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.
Equity and HIV/AIDS
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. .
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.
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.
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.
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.
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.
National surveys in Zimbabwe, Malawi, and Zambia reveal exceptional progress against HIV, with decreasing rates of new infection, stable numbers of people living with HIV, and more than half of all those living with HIV showing viral suppression through use of antiretroviral medication. For those on antiretroviral medication, viral suppression is close to 90%. These data are the first to emerge from the Population HIV Impact Assessment (PHIA) Project, a unique, multi-country initiative funded by the US President’s Emergency Plan for AIDS Relief (PEPFAR). The project deploys household surveys, which measure the reach and impact of HIV prevention, care and treatment programs in select countries. The data demonstrate that the 90-90-90 global targets set forth by UNAIDS in 2014 are attainable, (that is for 90% of people with HIV to be diagnosed, 90% of those diagnosed to receive HIV treatment, and 90% of those on treatment to be effectively treated and achieve suppression of their infection). This would translate to 73% of all HIV-positive people being virally suppressed. The data show that once diagnosed, individuals are accessing treatment, staying on treatment, and their viral load levels are suppressed to levels that maintain their health and dramatically decrease transmission to others. Preliminary data analyses show that, as of 2016: In Zimbabwe, among adults ages 15 to 64, HIV incidence is 0.45%; HIV prevalence is 14.6% (16.7% among females and 12.4% among males); 60.4% of all HIV-positive people are virally suppressed, and 86% of those on treatment are virally suppressed. In Malawi, among adults ages 15 to 64, HIV incidence is 0.37%; HIV prevalence is 10.6% (12.8% among females and 8.2% among males); 67.6% of all HIV-positive people are virally suppressed, and 91% of those on treatment are virally suppressed. In Zambia, among adults ages 15 to 59 years, HIV incidence is 0.66%; HIV prevalence is 12.3% (14.9% among females and 9.5% among males); 59.8% of all HIV-positive people are virally suppressed, and 89% of those on treatment are virally suppressed. The results from the first three PHIA surveys are argued to compel the global community to strengthen its efforts to reach those who have yet to receive an HIV test and to engage, support, and enable those who test HIV-positive to start and stay on effective treatment in order to achieve long-term viral suppression.
Young women aged 15 to 24 years in sub-Saharan Africa continue to be disproportionately affected by HIV. A growing number of studies have suggested that the practice of transactional sex may in part explain women’s heightened risk, but evidence on the association between transactional sex and HIV has not yet been synthesised. The authors set out to systematically review studies that assess the relationship between transactional sex and HIV among men and women in sub-Saharan Africa and to summarise the findings through a meta-analysis. Nineteen papers from 16 studies met the inclusion criteria. Of these 16 studies, 14 provided data on women and 10 on men. The authors found a significant, positive, unadjusted or adjusted association between transactional sex and HIV in 10 of 14 studies for women, one of which used a longitudinal design. Out of 10 studies involving men, only two indicate a positive association between HIV and transactional sex in unadjusted or adjusted models. The meta-analysis confirmed general findings from the systematic review. Transactional sex is associated with HIV among women, whereas findings for men were inconclusive. Given that only two studies used a longitudinal approach, there remains a need for better measurement of the practice of transactional sex and additional longitudinal studies to establish the causal pathways between transactional sex and HIV.
High rates of attrition are weakening Mozambique’s national HIV Program’s efforts to achieve 80% treatment coverage. In response, Mozambique implemented a national pilot of Community Adherence and Support Groups (CASG). CASG is a model in which antiretroviral therapy (ART) patients form groups of up to six patients. On a rotating basis one CASG group member collects ART medications at the health facility for all group members, and distributes those medications to the other members in the community. Patients also visit their health facility bi-annually to receive clinical services. A matched retrospective cohort study was implemented using routinely collected patient-level data in 68 health facilities with electronic data systems and CASG programs. A total of 129,938 adult ART patients were registered in those facilities. Of the 129,938 patients on ART, 6,760 were CASG members. A propensity score matched analysis was performed to assess differences in mortality and loss to follow-up (LTFU) between matched CASG and non-CASG members. Non-CASG participants had higher LTFU rates than matched CASG participants; however, there were no significant mortality differences between CASG and non-CASG participants. Compared with the full cohort of non-CASG members, CASG members were more likely to be female, tended to have a lower median CD4 counts at ART initiation and be less likely to have a secondary school education. ART patients enrolled in CASG were significantly less likely to be LTFU compared to matched patients who did not join CASG. CASG appears to be an effective strategy to decrease LTFU in Mozambique’s national ART program.