulting in discontinuation of ART. We sought to evaluate the barriers to care engagement among highly mobile individuals living with HIV and explore options aimed at improving engagement in care for this group. METHODS Qualitative in-depth interviews were conducted in 2020 among a purposive sample of twelve persons living with HIV and eight health care providers in western Kenya, within a mixed methods study of mobility in communities participating in the SEARCH trial (NCT01864603). We explored the barriers to care engagement among mobile individuals living with HIV and explored different options aimed at enhancing care engagement. These included options such as a coded card containing treatment details, alternative drug packaging to conceal drug identity, longer refills to cover travel period, wrist bands with data storage capability to enable data transfer and "warm handoff" by providers to new clinics upon transfer. Data were inductively analyzed to understand the barriers and acceptability of potential interventions to address them. RESULTS Stigma and lack of disclosure, rigid work schedules, and unpredictability of travel were major barriers to care engagement for highly mobile individuals living with HIV. Additionally, lack of flexibility in clinic schedules and poor provider attitude were identified as health-system-associated barriers to care engagement. Options that enhance flexibility, convenience and access to care were viewed as the most effective means of addressing the barriers to care by both patients and providers. The most preferred option was a coded card with treatment details followed by alternative drug packaging to conceal drug identity due to stigma and longer refills to cover travel periods. CONCLUSION Highly mobile individuals living with HIV desire responsive, flexible, convenient and patient-centered care delivery models to enhance care engagement. They embraced simple health delivery improvements such as coded cards, alternative drug packaging and longer refills to address challenges of mobility.
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Affiliation(s)
- James Ayieko
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Edwin D. Charlebois
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Irene Maeri
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Lawrence Owino
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Marguerite Thorp
- Department of Medicine, University of California Los Angeles, Los Angeles, California, United States of America
| | - Elizabeth A. Bukusi
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Maya L. Petersen
- School of Public Health, University of California Berkeley, Berkeley, California, United States of America
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Diane V. Havlir
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Carol S. Camlin
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
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Ayieko J, Thorp M, Getahun M, Gandhi M, Maeri I, Gutin SA, Okiring J, Kamya MR, Bukusi EA, Charlebois ED, Petersen M, Havlir DV, Camlin CS, Murnane PM. Geographic Mobility and HIV Care Engagement among People Living with HIV in Rural Kenya and Uganda. Trop Med Infect Dis 2023; 8:496. [PMID: 37999615 PMCID: PMC10675546 DOI: 10.3390/tropicalmed8110496] [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: 09/21/2023] [Revised: 10/31/2023] [Accepted: 11/08/2023] [Indexed: 11/25/2023] Open
Abstract
INTRODUCTION Human mobility is a critical aspect of existence and survival, but may compromise care engagement among people living with HIV (PLHIV). We examined the association between various forms of human mobility with retention in HIV care and antiretroviral treatment (ART) interruptions. METHODS In a cohort of adult PLHIV in Kenya and Uganda, we collected surveys in 2016 about past 6-month travel and lifetime migration histories, including reasons and locations, and engagement in HIV care defined as (1) discontinuation of care, and (2) history of a treatment interruption among those who remained in care. We estimated associations between mobility and these care engagement outcomes via logistic regression, adjusted for sex, prior mobility, age, region, marital status, household wealth, and education. RESULTS Among 1081 participants, 56 (5%) reported having discontinued care; among those in care, 104 (10%) reported treatment interruption. Past-year migration was associated with a higher risk of discontinuation of care (adjusted odds ratio [aOR] 1.98, 95% CI 1.08-3.63). In sex-stratified models, the association was somewhat attenuated in women, but remained robust among men. Past-year migration was associated with reduced odds of having a treatment interruption among men (aOR 0.51, 95% CI 0.34-0.77) but not among women (aOR 2.67, 95% CI 0.78, 9.16). Travel in the past 6 months was not associated with discontinuation of care or treatment interruptions. CONCLUSIONS We observed both negative and protective effects of recent migration on care engagement and ART use that were most pronounced among men in this cohort. Migration can break ties to ongoing care, but for men, who have more agency in the decision to migrate, may foster new care and treatment strategies. Strategies that enable health facilities to support individuals throughout the process of transferring care could alleviate the risk of care disengagement.
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Affiliation(s)
- James Ayieko
- Kenya Medical Research Institute, Center for Microbiology Research, Nairobi 00200, Kenya
| | - Marguerite Thorp
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90024, USA
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA 94143, USA
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, CA 94143, USA
| | - Irene Maeri
- Kenya Medical Research Institute, Center for Microbiology Research, Nairobi 00200, Kenya
| | - Sarah A. Gutin
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, CA 94143, USA
| | - Jaffer Okiring
- Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, Kampala P.O. Box 7072, Uganda
| | - Moses R. Kamya
- School of Medicine, Makerere University, Kampala P.O. Box 7072, Uganda
| | - Elizabeth A. Bukusi
- Kenya Medical Research Institute, Center for Microbiology Research, Nairobi 00200, Kenya
| | - Edwin D. Charlebois
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA 94143, USA
| | - Maya Petersen
- Division of Biostatistics, University of California, Berkeley, CA 94720, USA
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, CA 94143, USA
| | - Carol S. Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA 94143, USA
| | - Pamela M. Murnane
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA 94143, USA
- Institute for Global Health Sciences, University of California, San Francisco, CA 94143, USA
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5
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Puryear SB, Ayieko J, Hahn JA, Mucunguzi A, Owaraganise A, Schwab J, Balzer LB, Kwarisiima D, Charlebois ED, Cohen CR, Bukusi EA, Petersen ML, Havlir DV, Kamya MR, Chamie G. Universal HIV Testing and Treatment With Patient-Centered Care Improves ART Uptake and Viral Suppression Among Adults Reporting Hazardous Alcohol Use in Uganda and Kenya. J Acquir Immune Defic Syndr 2023; 94:37-45. [PMID: 37220015 PMCID: PMC10524467 DOI: 10.1097/qai.0000000000003226] [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: 08/01/2022] [Accepted: 04/28/2023] [Indexed: 05/25/2023]
Abstract
OBJECTIVES Determine whether patient-centered, streamlined HIV care achieves higher antiretroviral therapy (ART) uptake and viral suppression than the standard treatment model for people with HIV (PWH) reporting hazardous alcohol use. DESIGN Community cluster-randomized trial. METHODS The Sustainable East Africa Research in Community Health trial (NCT01864603) compared an intervention of annual population HIV testing, universal ART, and patient-centered care with a control of baseline population testing with ART by country standard in 32 Kenyan and Ugandan communities. Adults (15 years or older) completed a baseline Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) and were classified as no/nonhazardous (AUDIT-C 0-2 women/0-3 men) or hazardous alcohol use (≥3 women/≥4 men). We compared year 3 ART uptake and viral suppression of PWH reporting hazardous use between intervention and control arms. We compared alcohol use as a predictor of year 3 ART uptake and viral suppression among PWH, by arm. RESULTS Of 11,070 PWH with AUDIT-C measured, 1723 (16%) reported any alcohol use and 893 (8%) reported hazardous use. Among PWH reporting hazardous use, the intervention arm had higher ART uptake (96%) and suppression (87%) compared with control (74%, adjusted risk ratio [aRR] = 1.28, 95% CI: 1.19 to 1.38; and 72%, aRR = 1.20, 95% CI: 1.10 to 1.31, respectively). Within arm, hazardous alcohol use predicted lower ART uptake in control (aRR = 0.86, 95% CI: 0.78 to 0.96), but not intervention (aRR = 1.02, 95% CI: 1.00 to 1.04); use was not predictive of suppression in either arm. CONCLUSIONS The Sustainable East Africa Research in Community Health intervention improved ART uptake and viral suppression among PWH reporting hazardous alcohol use and eliminated gaps in ART uptake between PWH with hazardous and no/nonhazardous use. Patient-centered HIV care may decrease barriers to HIV care for PWH with hazardous alcohol use.
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Affiliation(s)
- Sarah B Puryear
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, CA
| | - James Ayieko
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Judith A Hahn
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, CA
| | | | | | - Joshua Schwab
- Division of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA
| | - Laura B Balzer
- Division of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA
| | | | - Edwin D Charlebois
- Division of Prevention Sciences, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA; and
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Maya L Petersen
- Division of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA
| | - Diane V Havlir
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, CA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | - Gabriel Chamie
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, CA
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Nugent JR, Marquez C, Charlebois ED, Abbott R, Balzer LB. Blurring cluster randomized trials and observational studies: Two-Stage TMLE for subsampling, missingness, and few independent units. Biostatistics 2023:kxad015. [PMID: 37531621 DOI: 10.1093/biostatistics/kxad015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 08/30/2022] [Revised: 05/15/2023] [Accepted: 07/02/2023] [Indexed: 08/04/2023] Open
Abstract
Cluster randomized trials (CRTs) often enroll large numbers of participants; yet due to resource constraints, only a subset of participants may be selected for outcome assessment, and those sampled may not be representative of all cluster members. Missing data also present a challenge: if sampled individuals with measured outcomes are dissimilar from those with missing outcomes, unadjusted estimates of arm-specific endpoints and the intervention effect may be biased. Further, CRTs often enroll and randomize few clusters, limiting statistical power and raising concerns about finite sample performance. Motivated by SEARCH-TB, a CRT aimed at reducing incident tuberculosis infection, we demonstrate interlocking methods to handle these challenges. First, we extend Two-Stage targeted minimum loss-based estimation to account for three sources of missingness: (i) subsampling; (ii) measurement of baseline status among those sampled; and (iii) measurement of final status among those in the incidence cohort (persons known to be at risk at baseline). Second, we critically evaluate the assumptions under which subunits of the cluster can be considered the conditionally independent unit, improving precision and statistical power but also causing the CRT to behave like an observational study. Our application to SEARCH-TB highlights the real-world impact of different assumptions on measurement and dependence; estimates relying on unrealistic assumptions suggested the intervention increased the incidence of TB infection by 18% (risk ratio [RR]=1.18, 95% confidence interval [CI]: 0.85-1.63), while estimates accounting for the sampling scheme, missingness, and within community dependence found the intervention decreased the incident TB by 27% (RR=0.73, 95% CI: 0.57-0.92).
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Affiliation(s)
- Joshua R Nugent
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Carina Marquez
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, 1001 Potrero Avenue, San Francisco, CA 94110, USA
| | - Edwin D Charlebois
- Center for AIDS Prevention Studies, University of California, 550 16th Street, San Francisco, CA 94158, USA
| | - Rachel Abbott
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, 1001 Potrero Avenue, San Francisco, CA 94110, USA
| | - Laura B Balzer
- Division of Biostatistics, School of Public Health, University of California, 2121 Berkeley Way, Berkeley, CA 94720, USA
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7
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Gutin SA, Neilands TB, Charlebois ED, Getahun M, Okiring J, Akullian A, Maeri I, Eyul P, Ssali S, Cohen CR, Kamya MR, Bukusi EA, Camlin CS. Mobility is Associated with Higher-risk Sexual Partnerships Among Both Men and Women in Co-resident Couples in Rural Kenya and Uganda: A Longitudinal Cohort Study. AIDS Behav 2023; 27:1418-1429. [PMID: 36318427 PMCID: PMC10129962 DOI: 10.1007/s10461-022-03878-0] [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] [Accepted: 09/24/2022] [Indexed: 11/06/2022]
Abstract
Population mobility is associated with higher-risk sexual behaviors in sub-Saharan Africa and is a key driver of the HIV epidemic. We conducted a longitudinal cohort study to estimate associations between recent mobility (overnight travel away from home in past six months) or migration (changes of residence over defined geopolitical boundaries) and higher-risk sexual behavior among co-resident couples (240 couples aged ≥ 16) from 12 rural communities in Kenya and Uganda. Data on concurrent mobility and sexual risk behaviors were collected every 6-months between 2015 and 2020. We used sex-pooled and sex-stratified multilevel models to estimate associations between couple mobility configurations (neither partner mobile, male mobile/female not mobile, female mobile/male not mobile, both mobile) and the odds of higher-risk (casual, commercial sex worker/client, one night stand, inherited partner, stranger) and concurrent sexual partnerships based on who was mobile. On average across all time points and subjects, mobile women were more likely than non-mobile women to have a higher-risk partner; similarly, mobile men were more likely than non-mobile men to report a higher-risk partnership. Men with work-related mobility versus not had higher odds of higher-risk partnerships. Women with work-related mobility versus not had higher odds of higher-risk partnerships. Couples where both members were mobile versus neither had greater odds of higher-risk partnerships. In analyses using 6-month lagged versions of key predictors, migration events of men, but not women, preceded higher-risk partnerships. Findings demonstrate HIV risks for men and women associated with mobility and the need for prevention approaches attentive to the risk-enhancing contexts of mobility.
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Affiliation(s)
- Sarah A Gutin
- Center for AIDS Prevention Studies, Division of Prevention Science, Department of Medicine, University of California, San Francisco (UCSF), 550 16th Street, 3rd Floor, 94143, San Francisco, CA, USA.
| | - Torsten B Neilands
- Center for AIDS Prevention Studies, Division of Prevention Science, Department of Medicine, University of California, San Francisco (UCSF), 550 16th Street, 3rd Floor, 94143, San Francisco, CA, USA
| | - Edwin D Charlebois
- Center for AIDS Prevention Studies, Division of Prevention Science, Department of Medicine, University of California, San Francisco (UCSF), 550 16th Street, 3rd Floor, 94143, San Francisco, CA, USA
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco (UCSF), Oakland, CA, USA
| | - Jaffer Okiring
- The Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Adam Akullian
- Institute for Disease Modeling, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Irene Maeri
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Patrick Eyul
- The Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Sarah Ssali
- School of Women and Gender Studies, Makerere University, Kampala, Uganda
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco (UCSF), Oakland, CA, USA
| | - Moses R Kamya
- The Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Carol S Camlin
- Center for AIDS Prevention Studies, Division of Prevention Science, Department of Medicine, University of California, San Francisco (UCSF), 550 16th Street, 3rd Floor, 94143, San Francisco, CA, USA
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco (UCSF), Oakland, CA, USA
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8
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Liang C, Suen SC, Nguyen A, Moucheraud C, Hsu L, Holloway IW, Charlebois ED, Steward WT. Impact of COVID-19 Response on the HIV Epidemic in Men Who Have Sex With Men in San Francisco County: The Importance of Rapid Return to Normalcy. J Acquir Immune Defic Syndr 2023; 92:370-377. [PMID: 36728397 PMCID: PMC9988211 DOI: 10.1097/qai.0000000000003156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 12/16/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND In response to the COVID-19 pandemic, San Francisco County (SFC) had to shift many nonemergency health care resources to COVID-19, reducing HIV control resources. We sought to quantify COVID-19 effects on HIV burden among men who have sex with men (MSM) as SFC returns to pre-COVID service levels and progresses toward the Ending the HIV Epidemic (EHE) goals. SETTING Microsimulation model of MSM in SFC tracking HIV progression and treatment. METHODS Scenario analysis where services affected by COVID-19 [testing, care engagement, pre-exposure prophylaxis (PrEP) uptake, and retention] return to pre-COVID levels by the end of 2022 or 2025, compared against a counterfactual where COVID-19 changes never occurred. We also examined scenarios where resources are prioritized to reach new patients or retain of existing patients from 2023 to 2025 before all services return to pre-COVID levels. RESULTS The annual number of MSM prescribed PrEP, newly acquired HIV, newly diagnosed, and achieving viral load suppression (VLS) rebound quickly after HIV care returns to pre-COVID levels. However, COVID-19 service disruptions result in measurable reductions in cumulative PrEP use, VLS person-years, incidence, and an increase in deaths over the 2020-2035 period. The burden is statistically significantly larger if these effects end in 2025 instead of 2022. Prioritizing HIV care/prevention initiation over retention results in more person-years of PrEP but less VLS person-years and more deaths, influencing EHE PrEP outcomes. CONCLUSIONS Earlier HIV care return to pre-COVID levels results in lower cumulative HIV burdens. Resource prioritization decisions may differentially affect different EHE goals.
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Affiliation(s)
- Citina Liang
- Daniel J. Epstein Department of Industrial and Systems Engineering, University of Southern California Viterbi School of Engineering, LA
| | - Sze-Chuan Suen
- Daniel J. Epstein Department of Industrial and Systems Engineering, University of Southern California Viterbi School of Engineering, LA
| | - Anthony Nguyen
- Daniel J. Epstein Department of Industrial and Systems Engineering, University of Southern California Viterbi School of Engineering, LA
| | - Corrina Moucheraud
- Department of Health Policy and Management, University of California Los Angeles Fielding School of Public Health, LA.,The Center for HIV Identification, Prevention, and Treatment Services (CHIPTS), University of California Los Angeles, Los Angeles, CA
| | - Ling Hsu
- San Francisco Department of Public Health, HIV Surveillance Unit, San Francisco, CA
| | - Ian W Holloway
- The Center for HIV Identification, Prevention, and Treatment Services (CHIPTS), University of California Los Angeles, Los Angeles, CA.,Department of Social Welfare, Luskin School of Public Affairs, University of California Los Angeles, Los Angeles, CA; and
| | - Edwin D Charlebois
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Wayne T Steward
- Department of Medicine, University of California, San Francisco, San Francisco, CA
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Okorie CN, Gutin SA, Getahun M, Lebu SA, Okiring J, Neilands TB, Ssali S, Cohen CR, Maeri I, Eyul P, Bukusi EA, Charlebois ED, Camlin CS. Sex specific differences in HIV status disclosure and care engagement among people living with HIV in rural communities in Kenya and Uganda. PLOS Glob Public Health 2023; 3:e0000556. [PMID: 37027350 PMCID: PMC10081749 DOI: 10.1371/journal.pgph.0000556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 02/28/2023] [Indexed: 04/08/2023]
Abstract
Non-disclosure of human immunodeficiency virus (HIV) status can hinder optimal health outcomes for people living with HIV (PLHIV). We sought to explore experiences with and correlates of disclosure among PLHIV participating in a study of population mobility. Survey data were collected from 1081 PLHIV from 2015-16 in 12 communities in Kenya and Uganda participating in a test-and-treat trial (SEARCH, NCT#01864603). Pooled and sex-stratified multiple logistic regression models examined associations of disclosure with risk behaviors controlling for covariates and community clustering. At baseline, 91.0% (n = 984) of PLHIV had disclosed their serostatus. Amongst those who had never disclosed, 31% feared abandonment (47.4% men vs. 15.0% women; p = 0.005). Non-disclosure was associated with no condom use in the past 6 months (aOR = 2.44; 95%CI, 1.40-4.25) and with lower odds of receiving care (aOR = 0.8; 95%CI, 0.04-0.17). Unmarried versus married men had higher odds of non- disclosure (aOR = 4.65, 95%CI, 1.32-16.35) and no condom use in the past 6 months (aOR = 4.80, 95%CI, 1.74-13.20), as well as lower odds of receiving HIV care (aOR = 0.15; 95%CI, 0.04-50 0.49). Unmarried versus married women had higher odds of non-disclosure (aOR = 3.14, 95%CI, 1.47-6.73) and lower odds of receiving HIV care if they had never disclosed (aOR = 0.05, 95%CI, 0.02-0.14). Findings highlight gender differences in barriers to HIV disclosure, use of condoms, and engagement in HIV care. Interventions focused on differing disclosure support needs for women and men are needed and may help facilitate better care engagement for men and women and improve condom use in men.
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Affiliation(s)
- Chinomnso N. Okorie
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California, United States of America
| | - Sarah A. Gutin
- Department of Medicine, Division of Prevention Science, University of California, San Francisco, California, United States of America
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California, United States of America
| | - Sarah A. Lebu
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California, United States of America
| | - Jaffer Okiring
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Torsten B. Neilands
- Department of Medicine, Division of Prevention Science, University of California, San Francisco, California, United States of America
| | - Sarah Ssali
- School of Women and Gender Studies, Makerere University, Kampala, Uganda
| | - Craig R. Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California, United States of America
| | - Irene Maeri
- Kenya Medical Research Institute, Centre for Microbiology Research, Nairobi, Kenya
| | - Patrick Eyul
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Elizabeth A. Bukusi
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California, United States of America
- Kenya Medical Research Institute, Centre for Microbiology Research, Nairobi, Kenya
| | - Edwin D. Charlebois
- Department of Medicine, Division of Prevention Science, University of California, San Francisco, California, United States of America
| | - Carol S. Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California, United States of America
- Department of Medicine, Division of Prevention Science, University of California, San Francisco, California, United States of America
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10
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Luetkemeyer AF, Donnell D, Dombrowski JC, Cohen S, Grabow C, Brown CE, Malinski C, Perkins R, Nasser M, Lopez C, Vittinghoff E, Buchbinder SP, Scott H, Charlebois ED, Havlir DV, Soge OO, Celum C. Postexposure Doxycycline to Prevent Bacterial Sexually Transmitted Infections. N Engl J Med 2023; 388:1296-1306. [PMID: 37018493 PMCID: PMC10140182 DOI: 10.1056/nejmoa2211934] [Citation(s) in RCA: 58] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
BACKGROUND Interventions to reduce sexually transmitted infections (STIs) among men who have sex with men (MSM) are needed. METHODS We conducted an open-label, randomized study involving MSM and transgender women who were taking preexposure prophylaxis (PrEP) against human immunodeficiency virus (HIV) infection (PrEP cohort) or living with HIV infection (persons living with HIV infection [PLWH] cohort) and who had had Neisseria gonorrhoeae (gonorrhea), Chlamydia trachomatis (chlamydia), or syphilis in the past year. Participants were randomly assigned in a 2:1 ratio to take 200 mg of doxycycline within 72 hours after condomless sex (doxycycline postexposure prophylaxis) or receive standard care without doxycycline. STI testing was performed quarterly. The primary end point was the incidence of at least one STI per follow-up quarter. RESULTS Of 501 participants (327 in the PrEP cohort and 174 in the PLWH cohort), 67% were White, 7% Black, 11% Asian or Pacific Islander, and 30% Hispanic or Latino. In the PrEP cohort, an STI was diagnosed in 61 of 570 quarterly visits (10.7%) in the doxycycline group and 82 of 257 quarterly visits (31.9%) in the standard-care group, for an absolute difference of -21.2 percentage points and a relative risk of 0.34 (95% confidence interval [CI], 0.24 to 0.46; P<0.001). In the PLWH cohort, an STI was diagnosed in 36 of 305 quarterly visits (11.8%) in the doxycycline group and 39 of 128 quarterly visits (30.5%) in the standard-care group, for an absolute difference of -18.7 percentage points and a relative risk of 0.38 (95% CI, 0.24 to 0.60; P<0.001). The incidences of the three evaluated STIs were lower with doxycycline than with standard care; in the PrEP cohort, the relative risks were 0.45 (95% CI, 0.32 to 0.65) for gonorrhea, 0.12 (95% CI, 0.05 to 0.25) for chlamydia, and 0.13 (95% CI, 0.03 to 0.59) for syphilis, and in the PLWH cohort, the relative risks were 0.43 (95% CI, 0.26 to 0.71), 0.26 (95% CI, 0.12 to 0.57), and 0.23 (95% CI, 0.04 to 1.29), respectively. Five grade 3 adverse events and no serious adverse events were attributed to doxycycline. Of the participants with gonorrhea culture available, tetracycline-resistant gonorrhea occurred in 5 of 13 in the doxycycline groups and 2 of 16 in the standard-care groups. CONCLUSIONS The combined incidence of gonorrhea, chlamydia, and syphilis was lower by two thirds with doxycycline postexposure prophylaxis than with standard care, a finding that supports its use among MSM with recent bacterial STIs. (Funded by the National Institutes of Health; DoxyPEP ClinicalTrials.gov number, NCT03980223.).
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Affiliation(s)
- Anne F Luetkemeyer
- From Zuckerberg San Francisco General Hospital and Trauma Center (A.F.L., C.L., D.V.H.), and the Departments of Medicine (A.F.L., S.C., C.L., E.V., D.V.H.) and Epidemiology and Biostatistics (E.D.C), University of California, San Francisco, and San Francisco Department of Public Health, Population Health Division (S.C., M.N., S.P.B., H.S.) - both in San Francisco; and Fred Hutchinson Cancer Center (D.D.), the Departments of Medicine (J.C.D., O.O.S., C.C.), Global Health (C.G., C.E.B., R.P., O.O.S., C.C.), and Epidemiology (C.C.), and the School of Nursing (R.P.), University of Washington, and Public Health-Seattle and King County (J.C.D., C.M.) - all in Seattle
| | - Deborah Donnell
- From Zuckerberg San Francisco General Hospital and Trauma Center (A.F.L., C.L., D.V.H.), and the Departments of Medicine (A.F.L., S.C., C.L., E.V., D.V.H.) and Epidemiology and Biostatistics (E.D.C), University of California, San Francisco, and San Francisco Department of Public Health, Population Health Division (S.C., M.N., S.P.B., H.S.) - both in San Francisco; and Fred Hutchinson Cancer Center (D.D.), the Departments of Medicine (J.C.D., O.O.S., C.C.), Global Health (C.G., C.E.B., R.P., O.O.S., C.C.), and Epidemiology (C.C.), and the School of Nursing (R.P.), University of Washington, and Public Health-Seattle and King County (J.C.D., C.M.) - all in Seattle
| | - Julia C Dombrowski
- From Zuckerberg San Francisco General Hospital and Trauma Center (A.F.L., C.L., D.V.H.), and the Departments of Medicine (A.F.L., S.C., C.L., E.V., D.V.H.) and Epidemiology and Biostatistics (E.D.C), University of California, San Francisco, and San Francisco Department of Public Health, Population Health Division (S.C., M.N., S.P.B., H.S.) - both in San Francisco; and Fred Hutchinson Cancer Center (D.D.), the Departments of Medicine (J.C.D., O.O.S., C.C.), Global Health (C.G., C.E.B., R.P., O.O.S., C.C.), and Epidemiology (C.C.), and the School of Nursing (R.P.), University of Washington, and Public Health-Seattle and King County (J.C.D., C.M.) - all in Seattle
| | - Stephanie Cohen
- From Zuckerberg San Francisco General Hospital and Trauma Center (A.F.L., C.L., D.V.H.), and the Departments of Medicine (A.F.L., S.C., C.L., E.V., D.V.H.) and Epidemiology and Biostatistics (E.D.C), University of California, San Francisco, and San Francisco Department of Public Health, Population Health Division (S.C., M.N., S.P.B., H.S.) - both in San Francisco; and Fred Hutchinson Cancer Center (D.D.), the Departments of Medicine (J.C.D., O.O.S., C.C.), Global Health (C.G., C.E.B., R.P., O.O.S., C.C.), and Epidemiology (C.C.), and the School of Nursing (R.P.), University of Washington, and Public Health-Seattle and King County (J.C.D., C.M.) - all in Seattle
| | - Cole Grabow
- From Zuckerberg San Francisco General Hospital and Trauma Center (A.F.L., C.L., D.V.H.), and the Departments of Medicine (A.F.L., S.C., C.L., E.V., D.V.H.) and Epidemiology and Biostatistics (E.D.C), University of California, San Francisco, and San Francisco Department of Public Health, Population Health Division (S.C., M.N., S.P.B., H.S.) - both in San Francisco; and Fred Hutchinson Cancer Center (D.D.), the Departments of Medicine (J.C.D., O.O.S., C.C.), Global Health (C.G., C.E.B., R.P., O.O.S., C.C.), and Epidemiology (C.C.), and the School of Nursing (R.P.), University of Washington, and Public Health-Seattle and King County (J.C.D., C.M.) - all in Seattle
| | - Clare E Brown
- From Zuckerberg San Francisco General Hospital and Trauma Center (A.F.L., C.L., D.V.H.), and the Departments of Medicine (A.F.L., S.C., C.L., E.V., D.V.H.) and Epidemiology and Biostatistics (E.D.C), University of California, San Francisco, and San Francisco Department of Public Health, Population Health Division (S.C., M.N., S.P.B., H.S.) - both in San Francisco; and Fred Hutchinson Cancer Center (D.D.), the Departments of Medicine (J.C.D., O.O.S., C.C.), Global Health (C.G., C.E.B., R.P., O.O.S., C.C.), and Epidemiology (C.C.), and the School of Nursing (R.P.), University of Washington, and Public Health-Seattle and King County (J.C.D., C.M.) - all in Seattle
| | - Cheryl Malinski
- From Zuckerberg San Francisco General Hospital and Trauma Center (A.F.L., C.L., D.V.H.), and the Departments of Medicine (A.F.L., S.C., C.L., E.V., D.V.H.) and Epidemiology and Biostatistics (E.D.C), University of California, San Francisco, and San Francisco Department of Public Health, Population Health Division (S.C., M.N., S.P.B., H.S.) - both in San Francisco; and Fred Hutchinson Cancer Center (D.D.), the Departments of Medicine (J.C.D., O.O.S., C.C.), Global Health (C.G., C.E.B., R.P., O.O.S., C.C.), and Epidemiology (C.C.), and the School of Nursing (R.P.), University of Washington, and Public Health-Seattle and King County (J.C.D., C.M.) - all in Seattle
| | - Rodney Perkins
- From Zuckerberg San Francisco General Hospital and Trauma Center (A.F.L., C.L., D.V.H.), and the Departments of Medicine (A.F.L., S.C., C.L., E.V., D.V.H.) and Epidemiology and Biostatistics (E.D.C), University of California, San Francisco, and San Francisco Department of Public Health, Population Health Division (S.C., M.N., S.P.B., H.S.) - both in San Francisco; and Fred Hutchinson Cancer Center (D.D.), the Departments of Medicine (J.C.D., O.O.S., C.C.), Global Health (C.G., C.E.B., R.P., O.O.S., C.C.), and Epidemiology (C.C.), and the School of Nursing (R.P.), University of Washington, and Public Health-Seattle and King County (J.C.D., C.M.) - all in Seattle
| | - Melody Nasser
- From Zuckerberg San Francisco General Hospital and Trauma Center (A.F.L., C.L., D.V.H.), and the Departments of Medicine (A.F.L., S.C., C.L., E.V., D.V.H.) and Epidemiology and Biostatistics (E.D.C), University of California, San Francisco, and San Francisco Department of Public Health, Population Health Division (S.C., M.N., S.P.B., H.S.) - both in San Francisco; and Fred Hutchinson Cancer Center (D.D.), the Departments of Medicine (J.C.D., O.O.S., C.C.), Global Health (C.G., C.E.B., R.P., O.O.S., C.C.), and Epidemiology (C.C.), and the School of Nursing (R.P.), University of Washington, and Public Health-Seattle and King County (J.C.D., C.M.) - all in Seattle
| | - Carolina Lopez
- From Zuckerberg San Francisco General Hospital and Trauma Center (A.F.L., C.L., D.V.H.), and the Departments of Medicine (A.F.L., S.C., C.L., E.V., D.V.H.) and Epidemiology and Biostatistics (E.D.C), University of California, San Francisco, and San Francisco Department of Public Health, Population Health Division (S.C., M.N., S.P.B., H.S.) - both in San Francisco; and Fred Hutchinson Cancer Center (D.D.), the Departments of Medicine (J.C.D., O.O.S., C.C.), Global Health (C.G., C.E.B., R.P., O.O.S., C.C.), and Epidemiology (C.C.), and the School of Nursing (R.P.), University of Washington, and Public Health-Seattle and King County (J.C.D., C.M.) - all in Seattle
| | - Eric Vittinghoff
- From Zuckerberg San Francisco General Hospital and Trauma Center (A.F.L., C.L., D.V.H.), and the Departments of Medicine (A.F.L., S.C., C.L., E.V., D.V.H.) and Epidemiology and Biostatistics (E.D.C), University of California, San Francisco, and San Francisco Department of Public Health, Population Health Division (S.C., M.N., S.P.B., H.S.) - both in San Francisco; and Fred Hutchinson Cancer Center (D.D.), the Departments of Medicine (J.C.D., O.O.S., C.C.), Global Health (C.G., C.E.B., R.P., O.O.S., C.C.), and Epidemiology (C.C.), and the School of Nursing (R.P.), University of Washington, and Public Health-Seattle and King County (J.C.D., C.M.) - all in Seattle
| | - Susan P Buchbinder
- From Zuckerberg San Francisco General Hospital and Trauma Center (A.F.L., C.L., D.V.H.), and the Departments of Medicine (A.F.L., S.C., C.L., E.V., D.V.H.) and Epidemiology and Biostatistics (E.D.C), University of California, San Francisco, and San Francisco Department of Public Health, Population Health Division (S.C., M.N., S.P.B., H.S.) - both in San Francisco; and Fred Hutchinson Cancer Center (D.D.), the Departments of Medicine (J.C.D., O.O.S., C.C.), Global Health (C.G., C.E.B., R.P., O.O.S., C.C.), and Epidemiology (C.C.), and the School of Nursing (R.P.), University of Washington, and Public Health-Seattle and King County (J.C.D., C.M.) - all in Seattle
| | - Hyman Scott
- From Zuckerberg San Francisco General Hospital and Trauma Center (A.F.L., C.L., D.V.H.), and the Departments of Medicine (A.F.L., S.C., C.L., E.V., D.V.H.) and Epidemiology and Biostatistics (E.D.C), University of California, San Francisco, and San Francisco Department of Public Health, Population Health Division (S.C., M.N., S.P.B., H.S.) - both in San Francisco; and Fred Hutchinson Cancer Center (D.D.), the Departments of Medicine (J.C.D., O.O.S., C.C.), Global Health (C.G., C.E.B., R.P., O.O.S., C.C.), and Epidemiology (C.C.), and the School of Nursing (R.P.), University of Washington, and Public Health-Seattle and King County (J.C.D., C.M.) - all in Seattle
| | - Edwin D Charlebois
- From Zuckerberg San Francisco General Hospital and Trauma Center (A.F.L., C.L., D.V.H.), and the Departments of Medicine (A.F.L., S.C., C.L., E.V., D.V.H.) and Epidemiology and Biostatistics (E.D.C), University of California, San Francisco, and San Francisco Department of Public Health, Population Health Division (S.C., M.N., S.P.B., H.S.) - both in San Francisco; and Fred Hutchinson Cancer Center (D.D.), the Departments of Medicine (J.C.D., O.O.S., C.C.), Global Health (C.G., C.E.B., R.P., O.O.S., C.C.), and Epidemiology (C.C.), and the School of Nursing (R.P.), University of Washington, and Public Health-Seattle and King County (J.C.D., C.M.) - all in Seattle
| | - Diane V Havlir
- From Zuckerberg San Francisco General Hospital and Trauma Center (A.F.L., C.L., D.V.H.), and the Departments of Medicine (A.F.L., S.C., C.L., E.V., D.V.H.) and Epidemiology and Biostatistics (E.D.C), University of California, San Francisco, and San Francisco Department of Public Health, Population Health Division (S.C., M.N., S.P.B., H.S.) - both in San Francisco; and Fred Hutchinson Cancer Center (D.D.), the Departments of Medicine (J.C.D., O.O.S., C.C.), Global Health (C.G., C.E.B., R.P., O.O.S., C.C.), and Epidemiology (C.C.), and the School of Nursing (R.P.), University of Washington, and Public Health-Seattle and King County (J.C.D., C.M.) - all in Seattle
| | - Olusegun O Soge
- From Zuckerberg San Francisco General Hospital and Trauma Center (A.F.L., C.L., D.V.H.), and the Departments of Medicine (A.F.L., S.C., C.L., E.V., D.V.H.) and Epidemiology and Biostatistics (E.D.C), University of California, San Francisco, and San Francisco Department of Public Health, Population Health Division (S.C., M.N., S.P.B., H.S.) - both in San Francisco; and Fred Hutchinson Cancer Center (D.D.), the Departments of Medicine (J.C.D., O.O.S., C.C.), Global Health (C.G., C.E.B., R.P., O.O.S., C.C.), and Epidemiology (C.C.), and the School of Nursing (R.P.), University of Washington, and Public Health-Seattle and King County (J.C.D., C.M.) - all in Seattle
| | - Connie Celum
- From Zuckerberg San Francisco General Hospital and Trauma Center (A.F.L., C.L., D.V.H.), and the Departments of Medicine (A.F.L., S.C., C.L., E.V., D.V.H.) and Epidemiology and Biostatistics (E.D.C), University of California, San Francisco, and San Francisco Department of Public Health, Population Health Division (S.C., M.N., S.P.B., H.S.) - both in San Francisco; and Fred Hutchinson Cancer Center (D.D.), the Departments of Medicine (J.C.D., O.O.S., C.C.), Global Health (C.G., C.E.B., R.P., O.O.S., C.C.), and Epidemiology (C.C.), and the School of Nursing (R.P.), University of Washington, and Public Health-Seattle and King County (J.C.D., C.M.) - all in Seattle
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11
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Marquez C, Chen Y, Atukunda M, Chamie G, Balzer LB, Kironde J, Ssemmondo E, Mwangwa F, Kabami J, Owaraganise A, Kakande E, Abbott R, Ssekyanzi B, Koss C, Kamya MR, Charlebois ED, Havlir DV, Petersen ML. The Association Between Social Network Characteristics and Tuberculosis Infection Among Adults in 9 Rural Ugandan Communities. Clin Infect Dis 2023; 76:e902-e909. [PMID: 35982635 PMCID: PMC10169405 DOI: 10.1093/cid/ciac669] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 04/05/2022] [Revised: 08/02/2022] [Accepted: 08/16/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Social network analysis can elucidate tuberculosis transmission dynamics outside the home and may inform novel network-based case-finding strategies. METHODS We assessed the association between social network characteristics and prevalent tuberculosis infection among residents (aged ≥15 years) of 9 rural communities in Eastern Uganda. Social contacts named during a census were used to create community-specific nonhousehold social networks. We evaluated whether social network structure and characteristics of first-degree contacts (sex, human immunodeficiency virus [HIV] status, tuberculosis infection) were associated with revalent tuberculosis infection (positive tuberculin skin test [TST] result) after adjusting for individual-level risk factors (age, sex, HIV status, tuberculosis contact, wealth, occupation, and Bacillus Calmette-Guérin [BCG] vaccination) with targeted maximum likelihood estimation. RESULTS Among 3 335 residents sampled for TST, 32% had a positive TST results and 4% reported a tuberculosis contact. The social network contained 15 328 first-degree contacts. Persons with the most network centrality (top 10%) (adjusted risk ratio, 1.3 [95% confidence interval, 1.1-1.1]) and the most (top 10%) male contacts (1.5 [1.3-1.9]) had a higher risk of prevalent tuberculosis, than those in the remaining 90%. People with ≥1 contact with HIV (adjusted risk ratio, 1.3 [95% confidence interval, 1.1-1.6]) and ≥2 contacts with tuberculosis infection were more likely to have tuberculosis themselves (2.6 [ 95% confidence interval: 2.2-2.9]). CONCLUSIONS Social networks with higher centrality, more men, contacts with HIV, and tuberculosis infection were positively associated with tuberculosis infection. Tuberculosis transmission within measurable social networks may explain prevalent tuberculosis not associated with a household contact. Further study on network-informed tuberculosis case finding interventions is warranted.
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Affiliation(s)
- Carina Marquez
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Yiqun Chen
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | | | - Gabriel Chamie
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Laura B Balzer
- Division of Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Joel Kironde
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Elijah Kakande
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Rachel Abbott
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Bob Ssekyanzi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Catherine Koss
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Edwin D Charlebois
- Center for AIDS Prevention Studies, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Diane V Havlir
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Maya L Petersen
- Division of Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, California, USA
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12
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Maeri I, Eyul P, Getahun M, Hatchett K, Owino L, Akatukwasa C, Itiakorit H, Gutin SA, Johnson-Peretz J, Ssali S, Cohen CR, Bukusi EA, Kamya MR, Charlebois ED, Camlin CS. Nothing about us without us: Community-based participatory research to improve HIV care for mobile patients in Kenya and Uganda. Soc Sci Med 2023; 318:115471. [PMID: 36628879 PMCID: PMC10184576 DOI: 10.1016/j.socscimed.2022.115471] [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: 01/14/2022] [Revised: 09/11/2022] [Accepted: 10/20/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Population mobility is prevalent and complex in sub-Saharan Africa, and can disrupt HIV care and fuel onward transmission. While differentiated care models show promise for meeting the needs of mobile populations by addressing care cascade gaps, the voices of mobile populations need to be included when designing care delivery models. We assessed the unmet needs of mobile populations and engaged mobile stakeholders in the design and implementation of service delivery to improve care outcomes for mobile people living with HIV (PLHIV). METHODS CBPR was conducted in 12 rural communities in Kenya and Uganda participating in a mobility study within the Sustainable East Africa Research in Community Health (SEARCH) test-and-treat trial (NCT# 01864603) from 2016 to 2019. Annual gender-balanced meetings with between 17 and 33 mobile community stakeholders per meeting were conducted in local languages to gather information on mobility and its influence on HIV-related outcomes. Discussions were audio-recorded, transcribed and translated into English. Findings were shared at subsequent meetings to engage mobile stakeholders in interpretation. At year three, intervention ideas to address mobile populations' needs were elicited. After refinement, these intervention options were presented to the same communities for prioritization the following year, using a participatory ranking approach. RESULTS Transit hubs, trading centers, and beach sites were identified as desirable service locations. Communities prioritized mobile health 'cards' with electronic medical records and peer-delivered home-based services. Mobile health clinics, longer antiretroviral refills, and 24/7 (after service) were less desirable options. Care challenges included: lack of transfer letters to other clinics; inability to adhere to scheduled appointments, medication regimens, and monitoring of treatment outcomes while mobile amongst others. CONCLUSIONS Iterative discussions with mobile community stakeholders elicited communities' health priorities and identified challenges to achieving HIV care cascade outcomes. Understanding the mobility patterns and unique needs of mobile populations through responsive community engagement is critical.
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Affiliation(s)
- Irene Maeri
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya.
| | - Patrick Eyul
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, USA
| | - Khalela Hatchett
- Department of Community Health Sciences, University of California Los Angeles, Los Angeles, USA
| | - Lawrence Owino
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | - Sarah A Gutin
- Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, USA
| | - Jason Johnson-Peretz
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, USA
| | - Sarah Ssali
- School of Women and Gender Studies, Makerere University, Kampala, Uganda
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, USA
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda; School of Medicine, Makerere University, Kampala, Uganda
| | - Edwin D Charlebois
- Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, USA
| | - Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, USA; Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, USA
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Lee JK, Gutin SA, Getahun M, Okiring J, Neilands TB, Akullian A, Ssali S, Cohen CR, Maeri I, Eyul P, Kamya MR, Bukusi EA, Charlebois ED, Camlin CS. Condom, modern contraceptive, and dual method use are associated with HIV status and relationship concurrency in a context of high mobility: A cross-sectional study of women of reproductive age in rural Kenya and Uganda, 2016. Contraception 2023; 117:13-21. [PMID: 36115610 PMCID: PMC9984206 DOI: 10.1016/j.contraception.2022.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 09/07/2022] [Accepted: 09/07/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Mobility (international/internal migration, and localized mobility) is a key driver of the HIV epidemic. While mobility is associated with higher-risk sexual behavior in women, a possible association with condom, modern contraceptive, and dual method use among women living with HIV (WLHIV), is unknown. In addition, HIV status and sexual behaviors such as relationship concurrency may also affect condom, modern contraceptive, and dual method use. STUDY DESIGN We surveyed sexually active women (N = 1067) aged 15 to 49 in 12 communities in Kenya and Uganda participating in a test-and-treat trial in 2015 to 2016. Generalized (unordered) multinomial logistic regression models accounting for community clustering examined associations between mobility (overnight travel away from home in past 6 months and any migration within past 2 years) and condom, modern contraceptive (i.e., oral contraceptive pills, injectables, intrauterine devices, implants, vasectomy, tubal ligation; excluding male/female condoms), and dual method use within past 6 months, adjusting for key covariates such as HIV status and relationship concurrency. RESULTS WLHIV relative to HIV-negative women (ratios of relative risk [RRR] = 3.76, 95% confidence interval [CI]: 2.40-5.89), and women in concurrent relative to monogamous relationships (RRR = 4.03, 95% CI 1.9-8.50) had higher odds of condom use alone. In contraceptive use models, WLHIV relative to HIV-negative women were less likely to use modern contraceptive methods alone (RRR = 0.51, 95% CI 0.36-0.73). Relationship concurrency (RRR = 4.51, 95% CI 2.10-9.67) and HIV status (RRR = 3.97, 95% CI 2.43-6.50) were associated with higher odds of dual method use while mobility was marginally associated with higher odds of dual method use (RRR = 1.65, 95% CI 0.99-2.77, p = 0.057). CONCLUSIONS Mobility had a potential impact on dual method use in Kenya and Uganda. In addition, our findings highlight that WLHIV were using condoms and dual methods more, but modern contraceptives less, than HIV-negative women. Those in concurrent relationships were also more likely to use condoms or dual methods. These findings suggest that in a context of high mobility, women may be appropriately assessing risks and taking measures to protect themselves and their partners from unintended pregnancies and acquisition and transmission of HIV. IMPLICATIONS Our findings point to a need to strengthen accessibility of sexual and reproductive health services for both mobile and residentially stable women in settings of high mobility and high HIV prevalence.
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Affiliation(s)
- Joi K. Lee
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA,Corresponding author: Joi Lee, , Advancing New Standards in Reproductive Health (ANSIRH) Program, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco (UCSF), 1330 Broadway, Suite 1100, Oakland, CA 94512
| | - Sarah A. Gutin
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, USA
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Jaffer Okiring
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Torsten B. Neilands
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, USA
| | - Adam Akullian
- Institute for Disease Modeling (IDM), Seattle, Washington, USA
| | - Sarah Ssali
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda,School of Women and Gender Studies, Makerere University College of Health Sciences, Kampala, Uganda
| | - Craig R. Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Irene Maeri
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Patrick Eyul
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda,School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Elizabeth A. Bukusi
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA,Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Edwin D. Charlebois
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, USA
| | - Carol S. Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA,Division of Prevention Science, Department of Medicine, University of California, San Francisco, USA
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14
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Mwangwa F, Charlebois ED, Ayieko J, Olio W, Black D, Peng J, Kwarisiima D, Kabami J, Balzer LB, Petersen ML, Kapogiannis B, Kamya MR, Havlir DV, Ruel TD. Two or more significant life-events in 6-months are associated with lower rates of HIV treatment and virologic suppression among youth with HIV in Uganda and Kenya. AIDS Care 2023; 35:95-105. [PMID: 35578398 PMCID: PMC9666617 DOI: 10.1080/09540121.2022.2052260] [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: 07/19/2021] [Accepted: 03/01/2022] [Indexed: 10/18/2022]
Abstract
Youth living with HIV in sub-Saharan Africa have poor HIV care outcomes. We determined the association of recent significant life-events with HIV antiretroviral treatment (ART) initiation and HIV viral suppression in youth aged 15-24 years living with HIV in rural Kenya and Uganda. This was a cross-sectional analysis of 995 youth enrolled in the SEARCH Youth study. At baseline, providers assessed recent (within 6 months) life-events, defined as changes in schooling/employment, residence, partnerships, sickness, incarceration status, family strife or death, and birth/pregnancy, self-reported alcohol use, being a parent, and HIV-status disclosure. We examined the frequencies of events and their association with ART status and HIV viral suppression (<400 copies/ul). Recent significant life-events were prevalent (57.7%). Having >2 significant life-events (aOR = 0.61, 95% CI:0.45-0.85) and consuming alcohol (aOR = 0.61, 95% CI:0.43-0.87) were associated with a lower odds of HIV viral suppression, while disclosure of HIV-status to partner (aOR = 2.39, 95% CI:1.6-3.5) or to family (aOR = 1.86, 95% CI:1.3-2.7), being a parent (aOR = 1.8, 95% CI:1.2-2.5), and being single (aOR = 1.6, 95% CI:1.3-2.1) had a higher odds. This suggest that two or more recent life-events and alcohol use are key barriers to ART initiation and achievement of viral suppression among youth living with HIV in rural East Africa.Trial registration: ClinicalTrials.gov identifier: NCT03848728..
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Affiliation(s)
| | - Edwin D. Charlebois
- University of California, San Francisco, San Francisco, California, United States of America
| | - James Ayieko
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Winter Olio
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Douglas Black
- University of California, San Francisco, San Francisco, California, United States of America
| | - James Peng
- University of California, San Francisco, San Francisco, California, United States of America
| | | | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Laura B. Balzer
- University of Massachusetts, Amherst, Massachusetts, United States of America
| | - Maya L. Petersen
- University of California, Berkeley School of Public Health, Berkeley, California, United States of America
| | - Bill Kapogiannis
- Eunice Kennedy Shriver National Institute of Child Health and Human Development at the National Institutes of Health, Bethesda, Maryland, United States of America
| | - Moses R. Kamya
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane V. Havlir
- University of California, San Francisco, San Francisco, California, United States of America
| | - Theodore D. Ruel
- University of California, San Francisco, San Francisco, California, United States of America
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15
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Camlin CS, Getahun M, Koss CA, Owino L, Akatukwasa C, Itiakorit H, Onyango A, Bakanoma R, Atwine F, Maeri I, Ayieko J, Atukunda M, Owaraganise A, Mwangwa F, Sang N, Kabami J, Kaplan RL, Chamie G, Petersen ML, Cohen CR, Bukusi EA, Kamya MR, Havlir DV, Charlebois ED. Providers' Attitudes and Experiences with Pre-Exposure Prophylaxis Implementation in a Population-Based Study in Kenya and Uganda. AIDS Patient Care STDS 2022; 36:396-404. [PMID: 36201226 PMCID: PMC9595612 DOI: 10.1089/apc.2022.0084] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Pre-exposure prophylaxis (PrEP) implementation is underway across sub-Saharan Africa. However, little is known about health care providers' experiences with PrEP provision in generalized epidemic settings, particularly outside of selected risk groups. In this study (NCT01864603), universal access to PrEP was offered to adolescents and adults at elevated risk during population-level HIV testing in rural Kenya and Uganda. Providers received training on PrEP prescribing and support from local senior clinicians. We conducted in-depth interviews with providers (n = 19) in four communities in Kenya and Uganda to explore the attitudes and experiences with implementation. Transcripts were coded and analyzed using interpretivist methods. Providers had heterogenous attitudes toward PrEP in its early implementation: some expressed enthusiasm, while others feared being blamed for "failures" (HIV seroconversions) if participants were nonadherent, or that offering PrEP would increase "immorality." Providers supported PrEP usage among HIV-serodifferent couples, whose mutual support for daily pill-taking facilitated harmony and protection from HIV. Providers reported challenges with counseling on "seasons of risk," and safely stopping and restarting PrEP. They felt uptake was hampered for women by difficulties negotiating with partners, and for youth by parental consent requirements. They believed PrEP continuation was hindered by transportation costs, stigma, pill burden, and side effects, and was facilitated by counseling, proactive management of side effects, and home/community-based provision. Providers are critical "implementation actors" in interventions to promote adoption of new technologies such as PrEP. Dedicated training and ongoing support for providers may facilitate successful scale-up.
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Affiliation(s)
- Carol S. Camlin
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco (UCSF), San Francisco, California, USA
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Monica Getahun
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Catherine A. Koss
- Division of HIV, Infectious Diseases & Global Medicine, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Lawrence Owino
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | | | | | | | - Robert Bakanoma
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Fredrick Atwine
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Irene Maeri
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - James Ayieko
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | | | | | - Florence Mwangwa
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Norton Sang
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Jane Kabami
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Rachel L. Kaplan
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Gabriel Chamie
- Division of HIV, Infectious Diseases & Global Medicine, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Maya L. Petersen
- Divisions of Biostatistics & Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Craig R. Cohen
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco (UCSF), San Francisco, California, USA
| | | | - Moses R. Kamya
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases & Global Medicine, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Edwin D. Charlebois
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco (UCSF), San Francisco, California, USA
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Nagata JM, Hampshire K, Epstein A, Lin F, Zakaras J, Murnane P, Charlebois ED, Tsai AC, Nash D, Weiser SD. Analysis of Heavy Rainfall in Sub-Saharan Africa and HIV Transmission Risk, HIV Prevalence, and Sexually Transmitted Infections, 2005-2017. JAMA Netw Open 2022; 5:e2230282. [PMID: 36074468 PMCID: PMC9459663 DOI: 10.1001/jamanetworkopen.2022.30282] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Extreme precipitation, including heavy rains and flooding, is associated with poor health outcomes mediated in part by decreases in income and food production. However, the association between heavy rains and HIV burden is unknown. OBJECTIVE To investigate the association between heavy rainfall, HIV prevalence, and HIV transmission risk over a 12-year span in sub-Saharan Africa. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional population-based study, using data collected from the 2005-2017 Demographic and Health Surveys, was conducted in 21 countries in sub-Saharan Africa and analyzed from July 29, 2021, to June 14, 2022. EXPOSURES Heavy rainfall was defined based on the extent to which annual rainfall deviated from the historical average (standardized precipitation index ≥1.5) at the enumeration area level. MAIN OUTCOMES AND MEASURES HIV, self-reported sexually transmitted infections (STIs), and number of sexual partners. RESULTS The study included 288 333 participants aged 15 to 59 years; 172 344 were women (59.8%), and 183 378 were married (63.6%). Mean (SD) age was 31.9 (10.0) years. Overall, 42.4% of participants were exposed to at least 1 year of heavy rainfall in the past 10 years. Each year of heavy rainfall was associated with 1.14 (95% CI, 1.11-1.18) times the odds of HIV infection and 1.11 (95% CI, 1.07-1.15) times the odds of an STI in the past 12 months. There was also an association between heavy rainfall and the reported number of sexual partners (incident rate ratio, 1.12; 95% CI, 1.10-1.15). The odds were greater for the association between heavy rainfall and HIV prevalence and STIs among participants aged older than 20 years and participants in rural areas. CONCLUSIONS AND RELEVANCE The findings of this study suggest that heavy rainfall was associated with a higher HIV burden in sub-Saharan Africa. The association between heavy rainfall and STIs and number of sexual partners suggests that an increase in the risk of sexual transmission is a plausible mechanism for the observed findings around HIV prevalence. Heavy rainfall could also worsen food insecurity, increasing the risk of transactional sex, or cause damage to public health infrastructure, reducing access to STI education, HIV testing, and treatment.
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Affiliation(s)
- Jason M. Nagata
- Department of Pediatrics, University of California, San Francisco
| | - Karly Hampshire
- Department of Medicine, University of California, San Francisco
| | - Adrienne Epstein
- Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Feng Lin
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | | | - Pamela Murnane
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | | | - Alexander C. Tsai
- Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York
| | - Sheri D. Weiser
- Department of Medicine, University of California, San Francisco
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17
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Pujol-Hodge E, Salazar-Gonzalez JF, Ssemwanga D, Charlebois ED, Ayieko J, Grant HE, Liegler T, Atkins KE, Kaleebu P, Kamya MR, Petersen M, Havlir DV, Leigh Brown AJ. Detection of HIV-1 Transmission Clusters from Dried Blood Spots within a Universal Test-and-Treat Trial in East Africa. Viruses 2022; 14:v14081673. [PMID: 36016295 PMCID: PMC9414799 DOI: 10.3390/v14081673] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/15/2022] [Accepted: 07/25/2022] [Indexed: 11/24/2022] Open
Abstract
The Sustainable East Africa Research in Community Health (SEARCH) trial was a universal test-and-treat (UTT) trial in rural Uganda and Kenya, aiming to lower regional HIV-1 incidence. Here, we quantify breakthrough HIV-1 transmissions occurring during the trial from population-based, dried blood spot samples. Between 2013 and 2017, we obtained 549 gag and 488 pol HIV-1 consensus sequences from 745 participants: 469 participants infected prior to trial commencement and 276 SEARCH-incident infections. Putative transmission clusters, with a 1.5% pairwise genetic distance threshold, were inferred from maximum likelihood phylogenies; clusters arising after the start of SEARCH were identified with Bayesian time-calibrated phylogenies. Our phylodynamic approach identified nine clusters arising after the SEARCH start date: eight pairs and one triplet, representing mostly opposite-gender linked (6/9), within-community transmissions (7/9). Two clusters contained individuals with non-nucleoside reverse transcriptase inhibitor (NNRTI) resistance, both linked to intervention communities. The identification of SEARCH-incident, within-community transmissions reveals the role of unsuppressed individuals in sustaining the epidemic in both arms of a UTT trial setting. The presence of transmitted NNRTI resistance, implying treatment failure to the efavirenz-based antiretroviral therapy (ART) used during SEARCH, highlights the need to improve delivery and adherence to up-to-date ART recommendations, to halt HIV-1 transmission.
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Affiliation(s)
- Emma Pujol-Hodge
- Ashworth Laboratories, School of Biological Sciences, University of Edinburgh, Edinburgh EH9 3FL, UK; (E.P.-H.); (H.E.G.)
| | - Jesus F. Salazar-Gonzalez
- Medical Research Council (MRC)/Uganda Virus Research Institute (UVRI) and London School of Hygiene and Tropical Medicine (LSHTM) Uganda Research Unit, Entebbe P.O. Box 49, Uganda; (J.F.S.-G.); (D.S.); (P.K.)
| | - Deogratius Ssemwanga
- Medical Research Council (MRC)/Uganda Virus Research Institute (UVRI) and London School of Hygiene and Tropical Medicine (LSHTM) Uganda Research Unit, Entebbe P.O. Box 49, Uganda; (J.F.S.-G.); (D.S.); (P.K.)
- Uganda Virus Research Institute, Entebbe P.O. Box 49, Uganda
| | - Edwin D. Charlebois
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, CA 94158, USA;
| | - James Ayieko
- Kenya Medical Research Institute, Nairobi P.O. Box 54840-00200, Kenya;
| | - Heather E. Grant
- Ashworth Laboratories, School of Biological Sciences, University of Edinburgh, Edinburgh EH9 3FL, UK; (E.P.-H.); (H.E.G.)
| | - Teri Liegler
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, CA 94110, USA; (T.L.); (D.V.H.)
| | - Katherine E. Atkins
- Usher Institute, University of Edinburgh, Edinburgh EH8 9AG, UK;
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, LSHTM, London WC1E 7HT, UK
- Centre for Mathematical Modelling of Infectious Diseases, LSHTM, London WC1E 7HT, UK
| | - Pontiano Kaleebu
- Medical Research Council (MRC)/Uganda Virus Research Institute (UVRI) and London School of Hygiene and Tropical Medicine (LSHTM) Uganda Research Unit, Entebbe P.O. Box 49, Uganda; (J.F.S.-G.); (D.S.); (P.K.)
- Uganda Virus Research Institute, Entebbe P.O. Box 49, Uganda
| | - Moses R. Kamya
- School of Medicine, Makerere University, Kampala P.O. Box 7072, Uganda;
| | - Maya Petersen
- Division of Biostatistics, School of Public Health, University of California, Berkeley, CA 94720, USA;
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, CA 94110, USA; (T.L.); (D.V.H.)
| | - Andrew J. Leigh Brown
- Ashworth Laboratories, School of Biological Sciences, University of Edinburgh, Edinburgh EH9 3FL, UK; (E.P.-H.); (H.E.G.)
- Correspondence:
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Johnson‐Peretz J, Lebu S, Akatukwasa C, Getahun M, Ruel T, Lee J, Ayieko J, Mwangwa F, Owino L, Onyango A, Maeri I, Atwine F, Charlebois ED, Bukusi EA, Kamya MR, Havlir DV, Camlin CS. "I was still very young": agency, stigma and HIV care strategies at school, baseline results of a qualitative study among youth in rural Kenya and Uganda. J Int AIDS Soc 2022; 25 Suppl 1:e25919. [PMID: 35818888 PMCID: PMC9274360 DOI: 10.1002/jia2.25919] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 04/28/2022] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Adolescents and young adults living with HIV (AYAH) have the lowest rates of retention in HIV care and antiretroviral therapy (ART) adherence, partly due to the demands of school associated with this life stage, to HIV-related stigma and to fears of serostatus disclosure. We explore the implications of school-based stigma and disclosure on the development of agency during a critical life stage in rural Kenya and Uganda. METHODS We conducted a qualitative study in the baseline year of the SEARCH Youth study, a combination intervention using a life-stage approach among youth (15-24 years old) living with HIV in western Kenya and southwestern Uganda to improve viral load suppression and health outcomes. We conducted in-depth, semi-structured interviews in 2019 with three cohorts of purposively selected study participants (youth [n = 83], balanced for sex, life stage and HIV care status; recommended family members of youth [n = 33]; and providers [n = 20]). Inductive analysis exploring contextual factors affecting HIV care engagement revealed the high salience of schooling environments. RESULTS Stigma within school settings, elicited by non-consensual serostatus disclosure, medication schedules and clinic appointments, exerts a constraining factor around which AYAH must navigate to identify and pursue opportunities available to them as young people. HIV status can affect cross-generational support and cohort formation, as AYAH differ from non-AYAH peers because of care-related demands affecting schooling, exams and graduation. However, adolescents demonstrate a capacity to overcome anticipated stigma and protect themselves by selectively disclosing HIV status to trusted peers and caregivers, as they develop a sense of agency concomitant with this life stage. Older adolescents showed greater ability to seek out supportive relationships than younger ones who relied on adult caregivers to facilitate this support. CONCLUSIONS School is a potential site of HIV stigma and also a setting for learning how to resist such stigma. School-going adolescents should be supported to identify helpful peers and selectively disclose serostatus as they master decision making about when and where to take medications, and who should know. Stigma is avoided by fewer visits to the clinic; providers should consider longer refills, discreet packaging and long-acting, injectable ART for students.
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Affiliation(s)
- Jason Johnson‐Peretz
- Department of ObstetricsGynecology, & Reproductive SciencesUniversity of CaliforniaSan Francisco (UCSF)San FranciscoCaliforniaUSA
| | - Sarah Lebu
- Department of ObstetricsGynecology, & Reproductive SciencesUniversity of CaliforniaSan Francisco (UCSF)San FranciscoCaliforniaUSA
| | | | - Monica Getahun
- Department of ObstetricsGynecology, & Reproductive SciencesUniversity of CaliforniaSan Francisco (UCSF)San FranciscoCaliforniaUSA
| | - Theodore Ruel
- Department of PediatricsUniversity of CaliforniaSan Francisco (UCSF)San FranciscoCaliforniaUSA
| | - Joi Lee
- Department of ObstetricsGynecology, & Reproductive SciencesUniversity of CaliforniaSan Francisco (UCSF)San FranciscoCaliforniaUSA
| | - James Ayieko
- Kenya Medical Research Institute (KEMRI)NairobiKenya
| | | | | | | | - Irene Maeri
- Kenya Medical Research Institute (KEMRI)NairobiKenya
| | | | - Edwin D. Charlebois
- Department of MedicineUniversity of CaliforniaSan Francisco (UCSF)Center for AIDS Prevention StudiesSan FranciscoCaliforniaUSA
| | | | - Moses R. Kamya
- Infectious Diseases Research Collaboration (IDRC)KampalaUganda
- Department of MedicineMakerere University College of Health SciencesKampalaUganda
| | - Diane V. Havlir
- Division of HIVInfectious Diseases & Global MedicineDepartment of MedicineUniversity of CaliforniaSan Francisco (UCSF)San FranciscoCaliforniaUSA
| | - Carol S. Camlin
- Department of ObstetricsGynecology, & Reproductive SciencesUniversity of CaliforniaSan Francisco (UCSF)San FranciscoCaliforniaUSA
- Department of MedicineUniversity of CaliforniaSan Francisco (UCSF)Center for AIDS Prevention StudiesSan FranciscoCaliforniaUSA
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19
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Okiring J, Getahun M, Gutin SA, Lebu S, Lee J, Maeri I, Eyul P, Bukusi EA, Cohen CR, Neilands TB, Ssali S, Charlebois ED, Camlin CS. Sexual partnership concurrency and age disparities associated with sexually transmitted infection and risk behavior in rural communities in Kenya and Uganda. Int J Infect Dis 2022; 120:158-167. [PMID: 35472527 PMCID: PMC9984205 DOI: 10.1016/j.ijid.2022.04.038] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 04/02/2022] [Accepted: 04/20/2022] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVES We examined sex-specific associations of partner age disparity and relationship concurrency with Neisseria gonorrhoeae and/or Chlamydia trachomatis (NG/CT) infection, higher-risk relationships, and condom use as proxies for HIV risk. METHODS Data were collected in 2016 from 2179 adults in 12 communities in Uganda and Kenya. Logistic regression models examined associations of age disparity and relationship concurrency with NG/CT infection, condom use, and higher-risk (commercial sex and other higher-risk) relationships in the past 6 months, controlling for covariates. RESULTS Partner age and relationship concurrency were associated with NG/CT infection in women but not men. Relative to women in age-disparate relationships, women in both age-disparate and age-homogeneous relationships had higher odds of NG/CT infection (adjusted odds ratio [aOR]=3.82, 95% confidence interval [CI]: 1.46-9.98). Among men and women, partnership concurrency was associated with higher-risk partnerships. In addition, relative to those with a single age-homogeneous partner, those with concurrent age-homogeneous partners had higher odds of condom use (men: aOR=2.85, 95% CI: 1.89-4.31; women: aOR=2.99, 95% CI: 1.52-5.89). Concurrent age-disparate partnerships were associated with condom use among men only (aOR=4.02, 95% CI: 2.54-6.37). CONCLUSION Findings underscore the importance of targeted HIV prevention efforts for couples in age-disparate and concurrent relationships.
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Affiliation(s)
- Jaffer Okiring
- Infectious Diseases Research Collaboration, Plot 2C Nakasero Hill Road, P.O. Box 7475, Kampala, Uganda
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 1330 Broadway, Ste. 1100, Oakland CA 94612, USA
| | - Sarah A Gutin
- Center for AIDS Prevention Studies (CAPS), Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA 94158, USA
| | - Sarah Lebu
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 1330 Broadway, Ste. 1100, Oakland CA 94612, USA
| | - Joi Lee
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 1330 Broadway, Ste. 1100, Oakland CA 94612, USA
| | - Irene Maeri
- Centre for Microbiology Research, Kenya Medical Research Institute, P.O. Box 54840 00200, Nairobi, Kenya
| | - Patrick Eyul
- Infectious Diseases Research Collaboration, Plot 2C Nakasero Hill Road, P.O. Box 7475, Kampala, Uganda
| | - Elizabeth A Bukusi
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 1330 Broadway, Ste. 1100, Oakland CA 94612, USA; Centre for Microbiology Research, Kenya Medical Research Institute, P.O. Box 54840 00200, Nairobi, Kenya
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 1330 Broadway, Ste. 1100, Oakland CA 94612, USA
| | - Torsten B Neilands
- Center for AIDS Prevention Studies (CAPS), Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA 94158, USA
| | - Sarah Ssali
- School of Women and Gender Studies, Makerere University, Pool Road, Kampala, Uganda
| | - Edwin D Charlebois
- Center for AIDS Prevention Studies (CAPS), Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA 94158, USA
| | - Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 1330 Broadway, Ste. 1100, Oakland CA 94612, USA; Center for AIDS Prevention Studies (CAPS), Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA 94158, USA.
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Sheira LA, Kwena ZA, Charlebois ED, Agot K, Ayieko B, Gandhi M, Bukusi EA, Thirumurthy H, Camlin CS. Testing a social network approach to promote HIV self-testing and linkage to care among fishermen at Lake Victoria: study protocol for the Owete cluster randomized controlled trial. Trials 2022; 23:463. [PMID: 35668499 PMCID: PMC9169331 DOI: 10.1186/s13063-022-06409-3] [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: 04/07/2022] [Accepted: 05/19/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Nearly 50% of men living with HIV in many countries are unaware of their HIV status; men also have lower uptake of HIV treatment and pre-exposure prophylaxis (PrEP). In SSA, highly mobile men such as those working in fishing communities alongside Lake Victoria have low uptake of HIV testing and low rates of linkage to HIV treatment and PrEP, despite increasing availability of these services. HIV self-testing (HIVST) kits hold promise for overcoming barriers to HIV testing and linkage to services for HIV-positive and HIV-negative men. We describe here a protocol for an HIV status-neutral, social network-based approach to promote HIV testing, linkage to care and prevention, and better health outcomes, including adherence, in fishermen around Lake Victoria. METHODS Utilizing beach management unit (BMU) registries of fishermen operating in three Lake Victoria fishing communities in Siaya County, Kenya, we completed a census and social network mapping to identify close social networks of men. Network clusters identified by a socially-central lead ("promotor") and selected to ensure maximal separation between treatment and control will be randomized. Promotors in both arms will receive basic HIV training; intervention promotors are further trained in HIVST to distribute kits to their cluster, while control promotors will distribute to their cluster vouchers for free HIVST at nearby clinics. We will test whether these promoters can enhance linkage to ART and PrEP after self-testing, thereby addressing a key limitation of HIVST. We will also measure 6- and 12-month viral load in those living with HIV and PrEP adherence among those without HIV via urine tenofovir levels as objective markers of adherence. DISCUSSION This study has the potential to improve HIV health and promote HIV prevention among a hard to reach, at-risk, and highly mobile population of men in Western Kenya-a critical population in Kenya's HIV prevention and treatment program. Further, if successful, this innovative social networks-based model could be scaled at the regional level to address HIV prevention and care among similarly at-risk populations of men in eastern Africa and inland fisheries settings across the continent. TRIAL REGISTRATION Self-Test Strategies and Linkage Incentives to Improve ART and PrEP Uptake in Men, registered on February 26, 2021, registration # NCT04772469 .
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Affiliation(s)
- Lila A. Sheira
- grid.266102.10000 0001 2297 6811Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, 1001 Potrero Ave. Building 100, Ward 84, San Francisco, USA
| | - Zachary A. Kwena
- grid.33058.3d0000 0001 0155 5938Centre for Microbiology Research, Kenya Medical Research institute, Nairobi, Kenya
| | - Edwin D. Charlebois
- grid.266102.10000 0001 2297 6811Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, USA
| | - Kawango Agot
- grid.434865.80000 0004 0605 3832Impact Research and Development Organization, Kisumu, Kenya
| | - Benard Ayieko
- grid.434865.80000 0004 0605 3832Impact Research and Development Organization, Kisumu, Kenya
| | - Monica Gandhi
- grid.266102.10000 0001 2297 6811Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, 1001 Potrero Ave. Building 100, Ward 84, San Francisco, USA
| | - Elizabeth A. Bukusi
- grid.33058.3d0000 0001 0155 5938Centre for Microbiology Research, Kenya Medical Research institute, Nairobi, Kenya ,grid.266102.10000 0001 2297 6811Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, USA
| | - Harsha Thirumurthy
- grid.25879.310000 0004 1936 8972Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Carol S. Camlin
- grid.266102.10000 0001 2297 6811Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, USA ,grid.266102.10000 0001 2297 6811Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, USA
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21
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Murnane PM, Gandhi M, Bacchetti P, Getahun M, Gutin SA, Okochi H, Maeri I, Eyul P, Omoding D, Okiring J, Tallerico R, Louie A, Akullian A, Kamya MR, Bukusi EA, Charlebois ED, Camlin CS. Distinct forms of migration and mobility are differentially associated with HIV treatment adherence. AIDS 2022; 36:1021-1030. [PMID: 35652674 PMCID: PMC9178682 DOI: 10.1097/qad.0000000000003213] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We examined whether human mobility was associated with antiretroviral treatment adherence, measured via antiretroviral hair concentrations. DESIGN This is a cross-sectional analysis of adults on antiretroviral treatment in East Africa at baseline in an observational cohort study. METHODS Participants reported recent mobility (overnight travel) and histories of migration (changes of residence), including reasons, frequency/duration, and locations. Hair antiretroviral concentrations were analyzed using validated methods. We estimated associations between mobility and antiretroviral concentrations via linear regression adjusted for age, sex, region, years on treatment. RESULTS Among 383 participants, half were women and the median age was 40. Among men, 25% reported recent work-related mobility, 30% nonwork mobility, and 11% migrated in the past year (mostly across district boundaries); among women, 6 and 57% reported work-related and nonwork mobility, respectively, and 8% recently migrated (mostly within district). Those reporting work-related trips 2 nights or less had 72% higher hair antiretroviral levels (P = 0.02) than those who did not travel for work; in contrast, nonwork mobility (any duration, vs. none) was associated with 24% lower levels (P = 0.06). Intra-district migrations were associated with 59% lower antiretroviral levels than nonmigrants (P = 0.003) while inter-district migrations were not (27% higher, P = 0.40). CONCLUSION We found that localized/intra-district migration and nonwork travel-more common among women-were associated with lower adherence, potentially reflecting care interruptions or staying with family/friends unaware of the participants' status. In contrast, short work-related trips-more common among men-were associated with higher adherence, perhaps reflecting higher income. Adherence interventions may require tailoring by sex and forms of mobility.
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Affiliation(s)
- Pamela M Murnane
- Department of Epidemiology and Biostatistics
- Institute for Global Health Sciences
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine
- UCSF-Hair Analytical Laboratory
| | | | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences
| | - Sarah A Gutin
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, California, USA
| | - Hideaki Okochi
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine
- UCSF-Hair Analytical Laboratory
| | - Irene Maeri
- Centre For Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Patrick Eyul
- Infectious Diseases Research Collaboration, Makerere University
| | - Daniel Omoding
- Infectious Diseases Research Collaboration, Makerere University
| | - Jaffer Okiring
- Clinical Epidemiology Unit, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Regina Tallerico
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine
- UCSF-Hair Analytical Laboratory
| | - Alexander Louie
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine
- UCSF-Hair Analytical Laboratory
| | - Adam Akullian
- Institute for Disease Modeling, Bellevue, Washington, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Makerere University
- School of Medicine, Makerere University, Kampala, Uganda
| | - Elizabeth A Bukusi
- Department of Obstetrics, Gynecology & Reproductive Sciences
- Centre For Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Edwin D Charlebois
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, California, USA
| | - Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, California, USA
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22
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Hickey MD, Ayieko J, Owaraganise A, Sim N, Balzer LB, Kabami J, Atukunda M, Opel FJ, Wafula E, Nyabuti M, Brown L, Chamie G, Jain V, Peng J, Kwarisiima D, Camlin CS, Charlebois ED, Cohen CR, Bukusi EA, Kamya MR, Petersen ML, Havlir DV. Effect of a patient-centered hypertension delivery strategy on all-cause mortality: Secondary analysis of SEARCH, a community-randomized trial in rural Kenya and Uganda. PLoS Med 2021; 18:e1003803. [PMID: 34543267 PMCID: PMC8489716 DOI: 10.1371/journal.pmed.1003803] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 10/04/2021] [Accepted: 09/09/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Hypertension treatment reduces morbidity and mortality yet has not been broadly implemented in many low-resource settings, including sub-Saharan Africa (SSA). We hypothesized that a patient-centered integrated chronic disease model that included hypertension treatment and leveraged the HIV care system would reduce mortality among adults with uncontrolled hypertension in rural Kenya and Uganda. METHODS AND FINDINGS This is a secondary analysis of the SEARCH trial (NCT:01864603), in which 32 communities underwent baseline population-based multidisease testing, including hypertension screening, and were randomized to standard country-guided treatment or to a patient-centered integrated chronic care model including treatment for hypertension, diabetes, and HIV. Patient-centered care included on-site introduction to clinic staff at screening, nursing triage to expedite visits, reduced visit frequency, flexible clinic hours, and a welcoming clinic environment. The analytic population included nonpregnant adults (≥18 years) with baseline uncontrolled hypertension (blood pressure ≥140/90 mm Hg). The primary outcome was 3-year all-cause mortality with comprehensive population-level assessment. Secondary outcomes included hypertension control assessed at a population level at year 3 (defined per country guidelines as at least 1 blood pressure measure <140/90 mm Hg on 3 repeated measures). Between-arm comparisons used cluster-level targeted maximum likelihood estimation. Among 86,078 adults screened at study baseline (June 2013 to July 2014), 10,928 (13%) had uncontrolled hypertension. Median age was 53 years (25th to 75th percentile 40 to 66); 6,058 (55%) were female; 677 (6%) were HIV infected; and 477 (4%) had diabetes mellitus. Overall, 174 participants (3.2%) in the intervention group and 225 participants (4.1%) in the control group died during 3 years of follow-up (adjusted relative risk (aRR) 0.79, 95% confidence interval (CI) 0.64 to 0.97, p = 0.028). Among those with baseline grade 3 hypertension (≥180/110 mm Hg), 22 (4.9%) in the intervention group and 42 (7.9%) in the control group died during 3 years of follow-up (aRR 0.62, 95% CI 0.39 to 0.97, p = 0.038). Estimated population-level hypertension control at year 3 was 53% in intervention and 44% in control communities (aRR 1.22, 95% CI 1.12 to 1.33, p < 0.001). Study limitations include inability to identify specific causes of death and control conditions that exceeded current standard hypertension care. CONCLUSIONS In this cluster randomized comparison where both arms received population-level hypertension screening, implementation of a patient-centered hypertension care model was associated with a 21% reduction in all-cause mortality and a 22% improvement in hypertension control compared to standard care among adults with baseline uncontrolled hypertension. Patient-centered chronic care programs for HIV can be leveraged to reduce the overall burden of cardiovascular mortality in SSA. TRIAL REGISTRATION ClinicalTrials.gov NCT01864603.
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Affiliation(s)
- Matthew D. Hickey
- Division of HIV, ID, & Global Medicine, Department of Medicine, UCSF, San Francisco, California, United States of America
| | - James Ayieko
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Nicholas Sim
- School of Public Health, University of California Berkeley, Berkeley, California, United States of America
| | - Laura B. Balzer
- School of Public Health & Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, United States of America
| | - Jane Kabami
- Infectious Disease Research Collaboration, Kampala, Uganda
| | | | - Fredrick J. Opel
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Erick Wafula
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Marilyn Nyabuti
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Lillian Brown
- Division of HIV, ID, & Global Medicine, Department of Medicine, UCSF, San Francisco, California, United States of America
| | - Gabriel Chamie
- Division of HIV, ID, & Global Medicine, Department of Medicine, UCSF, San Francisco, California, United States of America
| | - Vivek Jain
- Division of HIV, ID, & Global Medicine, Department of Medicine, UCSF, San Francisco, California, United States of America
| | - James Peng
- Division of HIV, ID, & Global Medicine, Department of Medicine, UCSF, San Francisco, California, United States of America
| | | | - Carol S. Camlin
- Center for AIDS Prevention Studies & Department of Medicine, UCSF, San Francisco, California, United States of America
| | - Edwin D. Charlebois
- Center for AIDS Prevention Studies & Department of Medicine, UCSF, San Francisco, California, United States of America
| | - Craig R. Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, UCSF, San Francisco, California, United States of America
| | - Elizabeth A. Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Moses R. Kamya
- Infectious Disease Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | - Maya L. Petersen
- School of Public Health, University of California Berkeley, Berkeley, California, United States of America
| | - Diane V. Havlir
- Division of HIV, ID, & Global Medicine, Department of Medicine, UCSF, San Francisco, California, United States of America
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Ayieko J, Petersen ML, Kabami J, Mwangwa F, Opel F, Nyabuti M, Charlebois ED, Peng J, Koss CA, Balzer LB, Chamie G, Bukusi EA, Kamya MR, Havlir DV. Uptake and outcomes of a novel community-based HIV post-exposure prophylaxis (PEP) programme in rural Kenya and Uganda. J Int AIDS Soc 2021; 24:e25670. [PMID: 34152067 PMCID: PMC8215805 DOI: 10.1002/jia2.25670] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 09/01/2020] [Revised: 12/23/2020] [Accepted: 01/21/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Antiretroviral-based HIV prevention, including pre-exposure prophylaxis (PrEP), is expanding in generalized epidemic settings, but additional prevention options are needed for individuals with periodic, high-risk sexual exposures. Non-occupational post-exposure prophylaxis (PEP) is recommended in global guidelines. However, in Africa, awareness of and access to PEP for sexual exposures are limited. We assessed feasibility, acceptability, uptake and adherence in a pilot study of a patient-centred PEP programme with options for facility- or community-based service delivery. METHODS After population-level HIV testing with universal access to PrEP for persons at elevated HIV risk (SEARCH Trial:NCT01864603), we conducted a pilot PEP study in five rural communities in Kenya and Uganda between December 2018 and May 2019. We assessed barriers to PEP in the population and implemented an intervention to address these barriers, building on existing in-country PEP protocols. We used community leaders for sensitization. Test kits and medications were acquired through the Ministry of Health supply chain and healthcare providers based at the Ministry of Health clinics were trained on PEP delivery. Additional intervention components were (a)PEP availability seven days/week, (b)PEP hotline staffed by providers and (c)option for out-of-facility medication delivery. We assessed implementation using the Proctor framework and measured seroconversions via repeat HIV testing. Successful "PEP completion" was defined as self-reported adherence over four weeks of therapy with post-PEP HIV testing. RESULTS Community leaders were able to sensitize and mobilize for PEP. The Ministry of Health supplied test kits and PEP medications; after training, healthcare providers delivered the 28-day regimen with high completion rates. Among 124 persons who sought PEP, 66% were female, 24% were ≤25 years and 42% were fisherfolk. Of these, 20% reported exposure with a serodifferent partner, 72% with a new or existing relationship and 7% from transactional sex. 12% of all visits were conducted at out-of-facility community-based sites; 35% of participants had ≥1 out-of-facility visit. No serious adverse events were reported. Overall, 85% met the definition of PEP completion. There were no HIV seroconversions. CONCLUSIONS Among individuals with elevated-risk exposures in rural East African communities, patient-centred PEP was feasible, acceptable and provides a promising addition to the current prevention toolkit.
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Affiliation(s)
- James Ayieko
- Center for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | - Maya L Petersen
- Department of BiostatisticsUniversity of CaliforniaBerkeleyCAUSA
| | - Jane Kabami
- Infectious Diseases Research CollaborationKampalaUganda
| | | | - Fred Opel
- Center for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | - Marilyn Nyabuti
- Center for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | | | - James Peng
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Catherine A Koss
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Laura B Balzer
- Department of Biostatistics and EpidemiologyUniversity of MassachusettsAmherstMAUSA
| | - Gabriel Chamie
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Elizabeth A Bukusi
- Center for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | - Moses R Kamya
- Department of MedicineMakerere UniversityKampalaUganda
| | - Diane V Havlir
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
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Akatukwasa C, Getahun M, El Ayadi AM, Namanya J, Maeri I, Itiakorit H, Owino L, Sanyu N, Kabami J, Ssemmondo E, Sang N, Kwarisiima D, Petersen ML, Charlebois ED, Chamie G, Clark TD, Cohen CR, Kamya MR, Bukusi EA, Havlir DV, Camlin CS. Dimensions of HIV-related stigma in rural communities in Kenya and Uganda at the start of a large HIV 'test and treat' trial. PLoS One 2021; 16:e0249462. [PMID: 33999961 PMCID: PMC8128261 DOI: 10.1371/journal.pone.0249462] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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: 07/02/2020] [Accepted: 03/18/2021] [Indexed: 11/19/2022] Open
Abstract
HIV-related stigma is a frequently cited barrier to HIV testing and care engagement. A nuanced understanding of HIV-related stigma is critical for developing stigma-reduction interventions to optimize HIV-related outcomes. This qualitative study documented HIV-related stigma across eight communities in east Africa during the baseline year of a large HIV test-and-treat trial (SEARCH, NCT: 01864603), prior to implementation of widespread community HIV testing campaigns and efforts to link individuals with HIV to care and treatment. Findings revealed experiences of enacted, internalized and anticipated stigma that were highly gendered, and more pronounced in communities with lower HIV prevalence; women, overwhelmingly, both held and were targets of stigmatizing attitudes about HIV. Past experiences with enacted stigma included acts of segregation, verbal discrimination, physical violence, humiliation and rejection. Narratives among women, in particular, revealed acute internalized stigma including feelings of worthlessness, shame, embarrassment, and these resulted in anxiety and depression, including suicidality among a small number of women. Anticipated stigma included fears of marital dissolution, verbal and physical abuse, gossip and public ridicule. Anticipated stigma was especially salient for women who held internalized stigma and who had experienced enacted stigma from their partners. Anticipated stigma led to care avoidance, care-seeking at remote facilities, and hiding of HIV medications. Interventions aimed at reducing individual and community-level forms of stigma may be needed to improve the lives of PLHIV and fully realize the promise of test-and-treat strategies.
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Affiliation(s)
| | - Monica Getahun
- Department of Obstetrics, Bixby Center for Global Reproductive Health, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States of America
| | - Alison M. El Ayadi
- Department of Obstetrics, Bixby Center for Global Reproductive Health, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States of America
| | - Judith Namanya
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Irene Maeri
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Lawrence Owino
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Naomi Sanyu
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Norton Sang
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Maya L. Petersen
- Divisions of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA, United States of America
| | - Edwin D. Charlebois
- Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, CA, United States of America
| | - Gabriel Chamie
- Division of HIV, Infectious Disease and Global Medicine, Department of Medicine, University of California, San Francisco, CA, United States of America
| | - Tamara D. Clark
- Division of HIV, Infectious Disease and Global Medicine, Department of Medicine, University of California, San Francisco, CA, United States of America
| | - Craig R. Cohen
- Department of Obstetrics, Bixby Center for Global Reproductive Health, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States of America
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Elizabeth A. Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Diane V. Havlir
- Division of HIV, Infectious Disease and Global Medicine, Department of Medicine, University of California, San Francisco, CA, United States of America
| | - Carol S. Camlin
- Department of Obstetrics, Bixby Center for Global Reproductive Health, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States of America
- Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, CA, United States of America
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Shade SB, Kirby VB, Stephens S, Moran L, Charlebois ED, Xavier J, Cajina A, Steward WT, Myers JJ. Outcomes and costs of publicly funded patient navigation interventions to enhance HIV care continuum outcomes in the United States: A before-and-after study. PLoS Med 2021; 18:e1003418. [PMID: 33983925 PMCID: PMC8118317 DOI: 10.1371/journal.pmed.1003418] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 03/29/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In the United States, patients with HIV face significant barriers to linkage to and retention in care which impede the necessary steps toward achieving the desired clinical outcome of viral suppression. Individual-level interventions, such as patient navigation, are evidence based, effective strategies for improving care engagement. In addition, use of surveillance and clinical data to identify patients who are not fully engaged in care may improve the effectiveness and cost-effectiveness of these programs. METHODS AND FINDINGS We employed a pre-post design to estimate the outcomes and costs, from the program perspective, of 5 state-level demonstration programs funded under the Health Resources and Services Administration's Special Projects of National Significance Program (HRSA/SPNS) Systems Linkages Initiative that employed existing surveillance and/or clinical data to identify individuals who had never entered HIV care, had fallen out of care, or were at risk of falling out of care and navigation strategies to engage patients in HIV care. Outcomes and costs were measured relative to standard of care during the first year of implementation of the interventions (2013 to 2014). We followed patients to estimate the number and proportion of additional patients linked, reengaged, retained, and virally suppressed by 12 months after enrollment in the interventions. We employed inverse probability weighting to adjust for differences in patient characteristics across programs, missing data, and loss to follow-up. We estimated the additional costs expended during the first year of each intervention and the cost per outcome of each intervention as the additional cost per HIV additional care continuum target achieved (cost per patient linked, reengaged, retained, and virally suppressed) 12 months after enrollment in each intervention. In this study, 3,443 patients were enrolled in Louisiana (LA), Massachusetts (MA), North Carolina (NC), Virginia (VA), and Wisconsin (WI) (147, 151, 2,491, 321, and 333, respectively). Patients were a mean of 40 years old, 75% male, and African American (69%) or Caucasian (22%). At baseline, 24% were newly diagnosed, 2% had never been in HIV care, 45% had fallen out of care, and 29% were at risk of falling out of care. All 5 interventions were associated with increases in the number and proportion of patients with viral suppression [percent increase: LA = 90.9%, 95% confidence interval (CI) = 88.4 to 93.4; MA = 78.1%, 95% CI = 72.4 to 83.8; NC = 47.5%, 95% CI = 45.2 to 49.8; VA = 54.6, 95% CI = 49.4 to 59.9; WI = 58.4, 95% CI = 53.4 to 63.4]. Overall, interventions cost an additional $4,415 (range = $3,746 to $5,619), $2,009 (range = $1,516 to $2,274), $920 (range = $627 to $941), $2,212 (range = $1,789 to $2,683), and $3,700 ($2,734 to $4,101), respectively per additional patient virally suppressed. The results of this study are limited in that we did not have contemporaneous controls for each intervention; thus, we are only able to assess patients against themselves at baseline and not against standard of care during the same time period. CONCLUSIONS Patient navigation programs were associated with improvements in engagement of patients in HIV care and viral suppression. Cost per outcome was minimized in states that utilized surveillance data to identify individuals who were out of care and/or those that were able to identify a larger number of patients in need of improvement at baseline. These results have the potential to inform the targeting and design of future navigation-type interventions.
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Affiliation(s)
- Starley B. Shade
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
- Institute for Global Health Sciences, Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Valerie B. Kirby
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Sally Stephens
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
- Institute for Global Health Sciences, Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Lissa Moran
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Edwin D. Charlebois
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Jessica Xavier
- Independent Consultant, Silver Spring, Maryland, United States of America
| | - Adan Cajina
- Health Resources and Services Administration, HIV/AIDS Bureau, Rockville, Maryland, United States of America
| | - Wayne T. Steward
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Janet J. Myers
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
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Kamya MR, Petersen ML, Kabami J, Ayieko J, Kwariisima D, Sang N, Clark TD, Schwab J, Charlebois ED, Cohen CR, Bukusi EA, Peng J, Jain V, Chen YH, Chamie G, Balzer LB, Havlir DV. SEARCH Human Immunodeficiency Virus (HIV) Streamlined Treatment Intervention Reduces Mortality at a Population Level in Men With Low CD4 Counts. Clin Infect Dis 2021; 73:e1938-e1945. [PMID: 33783495 DOI: 10.1093/cid/ciaa1782] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We tested the hypothesis that patient-centered, streamlined human immunodeficiency virus (HIV) care would achieve lower mortality than the standard treatment model for persons with HIV and CD4 ≤ 350/uL in the setting of population-wide HIV testing. METHODS In the SEARCH (Sustainable East Africa Research in Community Health) Study (NCT01864603), 32 communities in rural Uganda and Kenya were randomized to country-guided antiretroviral therapy (ART) versus streamlined ART care that included rapid ART start, visit spacing, flexible clinic hours, and welcoming environment. We assessed persons with HIV and CD4 ≤ 350/uL, ART eligible in both arms, and estimated the effect of streamlined care on ART initiation and mortality at 3 years. Comparisons between study arms used a cluster-level analysis with survival estimates from Kaplan-Meier; estimates of ART start among ART-naive persons treated death as a competing risk. RESULTS Among 13 266 adults with HIV, 2973 (22.4%) had CD4 ≤ 350/uL. Of these, 33% were new diagnoses, and 10% were diagnosed but ART-naive. Men with HIV were almost twice as likely as women with HIV to have CD4 ≤ 350/uL and be untreated (15% vs 8%, respectively). Streamlined care reduced mortality by 28% versus control (risk ratio [RR] = 0.72; 95% confidence interval [CI]: .56, .93; P = .02). Despite eligibility in both arms, persons with CD4 ≤ 350/uL started ART faster under streamlined care versus control (76% vs 43% by 12 months, respectively; P < .001). Mortality was reduced substantially more among men (RR = 0.61; 95% CI: .43, .86; P = .01) than among women (RR = 0.90; 95% CI: .62, 1.32; P = .58). CONCLUSIONS After population-based HIV testing, streamlined care reduced population-level mortality among persons with HIV and CD4 ≤ 350/uL, particularly among men. Streamlined HIV care models may play a key role in global efforts to reduce AIDS deaths.
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Affiliation(s)
- Moses R Kamya
- Makerere University, Kampala, Uganda.,Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Maya L Petersen
- University of California Berkeley, Berkeley, California, USA
| | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | | | - Tamara D Clark
- University of California San Francisco, San Francisco, California, USA
| | - Joshua Schwab
- University of California Berkeley, Berkeley, California, USA
| | | | - Craig R Cohen
- University of California San Francisco, San Francisco, California, USA
| | | | - James Peng
- University of California San Francisco, San Francisco, California, USA
| | - Vivek Jain
- University of California San Francisco, San Francisco, California, USA
| | - Yea-Hung Chen
- University of California San Francisco, San Francisco, California, USA
| | - Gabriel Chamie
- University of California San Francisco, San Francisco, California, USA
| | - Laura B Balzer
- University of Massachusetts Amherst, Amherst, Massachusetts, USA
| | - Diane V Havlir
- University of California San Francisco, San Francisco, California, USA
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Nyabuti MN, Petersen ML, Bukusi EA, Kamya MR, Mwangwa F, Kabami J, Sang N, Charlebois ED, Balzer LB, Schwab JD, Camlin CS, Black D, Clark TD, Chamie G, Havlir DV, Ayieko J. Characteristics of HIV seroconverters in the setting of universal test and treat: Results from the SEARCH trial in rural Uganda and Kenya. PLoS One 2021; 16:e0243167. [PMID: 33544717 PMCID: PMC7864429 DOI: 10.1371/journal.pone.0243167] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 11/14/2020] [Indexed: 12/05/2022] Open
Abstract
Background Additional progress towards HIV epidemic control requires understanding who remains at risk of HIV infection in the context of high uptake of universal testing and treatment (UTT). We sought to characterize seroconverters and risk factors in the SEARCH UTT trial (NCT01864603), which achieved high uptake of universal HIV testing and ART coverage in 32 communities of adults (≥15 years) in rural Uganda and Kenya. Methods In a pooled cohort of 117,114 individuals with baseline HIV negative test results, we described those who seroconverted within 3 years, calculated gender-specific HIV incidence rates, evaluated adjusted risk ratios (aRR) for seroconversion using multivariable targeted maximum likelihood estimation, and assessed potential infection sources based on self-report. Results Of 704 seroconverters, 63% were women. Young (15–24 years) men comprised a larger proportion of seroconverters in Western Uganda (18%) than Eastern Uganda (6%) or Kenya (10%). After adjustment for other risk factors, men who were mobile [≥1 month of prior year living outside community] (aRR:1.68; 95%CI:1.09,2.60) or who HIV tested at home vs. health fair (aRR:2.44; 95%CI:1.89,3.23) were more likely to seroconvert. Women who were aged ≤24 years (aRR:1.91; 95%CI:1.27,2.90), mobile (aRR:1.49; 95%CI:1.04,2.11), or reported a prior HIV test (aRR:1.34; 95%CI:1.06,1.70), or alcohol use (aRR:2.07; 95%CI:1.34,3.22) were more likely to seroconvert. Among survey responders (N = 607, 86%), suspected infection source was more likely for women than men to be ≥10 years older (28% versus 8%) or a spouse (51% vs. 31%) and less likely to be transactional sex (10% versus 16%). Conclusion In the context of universal testing and treatment, additional strategies tailored to regional variability are needed to address HIV infection risks of young women, alcohol users, mobile populations, and those engaged in transactional sex to further reduce HIV incidence rates.
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Affiliation(s)
| | - Maya L. Petersen
- Division of Biostatistics and Epidemiology, School of Public Health, University of California Berkeley, Berkeley, California, United States of America
| | | | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda, Makerere University College of Health Sciences, Kampala, Uganda
| | - Florence Mwangwa
- Infectious Diseases Research Collaboration, Kampala, Uganda, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda, Makerere University College of Health Sciences, Kampala, Uganda
| | - Norton Sang
- Kenya Medical Research Institute, Kisumu, Kenya
| | - Edwin D. Charlebois
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, California, United States of America
| | - Laura B. Balzer
- Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, Massachusetts, United States of America
| | - Joshua D. Schwab
- Division of Biostatistics and Epidemiology, School of Public Health, University of California Berkeley, Berkeley, California, United States of America
| | - Carol S. Camlin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Douglas Black
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Tamara D. Clark
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Gabriel Chamie
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, California, United States of America
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Koss CA, Havlir DV, Ayieko J, Kwarisiima D, Kabami J, Chamie G, Atukunda M, Mwinike Y, Mwangwa F, Owaraganise A, Peng J, Olilo W, Snyman K, Awuonda B, Clark TD, Black D, Nugent J, Brown LB, Marquez C, Okochi H, Zhang K, Camlin CS, Jain V, Gandhi M, Cohen CR, Bukusi EA, Charlebois ED, Petersen ML, Kamya MR, Balzer LB. HIV incidence after pre-exposure prophylaxis initiation among women and men at elevated HIV risk: A population-based study in rural Kenya and Uganda. PLoS Med 2021; 18:e1003492. [PMID: 33561143 PMCID: PMC7872279 DOI: 10.1371/journal.pmed.1003492] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 01/04/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Oral pre-exposure prophylaxis (PrEP) is highly effective for HIV prevention, but data are limited on HIV incidence among PrEP users in generalized epidemic settings, particularly outside of selected risk groups. We performed a population-based PrEP study in rural Kenya and Uganda and sought to evaluate both changes in HIV incidence and clinical and virologic outcomes following seroconversion on PrEP. METHODS AND FINDINGS During population-level HIV testing of individuals ≥15 years in 16 communities in the Sustainable East Africa Research in Community Health (SEARCH) study (NCT01864603), we offered universal access to PrEP with enhanced counseling for persons at elevated HIV risk (based on serodifferent partnership, machine learning-based risk score, or self-identified HIV risk). We offered rapid or same-day PrEP initiation and flexible service delivery with follow-up visits at facilities or community-based sites at 4, 12, and every 12 weeks up to week 144. Among participants with incident HIV infection after PrEP initiation, we offered same-day antiretroviral therapy (ART) initiation and analyzed HIV RNA, tenofovir hair concentrations, drug resistance, and viral suppression (<1,000 c/ml based on available assays) after ART start. Using Poisson regression with cluster-robust standard errors, we compared HIV incidence among PrEP initiators to incidence among propensity score-matched recent historical controls (from the year before PrEP availability) in 8 of the 16 communities, adjusted for risk group. Among 74,541 individuals who tested negative for HIV, 15,632/74,541 (21%) were assessed to be at elevated HIV risk; 5,447/15,632 (35%) initiated PrEP (49% female; 29% 15-24 years; 19% in serodifferent partnerships), of whom 79% engaged in ≥1 follow-up visit and 61% self-reported PrEP adherence at ≥1 visit. Over 7,150 person-years of follow-up, HIV incidence was 0.35 per 100 person-years (95% confidence interval [CI] 0.22-0.49) among PrEP initiators. Among matched controls, HIV incidence was 0.92 per 100 person-years (95% CI 0.49-1.41), corresponding to 74% lower incidence among PrEP initiators compared to matched controls (adjusted incidence rate ratio [aIRR] 0.26, 95% CI 0.09-0.75; p = 0.013). Among women, HIV incidence was 76% lower among PrEP initiators versus matched controls (aIRR 0.24, 95% CI 0.07-0.79; p = 0.019); among men, HIV incidence was 40% lower, but not significantly so (aIRR 0.60, 95% CI 0.12-3.05; p = 0.54). Of 25 participants with incident HIV infection (68% women), 7/25 (28%) reported taking PrEP ≤30 days before HIV diagnosis, and 24/25 (96%) started ART. Of those with repeat HIV RNA after ART start, 18/19 (95%) had <1,000 c/ml. One participant with viral non-suppression was found to have transmitted viral resistance, as well as emtricitabine resistance possibly related to PrEP use. Limitations include the lack of contemporaneous controls to assess HIV incidence without PrEP and that plasma samples were not archived to assess for baseline acute infection. CONCLUSIONS Population-level offer of PrEP with rapid start and flexible service delivery was associated with 74% lower HIV incidence among PrEP initiators compared to matched recent controls prior to PrEP availability. HIV infections were significantly lower among women who started PrEP. Universal HIV testing with linkage to treatment and prevention, including PrEP, is a promising approach to accelerate reductions in new infections in generalized epidemic settings. TRIAL REGISTRATION ClinicalTrials.gov NCT01864603.
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Affiliation(s)
- Catherine A. Koss
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - James Ayieko
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Gabriel Chamie
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | | | - Yusuf Mwinike
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | - James Peng
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Winter Olilo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Katherine Snyman
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Benard Awuonda
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Tamara D. Clark
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Douglas Black
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Joshua Nugent
- Department of Biostatistics and Epidemiology, University of Massachusetts, Amherst, Amherst, Massachusetts, United States of America
| | - Lillian B. Brown
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Carina Marquez
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Hideaki Okochi
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Kevin Zhang
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Carol S. Camlin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Vivek Jain
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Monica Gandhi
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Craig R. Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Elizabeth A. Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Edwin D. Charlebois
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Maya L. Petersen
- Graduate Group in Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Laura B. Balzer
- Department of Biostatistics and Epidemiology, University of Massachusetts, Amherst, Amherst, Massachusetts, United States of America
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Mwangwa F, Getahun M, Itiakorit H, Jain V, Ayieko J, Owino L, Akatukwasa C, Maeri I, Koss CA, Chamie G, Clark TD, Kabami J, Atukunda M, Kwarisiima D, Sang N, Bukusi EA, Kamya MR, Petersen ML, Cohen CR, Charlebois ED, Havlir DV, Camlin CS. Provider and Patient Perspectives of Rapid ART Initiation and Streamlined HIV Care: Qualitative Insights From Eastern African Communities. J Int Assoc Provid AIDS Care 2021; 20:23259582211053518. [PMID: 34841945 PMCID: PMC8641109 DOI: 10.1177/23259582211053518] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 09/21/2021] [Accepted: 09/26/2021] [Indexed: 11/30/2022] Open
Abstract
The Sustainable East Africa Research in Community Health (SEARCH), a universal test and treat (UTT) trial, implemented 'Streamlined Care'-a multicomponent strategy including rapid linkage to care and antiretroviral therapy (ART) start, 3-monthly refills, viral load counseling, and accessible, patient-centered care provision. To understand patient and provider experiences of Streamlined Care to inform future care innovations, we conducted in-depth interviews with patients (n = 18) and providers (n = 28) at baseline (2014) and follow-up (2015) (n = 17 patients; n = 21 providers). Audio recordings were transcribed, translated, and deductively and inductively coded. Streamlined Care helped to decongest clinic spaces and de-stigmatize human immunodeficiency virus (HIV) care. Patients credited the individualized counselling, provider-assisted HIV status disclosure, and providers' knowledge of patient's drug schedules, availability, and phone call reminders for their care engagement. However, for some, denial (repeated testing to disprove HIV+ results), feeling healthy, limited understanding of the benefits of early ART, and anticipated side-effects, and mistrust of researchers hindered rapid ART initiation. Patients' short and long-term mobility proved challenging for both patients and providers. Providers viewed viral load counselling as a powerful tool to convince otherwise healthy and high-CD4 patients to initiate ART. Patient-centered HIV care models should build on the successes of Streamlined Care, while addressing persistent barriers.#NCT01864683-https://clinicaltrials.gov/ct2/show/NCT01864603.
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Affiliation(s)
| | | | | | - Vivek Jain
- University of California San Francisco, San Francisco, USA
| | - James Ayieko
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | - Irene Maeri
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Gabriel Chamie
- University of California San Francisco, San Francisco, USA
| | | | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | - Norton Sang
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | | | | | | | | | - Carol S. Camlin
- University of California San Francisco, San Francisco, USA
- University of California, San Francisco, San Francisco, CA, USA
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30
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Balzer LB, Havlir DV, Kamya MR, Chamie G, Charlebois ED, Clark TD, Koss CA, Kwarisiima D, Ayieko J, Sang N, Kabami J, Atukunda M, Jain V, Camlin CS, Cohen CR, Bukusi EA, Van Der Laan M, Petersen ML. Machine Learning to Identify Persons at High-Risk of Human Immunodeficiency Virus Acquisition in Rural Kenya and Uganda. Clin Infect Dis 2020; 71:2326-2333. [PMID: 31697383 PMCID: PMC7904068 DOI: 10.1093/cid/ciz1096] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [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: 07/15/2019] [Accepted: 11/05/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND In generalized epidemic settings, strategies are needed to prioritize individuals at higher risk of human immunodeficiency virus (HIV) acquisition for prevention services. We used population-level HIV testing data from rural Kenya and Uganda to construct HIV risk scores and assessed their ability to identify seroconversions. METHODS During 2013-2017, >75% of residents in 16 communities in the SEARCH study were tested annually for HIV. In this population, we evaluated 3 strategies for using demographic factors to predict the 1-year risk of HIV seroconversion: membership in ≥1 known "risk group" (eg, having a spouse living with HIV), a "model-based" risk score constructed with logistic regression, and a "machine learning" risk score constructed with the Super Learner algorithm. We hypothesized machine learning would identify high-risk individuals more efficiently (fewer persons targeted for a fixed sensitivity) and with higher sensitivity (for a fixed number targeted) than either other approach. RESULTS A total of 75 558 persons contributed 166 723 person-years of follow-up; 519 seroconverted. Machine learning improved efficiency. To achieve a fixed sensitivity of 50%, the risk-group strategy targeted 42% of the population, the model-based strategy targeted 27%, and machine learning targeted 18%. Machine learning also improved sensitivity. With an upper limit of 45% targeted, the risk-group strategy correctly classified 58% of seroconversions, the model-based strategy 68%, and machine learning 78%. CONCLUSIONS Machine learning improved classification of individuals at risk of HIV acquisition compared with a model-based approach or reliance on known risk groups and could inform targeting of prevention strategies in generalized epidemic settings. CLINICAL TRIALS REGISTRATION NCT01864603.
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Affiliation(s)
- Laura B Balzer
- Department of Biostatistics and Epidemiology, University of Massachusetts, Amherst, Massachusetts, USA
| | - Diane V Havlir
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Gabriel Chamie
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Edwin D Charlebois
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, California, USA
| | - Tamara D Clark
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Catherine A Koss
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | | | - James Ayieko
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Norton Sang
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Vivek Jain
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Carol S Camlin
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Elizabeth A Bukusi
- Kenya Medical Research Institute, Nairobi, Kenya
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Mark Van Der Laan
- Division of Epidemiology and Biostatistics, University of California, Berkeley, California, USA
| | - Maya L Petersen
- Division of Epidemiology and Biostatistics, University of California, Berkeley, California, USA
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Camlin CS, Charlebois ED, Getahun M, Akatukwasa C, Atwine F, Itiakorit H, Bakanoma R, Maeri I, Owino L, Onyango A, Chamie G, Clark TD, Cohen CR, Kwarisiima D, Kabami J, Sang N, Kamya MR, Bukusi EA, Petersen ML, V Havlir D. Pathways for reduction of HIV-related stigma: a model derived from longitudinal qualitative research in Kenya and Uganda. J Int AIDS Soc 2020; 23:e25647. [PMID: 33283986 PMCID: PMC7720278 DOI: 10.1002/jia2.25647] [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: 05/21/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION The rollout of antiretroviral therapy (ART) has been associated with reductions in HIV-related stigma, but pathways through which this reduction occurs are poorly understood. In the newer context of universal test and treat (UTT) interventions, where rapid diffusion of ART uptake takes place, there is an opportunity to understand the processes through which HIV-related stigma can decline, and how UTT strategies may precipitate more rapid and widespread changes in stigma. This qualitative study sought to evaluate how a UTT intervention influenced changes in beliefs, attitudes and behaviours related to HIV. METHODS Longitudinal qualitative in-depth semi-structured interview data were collected within a community-cluster randomized UTT trial, the Sustainable East Africa Research in Community Health (SEARCH) study, annually over three rounds (2014 to 2016) from two cohorts of adults (n = 32 community leaders, and n = 112 community members) in eight rural communities in Uganda and Kenya. Data were inductively analysed to develop new theory for understanding the pathways of stigma decline. RESULTS We present an emergent theoretical model of pathways through which HIV-related stigma may decline: internalized stigma may be reduced by two processes accelerated through the uptake and successful usage of ART: first, a reduced fear of dying and increased optimism for prolonged and healthy years of life; second, a restoration of perceived social value and fulfilment of subjective role expectations via restored physical strength and productivity. Anticipated stigma may be reduced in response to widespread engagement in HIV testing, leading to an increasing number of HIV status disclosures in a community, "normalizing" disclosure and reducing fears. Improvements in the perceived quality of HIV care lead to people living with HIV (PLHIV) seeking care in nearby facilities, seeing other known community members living with HIV, reducing isolation and facilitating opportunities for social support and "solidarity." Finally, enacted stigma may be reduced in response to the community viewing the healthy bodies of PLHIV successfully engaged in treatment, which lessens the fears that trigger enacted stigma; it becomes no longer socially normative to stigmatize PLHIV. This process may be reinforced through public health messaging and anti-discrimination laws. CONCLUSIONS Declines in HIV-related stigma appear to underway and explained by social processes accelerated by UTT efforts. Widespread implementation of UTT shows promise for reducing multiple dimensions of stigma, which is critical for improving health outcomes among PLHIV.
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Affiliation(s)
- Carol S Camlin
- Department of ObstetricsGynecology & Reproductive SciencesUniversity of California San FranciscoSan FranciscoCAUSA
- Department of MedicineCenter for AIDS Prevention StudiesUniversity of California San FranciscoSan FranciscoCAUSA
| | - Edwin D Charlebois
- Department of MedicineCenter for AIDS Prevention StudiesUniversity of California San FranciscoSan FranciscoCAUSA
| | - Monica Getahun
- Department of ObstetricsGynecology & Reproductive SciencesUniversity of California San FranciscoSan FranciscoCAUSA
| | | | | | | | | | - Irene Maeri
- Kenya Medical Research InstituteNairobiKenya
| | | | | | - Gabriel Chamie
- Division of HIVDepartment of MedicineInfectious Diseases, and Global MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Tamara D Clark
- Division of HIVDepartment of MedicineInfectious Diseases, and Global MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Craig R Cohen
- Department of ObstetricsGynecology & Reproductive SciencesUniversity of California San FranciscoSan FranciscoCAUSA
| | | | - Jane Kabami
- Infectious Diseases Research CollaborationKampalaUganda
| | - Norton Sang
- Kenya Medical Research InstituteNairobiKenya
| | - Moses R Kamya
- Infectious Diseases Research CollaborationKampalaUganda
- School of MedicineMakerere UniversityKampalaUganda
| | | | - Maya L Petersen
- Divisions of Biostatistics and EpidemiologySchool of Public HealthUniversity of California BerkeleyBerkeleyCAUSA
| | - Diane V Havlir
- Division of HIVDepartment of MedicineInfectious Diseases, and Global MedicineUniversity of California San FranciscoSan FranciscoCAUSA
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Camlin CS, Koss CA, Getahun M, Owino L, Itiakorit H, Akatukwasa C, Maeri I, Bakanoma R, Onyango A, Atwine F, Ayieko J, Kabami J, Mwangwa F, Atukunda M, Owaraganise A, Kwarisiima D, Sang N, Bukusi EA, Kamya MR, Petersen ML, Cohen CR, Charlebois ED, Havlir DV. Understanding Demand for PrEP and Early Experiences of PrEP Use Among Young Adults in Rural Kenya and Uganda: A Qualitative Study. AIDS Behav 2020; 24:2149-2162. [PMID: 31955361 PMCID: PMC7909847 DOI: 10.1007/s10461-020-02780-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [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: 11/29/2022]
Abstract
Few studies have sought to understand factors influencing uptake and continuation of pre-exposure prophylaxis (PrEP) among young adults in sub-Saharan Africa in the context of population-based delivery of open-label PrEP. To address this gap, this qualitative study was implemented within the SEARCH study (NCT#01864603) in Kenya and Uganda, which achieved near-universal HIV testing, and offered PrEP in 16 intervention communities beginning in 2016-2017. Focus group discussions (8 groups, n = 88 participants) and in-depth interviews (n = 23) with young adults who initiated or declined PrEP were conducted in five communities, to explore PrEP-related beliefs and attitudes, HIV risk perceptions, motivations for uptake and continuation, and experiences. Grounded theoretical methods were used to analyze data. Young people felt personally vulnerable to HIV, but perceived the severity of HIV to be low, due to the success of antiretroviral therapy (ART): daily pill-taking was more threatening than the disease itself. Motivations for PrEP were highly gendered: young men viewed PrEP as a vehicle for safely pursuing multiple partners, while young women saw PrEP as a means to control risks in the context of engagement in transactional sex and limited agency to negotiate condom use and partner testing. Rumors, HIV/ART-related stigma, and desire for "proof" of efficacy militated against uptake, and many women required partners' permission to take PrEP. Uptake was motivated by high perceived HIV risk, and beliefs that PrEP use supported life goals. PrEP was often discontinued due to dissolution of partnerships/changing risk, unsupportive partners/peers, or early side effects/pill burden. Despite high perceived risks and interest, PrEP was received with moral ambivalence because of its associations with HIV/ART and stigmatized behaviors. Delivery models that promote youth access, frame messaging on wellness and goals, and foster partner and peer support, may facilitate uptake among young people.
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Affiliation(s)
- Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, ANSIRH Program, University of California San Francisco, 1330 Broadway, Suite 1100, Oakland, CA, 94612, USA.
- Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, USA.
| | - Catherine A Koss
- Department of Medicine, Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, USA
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, ANSIRH Program, University of California San Francisco, 1330 Broadway, Suite 1100, Oakland, CA, 94612, USA
| | | | | | | | - Irene Maeri
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | | | - James Ayieko
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | | | | | - Norton Sang
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Maya L Petersen
- Graduate Group in Biostatistics, School of Public Health, University of California Berkeley, Berkeley, USA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, ANSIRH Program, University of California San Francisco, 1330 Broadway, Suite 1100, Oakland, CA, 94612, USA
| | - Edwin D Charlebois
- Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, USA
| | - Diane V Havlir
- Department of Medicine, Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, USA
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Olilo WA, Petersen ML, Koss CA, Wafula E, Kwarisiima D, Kadede K, Clark TD, Cohen CR, Bukusi EA, Kamya MR, Charlebois ED, Havlir DV, Ayieko J. Pre-exposure Prophylaxis (PrEP) Uptake Among Older Individuals in Rural Western Kenya. J Acquir Immune Defic Syndr 2020; 82:e50-e53. [PMID: 31490343 PMCID: PMC6831040 DOI: 10.1097/qai.0000000000002150] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Winter A Olilo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | - Eric Wafula
- University of California, San Francisco, San Francisco, CA
| | | | - Kevin Kadede
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Tamara D Clark
- University of California, San Francisco, San Francisco, CA
| | - Craig R Cohen
- University of California, San Francisco, San Francisco, CA
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | - Diane V Havlir
- University of California, San Francisco, San Francisco, CA
| | - James Ayieko
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
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Finkelstein JL, Herman HS, Plenty A, Mehta S, Natureeba P, Clark TD, Kamya MR, Ruel T, Charlebois ED, Cohan D, Havlir D, Young SL. Anemia and Micronutrient Status during Pregnancy, and Their Associations with Obstetric and Infant Outcomes among HIV-Infected Ugandan Women Receiving Antiretroviral Therapy. Curr Dev Nutr 2020; 4:nzaa075. [PMID: 32440638 PMCID: PMC7229869 DOI: 10.1093/cdn/nzaa075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 03/18/2020] [Accepted: 04/09/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Women living with HIV (WLHIV) are at higher risk of micronutrient deficiencies and adverse health outcomes. There are limited data on the burden or sequelae of micronutrient deficiencies among pregnant WLHIV receiving antiretroviral therapy (ART). OBJECTIVES We aimed to examine anemia and vitamin B-12, folate, and vitamin D deficiencies, and their associations with obstetric and infant outcomes, among pregnant WLHIV initiating combination antiretroviral therapy (cART) in rural Uganda. METHODS This was a prospective analysis among pregnant WLHIV (12-28 weeks of gestation) in PROMOTE-Pregnant Women and Infants (PIs), a randomized trial comparing the effects of protease inhibitor (PI)-based ART with those of a non-PI-based ART on placental malaria risk. We conducted a substudy on the burden of anemia [trimester 1/3: hemoglobin (Hb) <11.0 g/dL; trimester 2: Hb <10.5 g/dL; n = 367] and micronutrient deficiencies (n = 127) in pregnant WLHIV and their associations with obstetric and infant outcomes. Hb was measured by cyanmethemoglobin, vitamin B-12 and folate were measured via electrochemiluminescence, and vitamin D was measured by ELISA. Linear and binomial regression were used to evaluate associations between micronutrient status during pregnancy and perinatal outcomes. RESULTS 26.8% women were anemic, 30.2% were vitamin B-12 insufficient (<221.0 pmol/L), 66.1% were folate insufficient (<13.5 nmol/L), and 65.4% were vitamin D insufficient (<30.0 ng/mL) at enrollment. Anemia during pregnancy was associated with a greater risk of small for gestational age (SGA) (RR: 1.88; 95% CI: 1.28, 2.77; P = 0.001); each 1-g/dL decrease in Hb was associated with greater risk of SGA (RR: 0.76; 95% CI: 0.65, 0.90; P = 0.001). Multivariate models showed that increased vitamin D concentrations predicted lower risk of infant wasting (WLZ < -2; RR: 0.94; 95% CI: 0.89, 0.99; P = 0.04). Multivariate models also indicated that maternal vitamin B-12 and folate concentrations at enrollment predicted maternal (P < 0.001) and infant (P = 0.02) concentrations postpartum. CONCLUSIONS Anemia and micronutrient deficiencies are associated with a variety of adverse obstetric and infant outcomes and are an important public health concern in perinatal WLHIV on cART and their children.This trial was registered at clinicaltrials.gov as NCT00993031.
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Affiliation(s)
| | - Heather S Herman
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Albert Plenty
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA, USA
| | - Saurabh Mehta
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Paul Natureeba
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Tamara D Clark
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | - Theodore Ruel
- Division of Infectious Disease, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Edwin D Charlebois
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA, USA
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Deborah Cohan
- Department of Obstetrics and Gynecology, University of California San Francisco, San Francisco, CA, USA
| | - Diane Havlir
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Sera L Young
- Department of Anthropology and Global Health Studies, Northwestern University, Evanston, IL, USA
- Institute for Policy Research, Northwestern University, Evanston, IL, USA
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Koss CA, Charlebois ED, Ayieko J, Kwarisiima D, Kabami J, Balzer LB, Atukunda M, Mwangwa F, Peng J, Mwinike Y, Owaraganise A, Chamie G, Jain V, Sang N, Olilo W, Brown LB, Marquez C, Zhang K, Ruel TD, Camlin CS, Rooney JF, Black D, Clark TD, Gandhi M, Cohen CR, Bukusi EA, Petersen ML, Kamya MR, Havlir DV. Uptake, engagement, and adherence to pre-exposure prophylaxis offered after population HIV testing in rural Kenya and Uganda: 72-week interim analysis of observational data from the SEARCH study. Lancet HIV 2020; 7:e249-e261. [PMID: 32087152 PMCID: PMC7208546 DOI: 10.1016/s2352-3018(19)30433-3] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/14/2019] [Accepted: 12/18/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Optimal strategies for pre-exposure prophylaxis (PrEP) engagement in generalised HIV epidemics are unknown. We aimed to assess PrEP uptake and engagement after population-level HIV testing and universal PrEP access to characterise gaps in the PrEP cascade in rural Kenya and Uganda. METHODS We did a 72-week interim analysis of observational data from the ongoing SEARCH (Sustainable East Africa Research in Community Health) study. Following community sensitisation and PrEP education, we did HIV testing and offered PrEP at health fairs and facilities in 16 rural communities in western Kenya, eastern Uganda, and western Uganda. We provided enhanced PrEP counselling to individuals 15 years and older who were assessed as having an elevated HIV risk on the basis of serodifferent partnership or empirical risk score, or who otherwise self-identified as being at high risk but were not in serodifferent partnerships or identified by the risk score. PrEP follow-up visits were done at facilities, homes, or community locations. We assessed PrEP uptake within 90 days of HIV testing, programme engagement (follow-up visit attendance at week 4, week 12, and every 12 weeks thereafter), refills, self-reported adherence up to 72 weeks, and concentrations of tenofovir in hair samples from individuals reporting HIV risk and adherence during follow-up, and analysed factors associated with uptake and adherence. This study is registered with ClinicalTrials.gov, NCT01864603. FINDINGS Between June 6, 2016, and June 23, 2017, 70 379 community residents 15 years or older who had not previously been diagnosed with HIV were tested during population-level HIV testing. Of these individuals, 69 121 tested HIV-negative, 12 935 of whom had elevated HIV risk (1353 [10%] serodifferent partnership, 6938 [54%] risk score, 4644 [36%] otherwise self-identified risk). 3489 (27%) initiated PrEP, 2865 (82%) of whom did so on the same day as HIV testing and 1733 (50%) of whom were men. PrEP uptake was lower among individuals aged 15-24 years (adjusted odds ratio 0·55, 95% CI 0·45-0·68) and mobile individuals (0·61, 0·41-0·91). At week 4, among 3466 individuals who initiated PrEP and did not withdraw or die before the first visit, 2215 (64%) were engaged in the programme, 1701 (49%) received medication refills, and 1388 (40%) self-reported adherence. At week 72, 1832 (56%) of 3274 were engaged, 1070 (33%) received a refill, and 900 (27%) self-reported adherence. Among participants reporting HIV risk at weeks 4-72, refills (89-93%) and self-reported adherence (70-76%) were high. Among sampled participants self-reporting adherence at week 24, the proportion with tenofovir concentrations in the hair reflecting at least four doses taken per week was 66%, and reflecting seven doses per week was 44%. Participants who stopped PrEP accepted HIV testing at 4274 (83%) of 5140 subsequent visits; half of these participants later restarted PrEP. 29 participants of 3489 who initiated PrEP had serious adverse events, including seven deaths. Five adverse events (all grade 3) were assessed as being possibly related to the study drug. INTERPRETATION During population-level HIV testing, inclusive risk assessment (combining serodifferent partnership, an empirical risk score, and self-identification of HIV risk) was feasible and identified individuals who could benefit from PrEP. The biggest gap in the PrEP cascade was PrEP uptake, particularly for young and mobile individuals. Participants who initiated PrEP and had perceived HIV risk during follow-up reported taking PrEP, but one-third had drug concentrations consistent with poor adherence, highlighting the need for novel approaches and long-acting formulations as PrEP roll-out expands. FUNDING National Institutes of Health, President's Emergency Plan for AIDS Relief, Bill & Melinda Gates Foundation, and Gilead Sciences.
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Affiliation(s)
- Catherine A Koss
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Edwin D Charlebois
- Division of Prevention Sciences, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - James Ayieko
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Laura B Balzer
- Department of Biostatistics and Epidemiology, University of Massachusetts Amherst, Amherst, MA, USA
| | | | | | - James Peng
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Yusuf Mwinike
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Gabriel Chamie
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Vivek Jain
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Norton Sang
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Winter Olilo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Lillian B Brown
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Carina Marquez
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Kevin Zhang
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Theodore D Ruel
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Carol S Camlin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
| | | | - Douglas Black
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Tamara D Clark
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Elizabeth A Bukusi
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA; Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Maya L Petersen
- Graduate Group in Biostatistics, School of Public Health, University of California Berkeley, Berkeley, CA, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda; School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane V Havlir
- Division of HIV, Infectious Diseases and Global Medicine, University of California San Francisco, San Francisco, CA, USA
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Muiru AN, Charlebois ED, Balzer LB, Kwarisiima D, Elly A, Black D, Okiror S, Kabami J, Atukunda M, Snyman K, Petersen M, Kamya M, Havlir D, Estrella MM, Hsu CY. The epidemiology of chronic kidney disease (CKD) in rural East Africa: A population-based study. PLoS One 2020; 15:e0229649. [PMID: 32130245 PMCID: PMC7055898 DOI: 10.1371/journal.pone.0229649] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [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: 09/02/2019] [Accepted: 02/11/2020] [Indexed: 12/19/2022] Open
Abstract
Background Chronic kidney disease (CKD) may be common among individuals living in sub-Saharan Africa due to the confluence of CKD risk factors and genetic predisposition. Methods We ascertained the prevalence of CKD and its risk factors among a sample of 3,686 participants of a population-based HIV trial in rural Uganda and Kenya. Prevalent CKD was defined as a serum creatinine-based estimated glomerular filtration rate <60 mL/min/1.73m2 or proteinuria (urine dipstick ≥1+). We used inverse-weighting to estimate the population prevalence of CKD, and multivariable log-link Poisson models to assess the associations of potential risk factors with CKD. Results The estimated CKD prevalence was 6.8% (95% CI 5.7–8.1%) overall and varied by region, being 12.5% (10.1–15.4%) in eastern Uganda, 3.9% (2.2–6.8%) in southwestern Uganda and 3.7% (2.7–5.1%) in western Kenya. Risk factors associated with greater CKD prevalence included age ≥60 years (adjusted prevalence ratio [aPR] 3.5 [95% CI 1.9–6.5] compared with age 18–29 years), HIV infection (aPR 1.6 [1.1–2.2]), and residence in eastern Uganda (aPR 3.9 [2.6–5.9]). However, two-thirds of individuals with CKD did not have HIV, diabetes, or hypertension as risk factors. Furthermore, we noted many individuals who did not have proteinuria had dipstick positive leukocyturia or hematuria. Conclusion The prevalence of CKD is appreciable in rural East Africa and there are considerable regional differences. Conventional risk factors appear to only explain a minority of cases, and leukocyturia and hematuria were common, highlighting the need for further research into understanding the nature of CKD in sub-Saharan Africa.
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Affiliation(s)
- Anthony N. Muiru
- University of California, San Francisco, California, United States of America
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Medical Center, San Francisco, California, United States of America
- * E-mail:
| | - Edwin D. Charlebois
- University of California, San Francisco, California, United States of America
| | - Laura B. Balzer
- University of Massachusetts, Amherst, Massachusetts, United States of America
| | | | - Assurah Elly
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Doug Black
- University of California, San Francisco, California, United States of America
| | - Samuel Okiror
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Katherine Snyman
- University of California, San Francisco, California, United States of America
| | - Maya Petersen
- School of Public Health, University of California, Berkeley, California, United States of America
| | | | - Diane Havlir
- University of California, San Francisco, California, United States of America
| | - Michelle M. Estrella
- University of California, San Francisco, California, United States of America
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Medical Center, San Francisco, California, United States of America
| | - Chi-yuan Hsu
- University of California, San Francisco, California, United States of America
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Epstein A, Bendavid E, Nash D, Charlebois ED, Weiser SD. Drought and intimate partner violence towards women in 19 countries in sub-Saharan Africa during 2011-2018: A population-based study. PLoS Med 2020; 17:e1003064. [PMID: 32191701 PMCID: PMC7081984 DOI: 10.1371/journal.pmed.1003064] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 02/21/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Drought has many known deleterious impacts on human health, but little is known about the relationship between drought and intimate partner violence (IPV). We aimed to evaluate this relationship and to assess effect heterogeneity between population subgroups among women in 19 sub-Saharan African countries. METHODS AND FINDINGS We used data from 19 Demographic and Health Surveys from 2011 to 2018 including 83,990 partnered women aged 15-49 years. Deviations in rainfall in the year before the survey date were measured relative to the 29 previous years using Climate Hazards Group InfraRed Precipitation with Station data, with recent drought classified as ordinal categorical variable (severe: ≤10th percentile; mild/moderate: >10th percentile to ≤30th percentile; none: >30th percentile). We considered 4 IPV-related outcomes: reporting a controlling partner (a risk factor for IPV) and experiencing emotional violence, physical violence, or sexual violence in the 12 months prior to survey. Logistic regression was used to estimate marginal risk differences (RDs). We evaluated the presence of effect heterogeneity by age group and employment status. Of the 83,990 women included in the analytic sample, 10.7% (9,019) experienced severe drought and 23.4% (19,639) experienced mild/moderate drought in the year prior to the survey, with substantial heterogeneity across countries. The mean age of respondents was 30.8 years (standard deviation 8.2). The majority of women lived in rural areas (66.3%) and were married (73.3%), while less than half (42.6%) were literate. Women living in severe drought had higher risk of reporting a controlling partner (marginal RD in percentage points = 3.0, 95% CI 1.3, 4.6; p < 0.001), experiencing physical violence (marginal RD = 0.8, 95% CI 0.1, 1.5; p = 0.019), and experiencing sexual violence (marginal RD = 1.2, 95% CI 0.4, 2.0; p = 0.001) compared with women not experiencing drought. Women living in mild/moderate drought had higher risk of reporting physical (marginal RD = 0.7, 95% CI 0.2, 1.1; p = 0.003) and sexual violence (marginal RD = 0.7, 95% CI 0.3, 1.2; p = 0.001) compared with those not living in drought. We did not find evidence for an association between drought and emotional violence. In analyses stratified by country, we found 3 settings where drought was protective for at least 1 measure of IPV: Namibia, Tanzania, and Uganda. We found evidence for effect heterogeneity (additive interaction) for the association between drought and younger age and between drought and employment status, with stronger associations between drought and IPV among adolescent girls and unemployed women. This study is limited by its lack of measured hypothesized mediating variables linking drought and IPV, prohibiting a formal mediation analysis. Additional limitations include the potential for bias due to residual confounding and potential non-differential misclassification of the outcome measures leading to an attenuation of observed associations. CONCLUSIONS Our findings indicate that drought was associated with measures of IPV towards women, with larger positive associations among adolescent girls and unemployed women. There was heterogeneity in these associations across countries. Weather shocks may exacerbate vulnerabilities among women in sub-Saharan Africa. Future work should further evaluate potential mechanisms driving these relationships.
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Affiliation(s)
- Adrienne Epstein
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Eran Bendavid
- Department of Medicine, Stanford University, Stanford, California, United States of America
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, United States of America
| | - Edwin D. Charlebois
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Sheri D. Weiser
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
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Marquez C, Atukunda M, Balzer LB, Chamie G, Kironde J, Ssemmondo E, Ruel TD, Mwangwa F, Tram KH, Clark TD, Kwarisiima D, Petersen M, Kamya MR, Charlebois ED, Havlir DV. The age-specific burden and household and school-based predictors of child and adolescent tuberculosis infection in rural Uganda. PLoS One 2020; 15:e0228102. [PMID: 31995631 PMCID: PMC6988961 DOI: 10.1371/journal.pone.0228102] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 08/14/2019] [Accepted: 01/07/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The age-specific epidemiology of child and adolescent tuberculosis (TB) is poorly understood, especially in rural areas of East Africa. We sought to characterize the age-specific prevalence and predictors of TB infection among children and adolescents living in rural Uganda, and to explore the contribution of household TB exposure on TB infection. METHODS From 2015-2016 we placed and read 3,121 tuberculin skin tests (TST) in children (5-11 years old) and adolescents (12-19 years old) participating in a nested household survey in 9 rural Eastern Ugandan communities. TB infection was defined as a positive TST (induration ≥10mm or ≥5mm if living with HIV). Age-specific prevalence was estimated using inverse probability weighting to adjust for incomplete measurement. Generalized estimating equations were used to assess the association between TB infection and multi-level predictors. RESULTS The adjusted prevalence of TB infection was 8.5% (95%CI: 6.9-10.4) in children and 16.7% (95% CI:14.0-19.7) in adolescents. Nine percent of children and adolescents with a prevalent TB infection had a household TB contact. Among children, having a household TB contact was strongly associated with TB infection (aOR 5.5, 95% CI: 1.7-16.9), but the strength of this association declined among adolescents and did not meet significance (aOR 2.3, 95% CI: 0.8-7.0). The population attributable faction of TB infection due to a household TB contact was 8% for children and 4% among adolescents. Mobile children and adolescents who travel outside of their community for school had a 1.7 (95% CI 1.0-2.9) fold higher odds of TB infection than those who attended school in the community. CONCLUSION Children and adolescents in this area of rural eastern Uganda suffer a significant burden of TB. The majority of TB infections are not explained by a known household TB contact. Our findings underscore the need for community-based TB prevention interventions, especially among mobile youth.
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Affiliation(s)
- Carina Marquez
- University of California, San Francisco, Division of HIV, Infectious Diseases and Global Medicine, San Francisco, California, United States of America
| | | | - Laura B. Balzer
- University of Massachusetts, Amherst, Department of Biostatistics and Epidemiology, Amherst, Massachusetts, United States of America
| | - Gabriel Chamie
- University of California, San Francisco, Division of HIV, Infectious Diseases and Global Medicine, San Francisco, California, United States of America
| | - Joel Kironde
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Theodore D. Ruel
- University of California, San Francisco, Department of Pediatrics, San Francisco, California, United States of America
| | | | - Khai Hoan Tram
- Stanford University School of Medicine, Palo Alto, California, United States of America
| | - Tamara D. Clark
- University of California, San Francisco, Division of HIV, Infectious Diseases and Global Medicine, San Francisco, California, United States of America
| | - Dalsone Kwarisiima
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Makerere University College of Health Sciences, School of Medicine, Kampala, Uganda
| | - Maya Petersen
- University of California, Berkeley School of Public Health, Berkeley, California, United States of America
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Makerere University College of Health Sciences, School of Medicine, Kampala, Uganda
| | - Edwin D. Charlebois
- Center for AIDS Prevention (CAPS), University of California, San Francisco, San Francisco, California United States of America
| | - Diane V. Havlir
- University of California, San Francisco, Division of HIV, Infectious Diseases and Global Medicine, San Francisco, California, United States of America
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Heller DJ, Balzer LB, Kazi D, Charlebois ED, Kwarisiima D, Mwangwa F, Jain V, Kotwani P, Chamie G, Cohen CR, Clark TD, Ayieko J, Byonanabye DM, Petersen M, Kamya MR, Havlir D, Kahn JG. Hypertension testing and treatment in Uganda and Kenya through the SEARCH study: An implementation fidelity and outcome evaluation. PLoS One 2020; 15:e0222801. [PMID: 31940346 PMCID: PMC6961918 DOI: 10.1371/journal.pone.0222801] [Citation(s) in RCA: 11] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 09/07/2019] [Indexed: 01/21/2023] Open
Abstract
Background Hypertension (HTN) is the single leading risk factor for human mortality worldwide, and more prevalent in sub-Saharan Africa than any other region [1]–although resources for HTN screening, treatment, and control are few. Most regional pilot studies to leverage HIV programs for HTN control have achieved blood pressure control in half of participants or fewer [2,3,4]. But this control gap may be due to inconsistent delivery of services, rather than ineffective underlying interventions. Methods We sought to evaluate the consistency of HTN program delivery within the SEARCH study (NCT01864603) among 95,000 adults in 32 rural communities in Uganda and Kenya from 2013–2016. To achieve this objective, we designed and performed a fidelity evaluation of the step-by-step process (cascade) of HTN care within SEARCH, calculating rates of HTN screening, linkage to care, and follow-up care. We evaluated SEARCH’s assessment of each participant’s HTN status against measured blood pressure and HTN history. Findings SEARCH completed blood pressure screens on 91% of participants. SEARCH HTN screening was 91% sensitive and over 99% specific for HTN relative to measured blood pressure and patient history. 92% of participants screened HTN+ received clinic appointments, and 42% of persons with HTN linked to subsequent care. At follow-up, 82% of SEARCH clinic participants received blood pressure checks; 75% received medication appropriate for their blood pressure; 66% remained in care; and 46% had normal blood pressure at their most recent visit. Conclusion The SEARCH study’s consistency in delivering screening and treatment services for HTN was generally high, but SEARCH could improve effectiveness in linking patients to care and achieving HTN control. Its model for implementing population-scale HTN testing and care through an existing HIV test-and-treat program–and protocol for evaluating the intervention’s stepwise fidelity and care outcomes–may be adapted, strengthened, and scaled up for use across multiple resource-limited settings.
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Affiliation(s)
- David J. Heller
- Arnhold Institute for Global Health, New York, New York, United States of America
- * E-mail:
| | - Laura B. Balzer
- University of Massachusetts, Amherst, Massachusetts, United States of America
| | - Dhruv Kazi
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Edwin D. Charlebois
- University of California, San Francisco, San Francisco, California, United States of America
| | | | | | - Vivek Jain
- University of California, San Francisco, San Francisco, California, United States of America
| | - Prashant Kotwani
- University of California, San Francisco, San Francisco, California, United States of America
| | - Gabriel Chamie
- University of California, San Francisco, San Francisco, California, United States of America
| | - Craig R. Cohen
- University of California, San Francisco, San Francisco, California, United States of America
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Tamara D. Clark
- University of California, San Francisco, San Francisco, California, United States of America
| | - James Ayieko
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Dathan M. Byonanabye
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Maya Petersen
- University of California Berkeley School of Public Health, Berkeley, California, United States of America
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane Havlir
- University of California, San Francisco, San Francisco, California, United States of America
| | - James G. Kahn
- University of California, San Francisco, San Francisco, California, United States of America
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Brown LB, Balzer LB, Kabami J, Kwarisiima D, Sang N, Ayieko J, Chen Y, Chamie G, Charlebois ED, Camlin CS, Cohen CR, Bukusi E, Kamya MR, Moody J, Havlir DV, Petersen ML. The Influence of Social Networks on Antiretroviral Therapy Initiation Among HIV-Infected Antiretroviral Therapy-Naive Youth in Rural Kenya and Uganda. J Acquir Immune Defic Syndr 2020; 83:9-15. [PMID: 31809357 PMCID: PMC7793612 DOI: 10.1097/qai.0000000000002199] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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] [Indexed: 11/26/2022]
Abstract
BACKGROUND HIV-infected youth in sub-Saharan Africa are less likely to initiate antiretroviral therapy (ART) than older adults. SETTING AND METHODS Adult (≥15 years) residents enumerated during a census in 32 communities in rural Kenya and Uganda named social contacts in 5 domains: health, money, emotional support, food, and free time. Named contacts were matched to other enumerated residents to build social networks among 150,395 adults; 90% were tested for HIV at baseline. Among youth (15-24 years) who were ART naive at baseline (2013-2014), we evaluated whether having ≥1 network contact who was HIV infected predicted ART initiation within 3 years and modification of this association by age and strength of contact, using logistic regression with robust standard errors. RESULTS Among 1120 HIV-infected youth who were ART naive at baseline, 805 remained alive and community residents after 3 years. Of these, 270 (33.5%) named at least one baseline HIV-infected contact; 70% (569/805) subsequently initiated ART. Youth with ≥1 HIV-infected same-age baseline contact were more likely to initiate ART [adjusted odds ratio (aOR), 2.95; 95% confidence interval (CI): 1.49 to 5.86] than those with no HIV-infected contact, particularly if the contact was a strong tie (named in >1 domain; aOR, 5.33; 95% CI: 3.34 to 8.52). When nonhousehold contacts were excluded, having an HIV-infected same age contact who was a strong tie remained associated with ART initiation (aOR, 2.81; 95% CI: 1.76 to 4.49). CONCLUSIONS Interventions that increase and strengthen existing social connections to other HIV-infected peers at the time of HIV diagnosis may increase ART initiation among HIV-infected youth.
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Affiliation(s)
| | | | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Norton Sang
- Kenya Medical Research Institute, Kisumu, Kenya
| | | | | | - Gabriel Chamie
- University of California San Francisco, San Francisco, CA
| | | | - Carol S Camlin
- University of California San Francisco, San Francisco, CA
| | - Craig R Cohen
- University of California San Francisco, San Francisco, CA
| | | | - Moses R Kamya
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Diane V Havlir
- University of California San Francisco, San Francisco, CA
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Koss CA, Ayieko J, Mwangwa F, Owaraganise A, Kwarisiima D, Balzer LB, Plenty A, Sang N, Kabami J, Ruel TD, Black D, Camlin CS, Cohen CR, Bukusi EA, Clark TD, Charlebois ED, Petersen ML, Kamya MR, Havlir DV. Early Adopters of Human Immunodeficiency Virus Preexposure Prophylaxis in a Population-based Combination Prevention Study in Rural Kenya and Uganda. Clin Infect Dis 2019; 67:1853-1860. [PMID: 29741594 DOI: 10.1093/cid/ciy390] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 05/01/2018] [Indexed: 12/16/2022] Open
Abstract
Background Global guidelines recommend preexposure prophylaxis (PrEP) for individuals with substantial human immunodeficiency virus (HIV) risk. Data on PrEP uptake in sub-Saharan Africa outside of clinical trials are limited. We report on "early adopters" of PrEP in the Sustainable East Africa Research in Community Health (SEARCH) study in rural Uganda and Kenya. Methods After community mobilization and PrEP education, population-based HIV testing was conducted. HIV-uninfected adults were offered PrEP based on an empirically derived HIV risk score or self-identified HIV risk (if not identified by score). Using logistic regression, we analyzed predictors of early PrEP adoption (starting PrEP within 30 days vs delayed/no start) among adults identified for PrEP. Results Of 21212 HIV-uninfected adults in 5 communities, 4064 were identified for PrEP (2991 by empiric risk score, 1073 by self-identified risk). Seven hundred and thirty nine individuals started PrEP within 30 days (11% of those identified by risk score; 39% of self-identified); 77% on the same day. Among adults identified by risk score, predictors of early adoption included male sex (adjusted odds ratio 1.53; 95% confidence interval, 1.09-2.15), polygamy (1.92; 1.27-2.90), serodiscordant spouse (3.89; 1.18-12.76), self-perceived HIV risk (1.66; 1.28-2.14), and testing at health campaign versus home (5.24; 3.33-8.26). Among individuals who self-identified for PrEP, predictors of early adoption included older age (2.30; 1.29-4.08) and serodiscordance (2.61; 1.01-6.76). Conclusions Implementation of PrEP incorporating a population-based empiric risk score, self-identified risk, and rapid initiation, is feasible in rural East Africa. Strategies are needed to overcome barriers to PrEP uptake, particularly among women and youth. Clinical Trials Registration NCT01864603.
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Affiliation(s)
| | | | | | | | | | - Laura B Balzer
- School of Public Health and Health Sciences, University of Massachusetts, Amherst
| | - Albert Plenty
- Department of Medicine, University of California, San Francisco
| | | | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Theodore D Ruel
- Department of Pediatrics, University of California, San Francisco
| | - Douglas Black
- Department of Medicine, University of California, San Francisco
| | - Carol S Camlin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
| | - Craig R Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
| | | | - Tamara D Clark
- Department of Medicine, University of California, San Francisco
| | | | | | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda.,School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane V Havlir
- Department of Medicine, University of California, San Francisco
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Havlir DV, Balzer LB, Charlebois ED, Clark TD, Kwarisiima D, Ayieko J, Kabami J, Sang N, Liegler T, Chamie G, Camlin CS, Jain V, Kadede K, Atukunda M, Ruel T, Shade SB, Ssemmondo E, Byonanebye DM, Mwangwa F, Owaraganise A, Olilo W, Black D, Snyman K, Burger R, Getahun M, Achando J, Awuonda B, Nakato H, Kironde J, Okiror S, Thirumurthy H, Koss C, Brown L, Marquez C, Schwab J, Lavoy G, Plenty A, Mugoma Wafula E, Omanya P, Chen YH, Rooney JF, Bacon M, van der Laan M, Cohen CR, Bukusi E, Kamya MR, Petersen M. HIV Testing and Treatment with the Use of a Community Health Approach in Rural Africa. N Engl J Med 2019; 381:219-229. [PMID: 31314966 PMCID: PMC6748325 DOI: 10.1056/nejmoa1809866] [Citation(s) in RCA: 153] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Universal antiretroviral therapy (ART) with annual population testing and a multidisease, patient-centered strategy could reduce new human immunodeficiency virus (HIV) infections and improve community health. METHODS We randomly assigned 32 rural communities in Uganda and Kenya to baseline HIV and multidisease testing and national guideline-restricted ART (control group) or to baseline testing plus annual testing, eligibility for universal ART, and patient-centered care (intervention group). The primary end point was the cumulative incidence of HIV infection at 3 years. Secondary end points included viral suppression, death, tuberculosis, hypertension control, and the change in the annual incidence of HIV infection (which was evaluated in the intervention group only). RESULTS A total of 150,395 persons were included in the analyses. Population-level viral suppression among 15,399 HIV-infected persons was 42% at baseline and was higher in the intervention group than in the control group at 3 years (79% vs. 68%; relative prevalence, 1.15; 95% confidence interval [CI], 1.11 to 1.20). The annual incidence of HIV infection in the intervention group decreased by 32% over 3 years (from 0.43 to 0.31 cases per 100 person-years; relative rate, 0.68; 95% CI, 0.56 to 0.84). However, the 3-year cumulative incidence (704 incident HIV infections) did not differ significantly between the intervention group and the control group (0.77% and 0.81%, respectively; relative risk, 0.95; 95% CI, 0.77 to 1.17). Among HIV-infected persons, the risk of death by year 3 was 3% in the intervention group and 4% in the control group (0.99 vs. 1.29 deaths per 100 person-years; relative risk, 0.77; 95% CI, 0.64 to 0.93). The risk of HIV-associated tuberculosis or death by year 3 among HIV-infected persons was 4% in the intervention group and 5% in the control group (1.19 vs. 1.50 events per 100 person-years; relative risk, 0.79; 95% CI, 0.67 to 0.94). At 3 years, 47% of adults with hypertension in the intervention group and 37% in the control group had hypertension control (relative prevalence, 1.26; 95% CI, 1.15 to 1.39). CONCLUSIONS Universal HIV treatment did not result in a significantly lower incidence of HIV infection than standard care, probably owing to the availability of comprehensive baseline HIV testing and the rapid expansion of ART eligibility in the control group. (Funded by the National Institutes of Health and others; SEARCH ClinicalTrials.gov number, NCT01864603.).
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Affiliation(s)
- Diane V Havlir
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Laura B Balzer
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Edwin D Charlebois
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Tamara D Clark
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Dalsone Kwarisiima
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - James Ayieko
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Jane Kabami
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Norton Sang
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Teri Liegler
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Gabriel Chamie
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Carol S Camlin
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Vivek Jain
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Kevin Kadede
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Mucunguzi Atukunda
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Theodore Ruel
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Starley B Shade
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Emmanuel Ssemmondo
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Dathan M Byonanebye
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Florence Mwangwa
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Asiphas Owaraganise
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Winter Olilo
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Douglas Black
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Katherine Snyman
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Rachel Burger
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Monica Getahun
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Jackson Achando
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Benard Awuonda
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Hellen Nakato
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Joel Kironde
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Samuel Okiror
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Harsha Thirumurthy
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Catherine Koss
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Lillian Brown
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Carina Marquez
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Joshua Schwab
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Geoff Lavoy
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Albert Plenty
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Erick Mugoma Wafula
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Patrick Omanya
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Yea-Hung Chen
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - James F Rooney
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Melanie Bacon
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Mark van der Laan
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Craig R Cohen
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Elizabeth Bukusi
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Moses R Kamya
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
| | - Maya Petersen
- From the Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine (D.V.H., T.D.C., T.L., G.C., V.J., D.B., K.S., C.K., L.B., C.M.), the Division of Prevention Science, Department of Medicine (E.D.C., S.B.S., A.P.), the Department of Obstetrics, Gynecology, and Reproductive Sciences (C.S.C., R.B., M.G., C.R.C.), and the Division of Infectious Diseases, Department of Pediatrics (T.R.), University of California, San Francisco, and the San Francisco Department of Public Health (Y.-H.C.), San Francisco, the Division of Epidemiology and Biostatistics, the School of Public Health, University of California, Berkeley (J.S., M.L., M.P.), and Gilead Sciences, Foster City (J.F.R.) - all in California; the School of Public Health and Health Sciences, University of Massachusetts, Amherst (L.B.B.); the Infectious Diseases Research Collaboration (D.K., J. Kabami, M.A., E.S., D.M.B., F.M., A.O., H.N., J. Kironde, S.O., G.L.) and the School of Medicine, Makerere University (M.R.K.), Kampala, Uganda; Kenya Medical Research Institute, Nairobi (J. Ayieko, N.S., K.K., W.O., J. Achando, B.A., E.M.W., P.O., E.B.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.T.); and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (M.B.)
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Tram KH, Mwangwa F, Chamie G, Atukunda M, Owaraganise A, Ayieko J, Jain V, Clark TD, Kwarisiima D, Petersen ML, Kamya MR, Charlebois ED, Havlir DV, Marquez C. Predictors of isoniazid preventive therapy completion among HIV-infected patients receiving differentiated and non-differentiated HIV care in rural Uganda. AIDS Care 2019; 32:119-127. [PMID: 31181961 DOI: 10.1080/09540121.2019.1619661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Rates of Isoniazid Preventive Therapy (IPT) completion remain low in programmatic settings in sub-Saharan Africa. Differentiated HIV care models may improve IPT completion by addressing joint barriers to IPT and HIV treatment. However, the impact of differentiated care on IPT completion remains unknown. In a cross-sectional study of people with HIV on antiretroviral therapy in 5 communities in rural Uganda, we compared IPT completion between patients receiving HIV care via a differentiated care model versus a standard HIV care model and assessed multi-level predictors of IPT completion. A total of 103/144 (72%) patients received differentiated care and 85/161 (53%) received standard care completed IPT (p < 0.01). Adjusting for age, gender and community, patients receiving differentiated care had higher odds of completing IPT (aOR: 2.6, 95% CI: 1.5-4.5, p < 0.01). Predictors of IPT completion varied by the care model, and differentiated care modified the positive association between treatment completion and the belief in the efficacy of IPT and the negative association with side-effects. Patients receiving a multi-component differentiated care model had a higher odds of IPT completion than standard care, and the model's impact on health beliefs, social support, and perceived side effects to IPT may underlie this positive association.
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Affiliation(s)
- Khai Hoan Tram
- School of Medicine, Stanford University, Stanford, CA, USA
| | | | - Gabriel Chamie
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, CA, USA
| | | | | | - James Ayieko
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Vivek Jain
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, CA, USA
| | - Tamara D Clark
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, CA, USA
| | - Dalsone Kwarisiima
- Infectious Diseases Research Collaboration, Kampala, Uganda.,School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Maya L Petersen
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.,Berkeley School of Public Health, University of California, Berkeley, CA, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda.,School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Edwin D Charlebois
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, CA, USA.,Center for AIDS Prevention (CAPS), University of California, San Francisco, CA, USA
| | - Diane V Havlir
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, CA, USA
| | - Carina Marquez
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, CA, USA
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- School of Medicine, Stanford University, Stanford, CA, USA
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44
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Camlin CS, Akullian A, Neilands TB, Getahun M, Bershteyn A, Ssali S, Geng E, Gandhi M, Cohen CR, Maeri I, Eyul P, Petersen ML, Havlir DV, Kamya MR, Bukusi EA, Charlebois ED. Gendered dimensions of population mobility associated with HIV across three epidemics in rural Eastern Africa. Health Place 2019; 57:339-351. [PMID: 31152972 DOI: 10.1016/j.healthplace.2019.05.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/25/2019] [Accepted: 05/03/2019] [Indexed: 11/18/2022]
Abstract
Mobility in sub-Saharan Africa links geographically-separate HIV epidemics, intensifies transmission by enabling higher-risk sexual behavior, and disrupts care. This population-based observational cohort study measured complex dimensions of mobility in rural Uganda and Kenya. Survey data were collected every 6 months beginning in 2016 from a random sample of 2308 adults in 12 communities across three regions, stratified by intervention arm, baseline residential stability and HIV status. Analyses were survey-weighted and stratified by sex, region, and HIV status. In this study, there were large differences in the forms and magnitude of mobility across regions, between men and women, and by HIV status. We found that adult migration varied widely by region, higher proportions of men than women migrated within the past one and five years, and men predominated across all but the most localized scales of migration: a higher proportion of women than men migrated within county of origin. Labor-related mobility was more common among men than women, while women were more likely to travel for non-labor reasons. Labor-related mobility was associated with HIV positive status for both men and women, adjusting for age and region, but the association was especially pronounced in women. The forms, drivers, and correlates of mobility in eastern Africa are complex and highly gendered. An in-depth understanding of mobility may help improve implementation and address gaps in the HIV prevention and care continua.
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Affiliation(s)
- Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, USA; Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, 3rd Floor, UCSF Mail Code 0886, San Francisco, CA 94158, USA.
| | - Adam Akullian
- Institute for Disease Modeling, 3150 139th Ave SE, Bellevue, WA 98005, USA; Department of Global Health, University of Washington, Seattle, USA.
| | - Torsten B Neilands
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, 3rd Floor, UCSF Mail Code 0886, San Francisco, CA 94158, USA.
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, USA.
| | - Anna Bershteyn
- Institute for Disease Modeling, 3150 139th Ave SE, Bellevue, WA 98005, USA; Department of Global Health, University of Washington, Seattle, USA.
| | - Sarah Ssali
- School of Medicine, Makerere University College of Health Sciences, Upper Mulago Hill Road, New Mulago Hospital Complex, P.O Box 7072, Kampala, Uganda.
| | - Elvin Geng
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, 1001 Potrero Ave., San Francisco, CA 94110, USA.
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, 1001 Potrero Ave., San Francisco, CA 94110, USA.
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, USA.
| | - Irene Maeri
- Kenya Medical Research Institute, Centre for Microbiology Research, Box 19464, Post Code 00202, Nairobi, Kenya.
| | - Patrick Eyul
- The Infectious Diseases Research Collaboration (IDRC), Plot 2C Nakasero Hill Road, P.O Box 7475, Kampala, Uganda.
| | - Maya L Petersen
- University of California, Berkeley, 101 Haviland Hall, Suite 102; School of Public Health, UC Berkeley, Berkeley, CA 94720-7358, USA.
| | - Diane V Havlir
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, 1001 Potrero Ave., San Francisco, CA 94110, USA.
| | - Moses R Kamya
- School of Medicine, Makerere University College of Health Sciences, Upper Mulago Hill Road, New Mulago Hospital Complex, P.O Box 7072, Kampala, Uganda.
| | - Elizabeth A Bukusi
- Kenya Medical Research Institute, Centre for Microbiology Research, Box 19464, Post Code 00202, Nairobi, Kenya.
| | - Edwin D Charlebois
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, 3rd Floor, UCSF Mail Code 0886, San Francisco, CA 94158, USA.
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Mayer CM, Owaraganise A, Kabami J, Kwarisiima D, Koss CA, Charlebois ED, Kamya MR, Petersen ML, Havlir DV, Jewell BL. Distance to clinic is a barrier to PrEP uptake and visit attendance in a community in rural Uganda. J Int AIDS Soc 2019; 22:e25276. [PMID: 31037845 PMCID: PMC6488759 DOI: 10.1002/jia2.25276] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [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: 09/11/2018] [Accepted: 03/14/2019] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Geographic and transportation barriers are associated with poorer HIV-related health outcomes in sub-Saharan Africa, but data on the impact of these barriers on prevention interventions are limited. We estimated the association between distance to clinic and other transportation-related barriers on pre-exposure prophylaxis (PrEP) uptake and initial clinic visit attendance in a rural community in southwestern Uganda enrolled in the ongoing SEARCH study (NCT01864603). METHODS Community-wide HIV testing was conducted and offered to adult (≥15 years) participants in Ruhoko. Participants were eligible for PrEP based on an empiric risk score, having an HIV-discordant partner, or self-referral at either the community health campaign or during home-based testing from March to April 2017. We collected data from PrEP-eligible households on GPS-measured distance to clinic, walking time to clinic and road difficulty. A sample of participants was also asked to identify their primary barriers to PrEP use with a semi-quantitative questionnaire. We used multivariable logistic regression to evaluate the association between transportation barriers and (1) PrEP uptake among PrEP-eligible individuals and (2) four-week clinic visit attendance among PrEP initiators. RESULTS Of the 701 PrEP-eligible participants, 272 (39%) started PrEP within four weeks; of these, 45 (17%) were retained at four weeks. Participants with a distance to clinic of ≥2 km were less likely to start PrEP (aOR 0.34; 95% CI 0.15 to 0.79, p = 0.012) and less likely to be retained on PrEP once initiated (aOR 0.29; 95% CI 0.10 to 0.84; p = 0.024). Participants who were deemed eligible during home-based testing and did not have the option of same-day PrEP start were also substantially less likely to initiate PrEP (aOR 0.16, 95% CI 0.07 to 0.37, p < 0.001). Of participants asked to name barriers to PrEP use (N = 98), the most frequently cited were "needing to take PrEP every day" (N = 18) and "low/no risk of getting HIV" (N = 18). Transportation-related barriers, including "clinic is too far away" (N = 6) and "travel away from home" (N = 4) were also reported. CONCLUSIONS Distance to clinic is a significant predictor of PrEP uptake and four-week follow-up visit attendance in a community in rural Uganda. Interventions that address geographic and transportation barriers may improve PrEP uptake and retention in sub-Saharan Africa.
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Affiliation(s)
| | | | - Jane Kabami
- Infectious Diseases Research CollaborationKampalaUganda
| | | | | | | | | | | | - Diane V Havlir
- University of California San FranciscoSan FranciscoCAUSA
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Ayieko J, Petersen ML, Charlebois ED, Brown LB, Clark TD, Kwarisiima D, Kamya MR, Cohen CR, Bukusi EA, Havlir DV, Van Rie A. A Patient-Centered Multicomponent Strategy for Accelerated Linkage to Care Following Community-Wide HIV Testing in Rural Uganda and Kenya. J Acquir Immune Defic Syndr 2019; 80:414-422. [PMID: 30807481 PMCID: PMC6410970 DOI: 10.1097/qai.0000000000001939] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [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: 08/06/2018] [Accepted: 11/26/2018] [Indexed: 01/01/2023]
Abstract
INTRODUCTION As countries move toward universal HIV treatment, many individuals fail to link to care after diagnosis of HIV. Efficient and effective linkage strategies are needed. METHODS We implemented a patient-centered, multicomponent linkage strategy in the SEARCH "test-and-treat" trial (NCT 01864603) in Kenya and Uganda. After population-based, community-wide HIV testing, eligible participants were (1) introduced to clinic staff after testing, (2) provided a telephone "hot-line" for enquiries, (3) provided an appointment reminder phone call, (4) given transport reimbursement on linkage, and (5) tracked if linkage appointment was missed. We estimated the proportion linked to care within 1 year and evaluated factors associated with linkage at 7, 30, and 365 days after diagnosis. RESULTS Among 71,308 adults tested, 6811 (9.6%) were HIV-infected; of these, 4760 (69.9%) were already in HIV care, and 30.1% were not. Among 2051 not in care, 58% were female, median age was 32 (interquartile range 26-40) years, and median CD4 count was 493 (interquartile range 331-683) cells/µL. Half (49.7%) linked within 1 week, and 73.4% linked within 1 year. Individuals who were younger [15-34 vs. >35 years, adjusted Risk Ratio (aRR) 0.83, 95% confidence interval (CI): 0.74 to 0.94], tested at home vs. community campaign (aRR = 0.87, 95% CI: 0.81 to 0.94), had a high HIV-risk vs. low-risk occupation (aRR = 0.81, 95% CI: 0.75 to 0.88), and were wealthier (aRR 0.90, 95% CI: 0.83 to 0.97) were less likely to link. Linkage did not differ by marital status, stable residence, level of education, or having a phone contact. CONCLUSIONS Using a multicomponent linkage strategy, high proportions of people living with HIV but not in care linked rapidly after HIV testing.
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Affiliation(s)
- James Ayieko
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Maya L. Petersen
- Department of Biostatistics, School of Public Health, University of California, Berkeley, CA
| | | | | | - Tamara D. Clark
- School of Medicine, University of California, San Francisco, CA
| | - Dalsone Kwarisiima
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Moses R. Kamya
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Craig R. Cohen
- School of Medicine, University of California, San Francisco, CA
| | - Elizabeth A. Bukusi
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Diane V. Havlir
- School of Medicine, University of California, San Francisco, CA
| | - Annelies Van Rie
- Faculty of Medicine and Public Health, University of Antwerp, Antwerp, Belgium
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Brown LB, Getahun M, Ayieko J, Kwarisiima D, Owaraganise A, Atukunda M, Olilo W, Clark T, Bukusi EA, Cohen CR, Kamya MR, Petersen ML, Charlebois ED, Havlir DV, Camlin CS. Factors predictive of successful retention in care among HIV-infected men in a universal test-and-treat setting in Uganda and Kenya: A mixed methods analysis. PLoS One 2019; 14:e0210126. [PMID: 30673744 PMCID: PMC6343966 DOI: 10.1371/journal.pone.0210126] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 12/17/2018] [Indexed: 11/23/2022] Open
Abstract
Background Previous research indicates clinical outcomes among HIV-infected men in sub-Saharan Africa are sub-optimal. The SEARCH test and treat trial (NCT01864603) intervention included antiretroviral care delivery designed to address known barriers to HIV-care among men by decreasing clinic visit frequency and providing flexible, patient-centered care with retention support. We sought to understand facilitators and barriers to retention in care in this universal treatment setting through quantitative and qualitative data analysis. Methods We used a convergent mixed methods study design to evaluate retention in HIV care among adults (age > = 15) during the first year of the SEARCH (NCT01864603) test and treat trial. Cox proportional hazards regression was used to evaluate predictors of retention in care. Longitudinal qualitative data from n = 190 in-depth interviews with HIV-positive individuals and health care providers were analyzed to identify facilitators and barriers to HIV care engagement. Results There were 1,863 men and 3,820 women who linked to care following baseline testing. Retention in care was 89.7% (95% CI 87.0–91.8%) among men and 89.0% (86.8–90.9%) among women at one year. In both men and women older age was associated with higher rates of retention in care at one year. Additionally, among men higher CD4+ at ART initiation and decreased time between testing and ART initiation was associated with higher rates of retention. Maintaining physical health, a patient-centered treatment environment, supportive partnerships, few negative consequences to disclosure, and the ability to seek care in facilities outside of their community of residence were found to promote retention in care. Conclusions Features of the ART delivery system in the SEARCH intervention and social and structural advantages emerged as facilitators to retention in HIV care among men. Messaging around the health benefits of early ART start, decreasing logistical barriers to HIV care, support of flexible treatment environments, and accelerated linkage to care, are important to men’s success in ART treatment programs. Men already benefit from increased social support following disclosure of their HIV-status. Future efforts to shift gender norms towards greater equity are a potential strategy to support high levels of engagement in care for both men and women.
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Affiliation(s)
- Lillian B Brown
- Division of HIV, ID and Global Medicine, University of California San Francisco, San Francisco, California, United States of America.,Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, California, United States of America
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| | | | | | | | | | | | - Tamara Clark
- Division of HIV, ID and Global Medicine, University of California San Francisco, San Francisco, California, United States of America
| | | | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda.,Makerere University College of Health Sciences, Kampala, Uganda
| | - Maya L Petersen
- Divisions of Biostatistics and Epidemiology, School of Public Health, University of California Berkeley, Berkeley, California, United States of America
| | - Edwin D Charlebois
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, California, United States of America
| | - Diane V Havlir
- Division of HIV, ID and Global Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Carol S Camlin
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, California, United States of America.,Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
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48
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Ayieko J, Brown L, Anthierens S, Van Rie A, Getahun M, Charlebois ED, Petersen ML, Clark TD, Kamya MR, Cohen CR, Bukusi EA, Havlir DV, Camlin CS. "Hurdles on the path to 90-90-90 and beyond": Qualitative analysis of barriers to engagement in HIV care among individuals in rural East Africa in the context of test-and-treat. PLoS One 2018; 13:e0202990. [PMID: 30161172 PMCID: PMC6116983 DOI: 10.1371/journal.pone.0202990] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [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: 03/21/2018] [Accepted: 08/12/2018] [Indexed: 11/19/2022] Open
Abstract
Background Despite substantial progress, gaps in the HIV care cascade remain large: globally, while about 36.7 million people were living with HIV in 2015, 11.9 million of these individuals did not know their HIV status, 12.7 million were in need of antiretroviral therapy (ART) and 13.0 million were not virally suppressed. We sought to deepen understanding of the barriers to care engagement at three critical steps of the care cascade proposed to make greatest impact for attaining the UNAIDS 90-90-90 targets aimed at shutting down the HIV epidemic. Methods Analyses were conducted among HIV-infected adults in rural East Africa. Qualitative data were collected using in-depth interviews among 63 individuals participating in an ongoing test-and treat trial (NCT01864683) in its baseline year (July 2013-June 2014). Audio recordings were transcribed, translated into English, and coded using Atlas.ti software. Data were analyzed using a thematic framework for explaining barriers to care engagement that drew upon both theory and prior empirical research in similar settings. Results Multiple barriers to engagement in care were observed. HIV-related stigma across dimensions of anticipated, internalized and enacted stigma manifested in denial and fears of disclosure, and influenced lapses in care engagement across multiple steps in the cascade. Poverty (lack of food and transport), lack of social support, work interference, prior negative experiences with health services, drug side effects, and treatment fatigue also negatively affected ART adherence and viral suppression. Gender differences were observed, with work interference and denial disproportionately affecting men compared to women. Conclusion Multiple barriers to HIV care engagement still pervade rural sub-Saharan settings threatening the realization of the UNAIDS 90-90-90 targets. To control the epidemic, efforts need to be accelerated to combat stigma. Patient economic empowerment, innovative drug formulations, as well as more patient-responsive health systems, may help overcome barriers to engagement in care.
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Affiliation(s)
- James Ayieko
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- * E-mail:
| | - Lillian Brown
- Division of HIV, Infectious Diseases & Global Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Sibyl Anthierens
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Annelies Van Rie
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Monica Getahun
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Edwin D. Charlebois
- Division of HIV, Infectious Diseases & Global Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Maya L. Petersen
- Department of Biostatistics and Epidemiology, University of California Berkeley, Berkeley, California, United States of America
| | - Tamara D. Clark
- Division of HIV, Infectious Diseases & Global Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Moses R. Kamya
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Craig R. Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Elizabeth A. Bukusi
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases & Global Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Carol S. Camlin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
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Camlin CS, Akullian A, Neilands TB, Getahun M, Eyul P, Maeri I, Ssali S, Geng E, Gandhi M, Cohen CR, Kamya MR, Odeny T, Bukusi EA, Charlebois ED. Population mobility associated with higher risk sexual behaviour in eastern African communities participating in a Universal Testing and Treatment trial. J Int AIDS Soc 2018; 21 Suppl 4:e25115. [PMID: 30027668 PMCID: PMC6053476 DOI: 10.1002/jia2.25115] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [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: 12/15/2017] [Accepted: 05/08/2018] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION There are significant knowledge gaps concerning complex forms of mobility emergent in sub-Saharan Africa, their relationship to sexual behaviours, HIV transmission, and how sex modifies these associations. This study, within an ongoing test-and-treat trial (SEARCH, NCT01864603), sought to measure effects of diverse metrics of mobility on behaviours, with attention to gender. METHODS Cross-sectional data were collected in 2016 from 1919 adults in 12 communities in Kenya and Uganda, to examine mobility (labour/non-labour-related travel), migration (changes of residence over geopolitical boundaries) and their associations with sexual behaviours (concurrent/higher risk partnerships), by region and sex. Multilevel mixed-effects logistic regression models, stratified by sex and adjusted for clustering by community, were fitted to examine associations of mobility with higher-risk behaviours, in past 2 years/past 6 months, controlling for key covariates. RESULTS The population was 45.8% male and 52.4% female, with mean age 38.7 (median 37, IQR: 17); 11.2% had migrated in the past 2 years. Migration varied by region (14.4% in Kenya, 11.5% in southwestern and 1.7% in eastern and Uganda) and sex (13.6% of men and 9.2% of women). Ten per cent reported labour-related travel and 45.9% non-labour-related travel in past 6 months-and varied by region and sex: labour-related mobility was more common in men (18.5%) than women (2.9%); non-labour-related mobility was more common in women (57.1%) than men (32.6%). In 2015 to 2016, 24.6% of men and 6.6% of women had concurrent sexual partnerships; in past 6 months, 21.6% of men and 5.4% of women had concurrent partnerships. Concurrency in 2015 to 2016 was more strongly associated with migration in women [aRR = 2.0, 95% CI(1.1 to 3.7)] than men [aRR = 1.5, 95% CI(1.0 to 2.2)]. Concurrency in past 6 months was more strongly associated with labour-related mobility in women [aRR = 2.9, 95% CI(1.0 to 8.0)] than men [aRR = 1.8, 95% CI(1.2 to 2.5)], but with non-labour-related mobility in men [aRR = 2.2, 95% CI(1.5 to 3.4)]. CONCLUSIONS In rural eastern Africa, both longer-distance/permanent, and localized/shorter-term forms of mobility are associated with higher-risk behaviours, and are highly gendered: the HIV risks associated with mobility are more pronounced for women. Gender-specific interventions among mobile populations are needed to combat HIV in the region.
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Affiliation(s)
- Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive SciencesUniversity of CaliforniaSan Francisco (UCSF)San FranciscoCAUSA
- Department of MedicineCenter for AIDS Prevention StudiesUCSFSan FranciscoCAUSA
| | - Adam Akullian
- Institute for Disease ModelingUniversity of WashingtonSeattleWashingtonUSA
| | - Torsten B Neilands
- Department of MedicineCenter for AIDS Prevention StudiesUCSFSan FranciscoCAUSA
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive SciencesUniversity of CaliforniaSan Francisco (UCSF)San FranciscoCAUSA
| | - Patrick Eyul
- Infectious Diseases Research Collaboration (IDRC)Makerere University (MU‐UCSF)KampalaUganda
| | - Irene Maeri
- Kenya Medical Research Institute (KEMRI)NairobiKenya
| | - Sarah Ssali
- Infectious Diseases Research Collaboration (IDRC)Makerere University (MU‐UCSF)KampalaUganda
| | - Elvin Geng
- Department of MedicineDivision of HIV, Infectious Diseases and Global MedicineUCSFSan FranciscoCAUSA
| | - Monica Gandhi
- Department of MedicineDivision of HIV, Infectious Diseases and Global MedicineUCSFSan FranciscoCAUSA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive SciencesUniversity of CaliforniaSan Francisco (UCSF)San FranciscoCAUSA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration (IDRC)Makerere University (MU‐UCSF)KampalaUganda
| | - Thomas Odeny
- Kenya Medical Research Institute (KEMRI)NairobiKenya
| | | | - Edwin D Charlebois
- Department of MedicineCenter for AIDS Prevention StudiesUCSFSan FranciscoCAUSA
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50
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Jagannathan P, Kakuru A, Okiring J, Muhindo MK, Natureeba P, Nakalembe M, Opira B, Olwoch P, Nankya F, Ssewanyana I, Tetteh K, Drakeley C, Beeson J, Reiling L, Clark TD, Rodriguez-Barraquer I, Greenhouse B, Wallender E, Aweeka F, Prahl M, Charlebois ED, Feeney ME, Havlir DV, Kamya MR, Dorsey G. Dihydroartemisinin-piperaquine for intermittent preventive treatment of malaria during pregnancy and risk of malaria in early childhood: A randomized controlled trial. PLoS Med 2018; 15:e1002606. [PMID: 30016328 PMCID: PMC6049882 DOI: 10.1371/journal.pmed.1002606] [Citation(s) in RCA: 18] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 06/08/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Intermittent preventive treatment of malaria in pregnancy (IPTp) with dihydroartemisinin-piperaquine (IPTp-DP) has been shown to reduce the burden of malaria during pregnancy compared to sulfadoxine-pyrimethamine (IPTp-SP). However, limited data exist on how IPTp regimens impact malaria risk during infancy. We conducted a double-blinded randomized controlled trial (RCT) to test the hypothesis that children born to mothers given IPTp-DP would have a lower incidence of malaria during infancy compared to children born to mothers who received IPTp-SP. METHODS AND FINDINGS We compared malaria metrics among children in Tororo, Uganda, born to women randomized to IPTp-SP given every 8 weeks (SP8w, n = 100), IPTp-DP every 8 weeks (DP8w, n = 44), or IPTp-DP every 4 weeks (DP4w, n = 47). After birth, children were given chemoprevention with DP every 12 weeks from 8 weeks to 2 years of age. The primary outcome was incidence of malaria during the first 2 years of life. Secondary outcomes included time to malaria from birth and time to parasitemia following each dose of DP given during infancy. Results are reported after adjustment for clustering (twin gestation) and potential confounders (maternal age, gravidity, and maternal parasitemia status at enrolment).The study took place between June 2014 and May 2017. Compared to children whose mothers were randomized to IPTp-SP8w (0.24 episodes per person year [PPY]), the incidence of malaria was higher in children born to mothers who received IPTp-DP4w (0.42 episodes PPY, adjusted incidence rate ratio [aIRR] 1.92; 95% CI 1.00-3.65, p = 0.049) and nonsignificantly higher in children born to mothers who received IPT-DP8w (0.30 episodes PPY, aIRR 1.44; 95% CI 0.68-3.05, p = 0.34). However, these associations were modified by infant sex. Female children whose mothers were randomized to IPTp-DP4w had an apparently 4-fold higher incidence of malaria compared to female children whose mothers were randomized to IPTp-SP8w (0.65 versus 0.20 episodes PPY, aIRR 4.39, 95% CI 1.87-10.3, p = 0.001), but no significant association was observed in male children (0.20 versus 0.28 episodes PPY, aIRR 0.66, 95% CI 0.25-1.75, p = 0.42). Nonsignificant increases in malaria incidence were observed among female, but not male, children born to mothers who received DP8w versus SP8w. In exploratory analyses, levels of malaria-specific antibodies in cord blood were similar between IPTp groups and sex. However, female children whose mothers were randomized to IPTp-DP4w had lower mean piperaquine (PQ) levels during infancy compared to female children whose mothers received IPTp-SP8w (coef 0.81, 95% CI 0.65-1.00, p = 0.048) and male children whose mothers received IPTp-DP4w (coef 0.72, 95% CI 0.57-0.91, p = 0.006). There were no significant sex-specific differences in PQ levels among children whose mothers were randomized to IPTp-SP8w or IPTp-DP8w. The main limitations were small sample size and childhood provision of DP every 12 weeks in infancy. CONCLUSIONS Contrary to our hypothesis, preventing malaria in pregnancy with IPTp-DP in the context of chemoprevention with DP during infancy does not lead to a reduced incidence of malaria in childhood; in this setting, it may be associated with an increased incidence of malaria in females. Future studies are needed to better understand the biological mechanisms of in utero drug exposure on drug metabolism and how this may affect the dosing of antimalarial drugs for treatment and prevention during infancy. TRIAL REGISTRATION ClinicalTrials.gov number NCT02163447.
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MESH Headings
- Adolescent
- Adult
- Antimalarials/administration & dosage
- Antimalarials/adverse effects
- Artemisinins/administration & dosage
- Artemisinins/adverse effects
- Child, Preschool
- Double-Blind Method
- Drug Administration Schedule
- Drug Combinations
- Female
- Humans
- Incidence
- Infant
- Infant, Newborn
- Infectious Disease Transmission, Vertical/prevention & control
- Malaria, Falciparum/epidemiology
- Malaria, Falciparum/parasitology
- Malaria, Falciparum/prevention & control
- Malaria, Falciparum/transmission
- Pregnancy
- Pregnancy Complications, Parasitic/epidemiology
- Pregnancy Complications, Parasitic/parasitology
- Pregnancy Complications, Parasitic/prevention & control
- Pyrimethamine/administration & dosage
- Pyrimethamine/adverse effects
- Quinolines/administration & dosage
- Quinolines/adverse effects
- Sulfadoxine/administration & dosage
- Sulfadoxine/adverse effects
- Time Factors
- Treatment Outcome
- Uganda/epidemiology
- Young Adult
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Affiliation(s)
- Prasanna Jagannathan
- Department of Medicine, Stanford University, Stanford, California, United States of America
| | - Abel Kakuru
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Jaffer Okiring
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Paul Natureeba
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Miriam Nakalembe
- Department of Obstetrics and Gynecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Bishop Opira
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Peter Olwoch
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | - Kevin Tetteh
- Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Chris Drakeley
- Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | - Tamara D. Clark
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Isabel Rodriguez-Barraquer
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Bryan Greenhouse
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Erika Wallender
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Francesca Aweeka
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California, United States of America
| | - Mary Prahl
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, United States of America
| | - Edwin D. Charlebois
- Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, California, United States of America
| | - Margaret E. Feeney
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, United States of America
| | - Diane V. Havlir
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Grant Dorsey
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
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