Equity and HIV/AIDS

Effect of non-monetary incentives on uptake of couples’ counselling and testing among clients attending mobile HIV services in rural Zimbabwe: a cluster-randomised trial
Sibanda E; Tumushime M; Mufuka J; et al.: The Lancet Global Health 5(9), doi: https://doi.org/10.1016/S2214-109X(17)30296-6, 2017

Couples’ HIV testing and counselling (CHTC) is associated with greater engagement with HIV prevention and care than individual testing and is cost-effective, but uptake remains suboptimal. The authors aimed in this work to determine the impact of incentives for CHTC on uptake of couples testing and HIV case diagnosis in rural Zimbabwe. 68 rural communities (the clusters) in four districts receiving mobile HIV testing services were randomly assigned to incentives for CHTC or not. Allocation was not masked to participants and researchers. Randomisation was stratified by district and proximity to a health facility. Within each stratum random permutation was done to allocate clusters to the study groups. In intervention communities, residents were informed that couples who tested together could select one of three grocery items worth US$1·50. Standard mobilisation for testing was done in comparison communities. The primary outcome was the proportion of individuals testing with a partner. Analysis was by intention to treat. 3 months after CHTC, couple-testers from four communities per group individually completed a telephone survey to evaluate any social harms resulting from incentives or CHTC. The study indicated that small non-monetary incentives, which are potentially scalable, were associated with significantly increased CHTC and HIV case diagnosis. Incentives did not increase social harms beyond the few typically encountered with CHTC without incentives. The authors suggest that the intervention could help achieve UNAIDS 90-90-90 targets.

Effect of eliminating CD4-count thresholds on HIV treatment initiation in South Africa: An empirical modelling study
Bor J; Ahmed S; Fox M; Rosen S; Meyer-Rath G; Katz I; Tanser F; Pillay D; Bärnighausen T: PLOS One, doi: https://doi.org/10.1371/journal.pone.0178249, 2017

The World Health Organisation recommends initiating antiretroviral therapy (ART) regardless of CD4 count. The authors assessed the effect of ART eligibility on treatment uptake and simulated the impact of WHO’s recommendations in South Africa, through an empirical analysis of cohort data using a regression discontinuity design, used for policy simulation. They enrolled all patients (n = 19,279) diagnosed with HIV between August 2011 and December 2013 in the Hlabisa HIV Treatment and Care Programme in rural South Africa. Patients were ART-eligible with CD4<350 cells/mm3 or Stage III/IV illness. The authors estimated: (1) distribution of first CD4 counts in 2013; (2) probability of initiating ART ≤6 months of HIV diagnosis under existing criteria at each CD4 count; (3) probability of initiating ART by CD4 count if thresholds were eliminated; and (4) number of expected new initiators if South Africa eliminates thresholds. In 2013, 39% of patients diagnosed had a CD4 count ≥500. 8% of these patients initiated even without eligible CD4 counts. If CD4 criteria were eliminated, the authors project that an additional 19% of patients with CD4 ≥500 would initiate ART; and 73% would not initiate ART despite being eligible. Eliminating CD4 criteria would increase the number starting ART by 27%. If these numbers hold nationally, this would represent an additional 164,000 initiators per year, a 5% increase in patients receiving ART and 5% increase in programme costs. Removing CD4 criteria alone will modestly increase timely uptake of ART. However, the authors results suggest the majority of newly-eligible patients will not initiate. Improved testing, linkage, and initiation procedures are needed to achieve 90-90-90 targets.

The importance of sexual and reproductive health and rights to prevent HIV in adolescent girls and young women in eastern and southern Africa
World Health Organisation: WHO Evidence Brief, WHO/RHR/17.05, Geneva, 2017

Over the last several years, countries in the eastern and southern Africa (ESA) region have made significant and commendable progress in preventing mother-to-child transmission (PMTCT) of HIV and in scaling up HIV treatment efforts. However, despite these gains, there have been no significant reductions in new HIV infections and the region continues to be the hardest hit by the epidemic, highlighting the need to place stronger emphasis on HIV prevention. The risk of HIV infection among adolescent girls and young women (AGYW) in the ESA region is of particular concern. The 2016 UNAIDS World AIDS Day report, Get on the Fast-Track – The life-cycle approach to HIV, stated that efforts to reduce new HIV infections among young people and adults have stalled, threatening to undermine progress towards ending AIDS as a global public health threat by 2030. This evidence brief reviews the background and makes recommendations for steps to develop a comprehensive approach to HIV prevention for AGYW in the context of sexual and reproductive health and rights. Firstly, it calls for measures to build on current commitments and national priorities and in a comprehensive approach. Further steps include reviewing evidence-based interventions for AGYW, operationalising and evaluating multisectoral approaches through reviewing different country strategies and identifying funding opportunities. Several next steps were proposed, including exploring and developing a few case studies of specific programme experience or coordination processes and mechanisms to illustrate possible best practices and address outstanding questions and monitoring, evaluating and documenting the scale-up of integrated HIV-prevention and SRHR interventions for AGYW in the context of different initiatives, to identify optimal approaches to scaling up the delivery of successful interventions.

Sex in the shadow of HIV: A systematic review of prevalence, risk factors, and interventions to reduce sexual risk-taking among HIV-positive adolescents and youth in sub-Saharan Africa
Toska E; Pantelic M; Meinck F; Keck K; Haghighat R; Cluver L: PLOS One, doi: https://doi.org/10.1371/journal.pone.0178106, 2017

This systematic review synthesises the extant research on prevalence, factors associated with, and interventions to reduce sexual risk-taking among HIV-positive adolescents and youth in sub-Saharan Africa. Studies were located through electronic databases, grey literature, reference harvesting, and contact with researchers. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Quantitative studies that reported on HIV-positive participants (10–24 year olds), included data on at least one of eight outcomes (early sexual debut, inconsistent condom use, older partner, transactional sex, multiple sexual partners, sex while intoxicated, sexually transmitted infections, and pregnancy), and were conducted in sub-Saharan Africa were included. Forty-two records reported one or multiple sexual practices for 13,536 HIV-positive adolescents/youth from 13 sub-Saharan African countries. Seventeen cross-sectional studies reported on individual, relationship, family, structural, and HIV-related factors associated with sexual risk-taking. However, the majority of the findings were inconsistent across studies, and most studies scored <50% in the quality checklist. Living with a partner, living alone, gender-based violence, food insecurity, and employment were correlated with increased sexual risk-taking, while knowledge of own HIV-positive status and accessing HIV support groups were associated with reduced sexual risk-taking. Of the four intervention studies (three RCTs), three were effective at reducing sexual risk-taking, with one reporting no difference between the intervention and control groups. Sexual risk-taking among HIV-positive adolescents and youth is high, with inconclusive evidence on potential determinants and the authors argue for ffective and feasible low-cost interventions to reduce risk for this group.

What is it going to take to move youth-related HIV programme policies into practice in Africa?
Mark D; Taing L; Cluver L; Collins C; Iorpenda K; Andrade A; Hatane L: Journal of the International AIDS Society 20(Suppl 3)21491, 2017

HIV has been reported to be the leading cause of mortality amongst adolescents in Africa. This has brought attention to the changes in service provision and health management that many adolescents living with HIV experience when transferring from specialised paediatric- or adolescent-focused services to adult care. When transition is enacted poorly, adherence may be affected and the continuum of care disrupted. The authors present the case that considerable gaps remain in moving policy to practice on this at global, national, and local levels and that standard operating procedures or tools to support this transition are lacking. Guidance often overlooks the specific needs and rights of adolescents, in particular for those living with HIV. In some cases, prohibitive laws can impede adolescent access by applying age of consent restriction to HIV testing, counselling and treatment, as well as SRH services. Where adolescent-focused policies do exist, they have been slow to emerge as tangible operating procedures at health facility level. A key barrier is the nature of existing transition guidance, which tends to recommend an individualised, client-centred approach, driven by clinicians. In low- and middle-income settings, flexible responses are resource intensive and time consuming, and therefore challenging to implement amidst staff shortages and administrative challenges. They propose that national governments adopt transition-specific policies to ensure that adolescents seamlessly receive appropriate and supportive care, as part of a broader adolescent-centred policy landscape and adolescent-friendly orientation and approach at health system level. Youth involvement and community mobilisation are seen to be essential for this. .

Incidence and risk factors for hypertension among HIV patients in rural Tanzania – A prospective cohort study
Rodríguez-Arbolí E; Mwamelo K; Kalinjuma A; Furrer H; Hatz C; Tanner M; Battegay M; Letang E; KIULARCO Study Group: Plos One, doi: https://doi.org/10.1371/journal.pone.0172089, 2017

Scarce data are available on the epidemiology of hypertension among HIV patients in rural sub-Saharan Africa. The authors explored the prevalence, incidence and risk factors for incident hypertension among patients who were enrolled in a rural HIV cohort in Tanzania. A prospective longitudinal study including HIV patients enrolled in the Kilombero and Ulanga Antiretroviral Cohort was carried out between 2013 and 2015. Non-ART subjects at baseline and pregnant women during follow-up were excluded from the analysis. Incident hypertension was defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg on two consecutive visits. Cox proportional hazards models were used to assess the association of baseline characteristics and incident hypertension. Among 955 ART-naïve, eligible subjects, 111 (11.6%) were hypertensive at recruitment. Ten women were excluded due to pregnancy. Of the remaining individuals, 9.6% developed hypertension during a median follow-up of 144 days from time of enrolment into the cohort. ART was started in 75.5% of patients, with a median follow-up on ART of 7 months. Cox regression models identified age, body mass index and estimated glomerular filtration rate as independent risk factors for hypertension development. Traditional cardiovascular risk factors predicted incident hypertension, but no association was observed with immunological or ART status. These data support the implementation of routine hypertension screening and integrated management into HIV programmes in rural sub-Saharan Africa.

Should trained lay providers perform HIV testing? A systematic review to inform World Health Organization guidelines
Kennedy C; Yeh P; Johnson C; Baggaley R: AIDS Care, 2017, doi: 10.1080/09540121.2017.1317710.

The authors conducted a systematic review of studies evaluating HIV testing services (HTS) by lay providers using rapid diagnostic tests (RDTs). Peer-reviewed articles were included if they compared HTS using RDTs performed by trained lay providers to HTS by health professionals, or to no intervention. The authors also reviewed data on end-users' values and preferences around lay providers preforming HTS. Searching was conducted through 10 online databases, reviewing reference lists, and contacting experts. Screening and data abstraction were conducted in duplicate using systematic methods. Of 6113 unique citations identified, 5 studies were included in the effectiveness review and 6 in the values and preferences review. One US-based randomised trial found patients' uptake of HTS doubled with lay providers (57% vs. 27%). In Malawi, a pre/post study showed increases in HTS sites and tests after delegation to lay providers. Studies from Cambodia, Malawi, and South Africa comparing testing quality between lay providers and laboratory staff found little discordance and high sensitivity and specificity between them. Based on evidence supporting using trained lay providers, a WHO expert panel recommended lay providers be allowed to conduct HTS using HIV RDTs. Uptake of this recommendation could expand HIV testing to more people globally.

Hope for HIV control in southern Africa: The continued quest for a vaccine
Bekker Linda-Gail; Gray G, PLoS Med 14(2) 2017, doi: https://doi.org/10.1371/journal.pmed.1002241

Southern and eastern Africa, with 6.2% of the world’s population, bear a disparate half of the world’s HIV infection burden and would benefit greatly from inexpensive innovations aimed at curtailing the epidemic. A recent modelling study showed that introducing a partially (30%) effective vaccine for HIV in resource-limited settings such as southern Africa would result in an estimated 67% reduction in HIV incidence compared to a non-vaccine scenario. As sub-Saharan Africa has the highest incidence of HIV infection in the world, that the introduction of a vaccine with only partial efficacy could have such a dramatic effect, despite the existing availability of comprehensive prevention methods, is argued by the authors to be strongly persuasive for the pursuit of a vaccine-based approach. Whilst there is great optimism that increasing access to antiretroviral treatment in the region will reduce infection incidence, there is also recognition that epidemic control will not be achieved without a substantial and sustained scale-up of additional primary prevention resources. There are challenges to HIV prevention in resource-limited settings that a vaccine alone is seen to be well positioned to meet. These include the rate of HIV infections and the scale and complexity of the HIV epidemic in the region, juxtaposed with ailing health systems ill equipped to respond effectively. Challenges with antiretroviral drug therapy adherence, poor linkage to care following diagnosis, multiple and diverse vulnerable populations who require population-specific services (such as women, adolescents, and men who have sex with men, stigma, and discrimination, as well as generally limited health care facilities and health personnel impair the region’s capacity to manage the scale of the epidemic. Even with the success of pre-exposure prophylaxis demonstration projects and the encouraging results emerging, the extent of protection relies on fidelity to adherence, continuous uninterrupted access, and sustainable resources for provision. It is well documented that in resource-restricted areas, where education levels and access to health care are low, reliance on behavioural and structural support is also an enormous challenge. A vaccine, even if partially effective, is argued by the authors to be a way of filling these prevention gaps in a cost-effective manner. Whilst countries in this region must find ways to access all the available opportunities that the modern HIV prevention toolkit has on offer, such a vaccine is seen to potentially change the prevention landscape.

Is Socio-Economic Status a Determinant of HIV-Related Stigma Attitudes in Zimbabwe? Findings from Project Accept
Mateveke K; Singh B; Chingono A; et al.: Journal of Public Health in Africa 7(1), 2016, doi: http://dx.doi.org/10.4081/jphia.2016.533

HIV related stigma and discrimination is a known barrier for HIV prevention and care. The authors aimed to assess the relationship between socio-economic status (SES) and HIV related stigma in Zimbabwe, using data from a project that examined the impact of community-based voluntary counselling and testing intervention on HIV incidence and stigma. A total of 2522 eligible participants responded to a psychometric assessment tool, which assessed HIV related stigma and discrimination attitudes on 4 point Likert scale. The tool measured three components of HIV related stigma: shame, blame and social isolation, perceived discrimination, and equity. Participants’ ownership of basic assets was used to assess the socio-economic status. Shame, blame and social isolation component of HIV related stigma was found to be significantly associated with medium and low SES indicating more stigmatising attitudes by participants belonging to medium and low SES in comparison to high SES.

Assessment of the World Health Organisation’s HIV Drug Resistance Early Warning Indicators in Main and Decentralised Outreach Antiretroviral Therapy Sites in Namibia
Mutenda N; Bukowski A; Nitschke A; et al.: PLoS ONE 11(12): e0166649, 2016, doi:10.1371/journal.pone.0166649

The World Health Organization early warning indicators (EWIs) of HIV drug resistance (HIVDR) assess factors at individual ART sites that are known to create situations favourable to the emergence of HIVDR. In 2014, the Namibia HIV care and treatment program abstracted adult and paediatric EWIs from all public ART sites (50 main sites and 143 outreach sites) related to on-time pill pick-up, retention in care, pharmacy stock-outs, dispensing practices, and viral load suppression. Comparisons were made between main and outreach sites and between 2014 and 2012. The national estimates were: On-time pill pick-up 81.9% for adults and 82.4% for paediatrics, Retention in care 79% retained on ART after 12 months for adults and 82% for paediatrics, Pharmacy stock-outs 94% of months without a stock-out for adults and 88% for paediatrics. Viral load suppression was significantly affected by low rates of viral load completion. Main sites had higher on-time pill pick-up than outreach sites for adults and paediatrics and no difference between main and outreach sites for retention in care for adults or paediatrics. From 2012 to 2014 in adult and paediatric sites, on-time pill pick-up, retention in care and pharmacy stock-outs worsened. Results of EWIs monitoring in Namibia provide evidence about ART programmatic functioning and contextualise results from national surveys of HIVDR. These results are worrisome as they show a decline in program performance over time. The national ART program is taking steps to minimise the emergence of HIVDR by strengthening adherence and retention of patients on ART, reducing stock-outs, and strengthening ART data quality.