Equity and HIV/AIDS

Community burden of undiagnosed HIV infection among adolescents in Zimbabwe following primary healthcare-based provider-initiated HIV testing and counselling: A cross-sectional survey
Simms V; Dauya E; Dakshina S, et al.: Public Library of Science Medicine (PLOSMed) 14(7) doi: https://doi.org/10.1371/journal.pmed.1002360, 2017

The authors investigated the change in the community burden of undiagnosed HIV infection among older children and adolescents following implementation of provider-initiated testing and counselling (PITC) in Harare, Zimbabwe. Over the course of 2 years (2013–2015), 7 primary health clinics (PHCs) in southwestern Harare implemented optimised, opt-out PITC for all attendees aged 6–15 years. In 2015, the authors conducted a representative cross-sectional survey of 8–17-year-olds living in the 7 communities served by the study PHCs, who would have had 2 years of exposure to PITC. Knowledge of HIV status was ascertained through a caregiver questionnaire, and anonymised HIV testing was carried out. Of 7,146 children in 4,251 eligible households, 76.8% agreed to participate in the survey, and 141 were HIV positive. HIV prevalence was 2.6% and over a third of participants with HIV were undiagnosed. Based on extrapolation from the survey sample to the community, the authors estimated that PITC over 2 years identified between 18% and 42% of previously undiagnosed children in the community. The main limitation is that prevalence of undiagnosed HIV was defined using a combination of 3 measures none of which are perfect. Facility-based approaches are argued to be inadequate in achieving universal coverage of HIV testing among older children and adolescents, and community-based approaches are identified as necessary in this age group.

Voluntary Medical Male Circumcision for HIV Prevention in 14 Priority Countries in Eastern and Southern Africa
World Health Organisation: WHO, Geneva, 2017

This progress brief outlines key highlights of the VMMC (Voluntary Medical Male Circumcision) intervention in Eastern and Southern Africa. Nearly 15 million VMMCs have been performed for HIV prevention in 14 countries of eastern and southern Africa. These circumcisions are reported to potentially avert over half a million new HIV infections through to 2030. In 2016, 2.8 million VMMCs were performed and all countries in the region, except Uganda and Rwanda, increased the number of VMMCs performed in the year. The majority of clients were aged 15 years or older.

Socioeconomic differences in mortality in the antiretroviral therapy era in Agincourt, rural South Africa, 2001–13: a population surveillance analysis
Kabudula C; Houle B; Collinson M; et al.: The Lancet Global Health 5(9) doi: https://doi.org/10.1016/S2214-109X(17)30297-8, 2017

The authors assessed socioeconomic disparities in mortality indicators in a rural South African population over the period 2001–13 using data from 21 villages of the Agincourt Health and socio-Demographic Surveillance System (HDSS). They calculated the probabilities of death from birth to age 5 years and from age 15 to 60 years, life expectancy at birth, and cause-specific and age-specific mortality by sex (not in children <5 years), time period, and socioeconomic status (household wealth) quintile for HIV/AIDS and tuberculosis, other communicable diseases (excluding HIV/AIDS and tuberculosis) and maternal, perinatal, and nutritional causes, non-communicable diseases, and injury. They quantified differences with relative risk ratios and relative and slope indices of inequality. The authors found significant socioeconomic status gradients for mortality and life expectancy at birth, with outcomes improving with increasing socioeconomic status. An inverse relation was seen for HIV/AIDS and tuberculosis mortality and socioeconomic status that persisted from 2001 to 2013. Deaths from non-communicable diseases increased over time in both sexes, and injury was an important cause of death in men and boys. Neither of these causes of death, however, showed consistent significant associations with household socioeconomic status. The poorest people in the population continue to bear a high burden of HIV/AIDS and tuberculosis mortality, despite free antiretroviral therapy being made available from public health facilities. They argue that integrated strategies are needed to improve access to and uptake of HIV testing, care, and treatment, and management of non-communicable diseases in the poorest populations.

Understanding the relationship between couple dynamics and engagement with HIV care services: insights from a qualitative study in Eastern and Southern Africa
Wamoyi J; Renju J; Moshabela M, et al.: Sexually Transmitted Infections, 93(Issue Supplement 3), doi: http://dx.doi.org/10.1136/sextrans-2016-052976, 2017

This paper explores the interplay between couple dynamics and the engagement of people living with HIV (PLHIV) with HIV care and treatment services in three health and demographic surveillance sites in Tanzania, Malawi and South Africa. A qualitative study was conducted involving 107 in-depth interviews with PLHIV with a range of HIV care and treatment histories, including current users of HIV clinics, and people not enrolled in HIV care. Interviews explored experiences of living with HIV and how and why they chose to engage or not with HIV services. The authors found an interplay between couple dynamics and HIV care and treatment-seeking behaviour in the three countries. Being in a relationship impacted on the level and type of engagement with HIV services in multiple ways. In some instances, couples living with HIV supported each other which improved their engagement with care and strengthened their relationships. The desire to fulfil societal expectations and attract a new partner, or have a baby with a new partner, or to receive emotional or financial support, strengthened on-going engagement with HIV care and treatment. However, fear of blame, abandonment or abuse resulted in unwillingness to disclose and often led to disputes or discord between couples. There was little evidence of intra-couple understanding of each other’s lived experiences with HIV, and the authors found that couples rarely interacted with the formal health system together. Couple dynamics influenced engagement with HIV testing, care and treatment for both partners through a myriad of pathways. The authors propose that couple-friendly approaches to HIV care and treatment move beyond individualised care and which recognise partner roles in HIV care engagement.

Adolescent HIV Programming: Ready here we come!
International HIV/AIDS Alliance: International HIV/AIDS Alliance. UK 2017

This guide is one of a series of good practice guides, and contains information, strategies and resources to help HIV programmers implement HIV programming for adolescents. Adolescents are now included as a separate target group in global and national strategies. Increased access to HIV testing and treatment means that, more than ever, adolescents living with HIV know their status and are living longer on antiretroviral therapy (ART). Much more work is needed, however, to meet adolescents’ needs for prevention, care, treatment and support services. Barriers to access, poor uptake of both prevention and treatment services, stigma and discrimination, as well as challenges with adherence to treatment contribute significantly to HIV-related morbidity and mortality among adolescents. This Good Practice Guide contains information, strategies and resources to help programmers meet the standards for Alliance HIV programming for adolescents. Implementing these standards is one of the ways that the Alliance, our partners and other organisations define and promote a unified and quality-driven approach to HIV programming.

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. .