Voluntary Medical Male Circumcision: Strategies for Meeting the Human Resource Needs of Scale-Up in Southern and Eastern Africa

Kelly Curran and colleagues conducted a program review to identify human resource approaches that are being used to improve voluntary medical male circumcision volume and efficiency, identifying several innovative responses to human resource challenges

Homelessness, unstable housing, and risk of HIV and hepatitis C virus acquisition among people who inject drugs: a systematic review and meta-analysis

Background: People who inject drugs (PWID) are at increased risk for HIV and hepatitis C virus (HCV) infection and also have high levels of homelessness and unstable housing. We assessed whether homelessness or unstable housing is associated with an increased risk of HIV or HCV acquisition among PWID compared with PWID who are not homeless or are stably housed. Methods: In this systematic review and meta-analysis, we updated an existing database of HIV and HCV incidence studies published between Jan 1, 2000, and June 13, 2017. Using the same strategy as for this existing database, we searched MEDLINE, Embase, and PsycINFO for studies, including conference abstracts, published between June 13, 2017, and Sept 14, 2020, that estimated HIV or HCV incidence, or both, among community-recruited PWID. We only included studies reporting original results without restrictions to study design or language. We contacted authors of studies that reported HIV or HCV incidence, or both, but did not report on an association with homelessness or unstable housing, to request crude data and, where possible, adjusted effect estimates. We extracted effect estimates and pooled data using random-effects meta-analyses to quantify the associations between recent (current or within the past year) homelessness or unstable housing compared with not recent homelessness or unstable housing, and risk of HIV or HCV acquisition. We assessed risk of bias using the Newcastle-Ottawa Scale and between-study heterogeneity using the I2 statistic and p value for heterogeneity. Findings: We identified 14 351 references in our database search, of which 392 were subjected to full-text review alongside 277 studies from our existing database. Of these studies, 55 studies met inclusion criteria. We contacted the authors of 227 studies that reported HIV or HCV incidence in PWID but did not report association with the exposure of interest and obtained 48 unpublished estimates from 21 studies. After removal of duplicate data, we included 37 studies with 70 estimates (26 for HIV; 44 for HCV). Studies originated from 16 countries including in North America, Europe, Australia, east Africa, and Asia. Pooling unadjusted estimates, recent homelessness or unstable housing was associated with an increased risk of acquiring HIV (crude relative risk [cRR] 1·55 [95% CI 1·23–1·95; p=0·0002]; I2= 62·7%; n=17) and HCV (1·65 [1·44–1·90; p<0·0001]; I2= 44·8%; n=28]) among PWID compared with those who were not homeless or were stably housed. Associations for both HIV and HCV persisted when pooling adjusted estimates (adjusted relative risk for HIV: 1·39 [95% CI 1·06–1·84; p=0·019]; I2= 65·5%; n=9; and for HCV: 1·64 [1·43–1·89; p<0·0001]; I2= 9·6%; n=14). For risk of HIV acquisition, the association for unstable housing (cRR 1·82 [1·13–2·95; p=0·014]; n=5) was higher than for homelessness (1·44 [1·13–1·83; p=0·0036]; n=12), whereas no difference was seen between these outcomes for risk of HCV acquisition (1·72 [1·48–1·99; p<0·0001] for unstable housing, 1·66 [1·37–2·00; p<0·0001] for homelessness). Interpretation: Homelessness and unstable housing are associated with increased risk of HIV and HCV acquisition among PWID. Our findings support the development of interventions that simultaneously address homelessness and unstable housing and HIV and HCV transmission in this population

Feasibility, effectiveness, budget impact and surveillance of partner services for HIV in Kenya

Thesis (Ph.D.)--University of Washington, 2015Abstract Introduction: HIV assisted partner services (aPS), is widely practiced in the United States and Europe but less so in Africa largely due to limited data on their effectiveness and feasibility in routine health care settings. Yet aPS could increase HIV testing rates, reduce STI/HIV exposure, and assure prompt linkage to antiretroviral therapy (ART) initiation. We report the effect of immediate aPS in improving 1) the rate of HIV testing, 2) case-finding of HIV-infected individuals, and 3) linkages to HIV care for their partners. The trial determined the number needed to interview to identify one new case of HIV and explored, geographical differences in case finding rates. Additionally we assess the budget impact of scaling up aPS in Kisumu County, the region with the third highest number of HIV-infected persons in Kenya. We also present results of the pilot of a surveillance system for aPS. Methods: A cluster-randomized design was used to recruit eligible HIV-infected index cases from 18 clusters allocated to two study arms, immediate and delayed. The intervention was elicitation of sexual history from index cases and enumeration of sexual partners of HIV infected index cases in the preceding three years, notification, testing and referral to care if HIV-infected, of the named sexual partners. Participants in the delayed arm received a similar service only that this was delivered six weeks later. We used generalized estimating equations to evaluate the effect of the intervention on rates of HIV testing, identification of new HIV tests, HIV infections and enrollment to HIV care. The number of index cases needed to interview and the case finding rates were also evaluated using a similar approach. The study was registered in ClinicalTrials.gov as number NCT01616420. To estimate the budget impact, we constructed an Excel-based costing tool to simulate the budget impact analysis of HIV partner services on an annual basis over a 5 year time horizon. HIV Testing and Counseling (HTC) and aPS unit and total costs were estimated and allocated using ingredient-based approaches. Time motion was used to determine full-time equivalent of tracing sexual partners of index patients. Weighted costs of ART, clinic visits and hospitalizations that accrued due to aPS were generated through decision tree modeling. We estimated a range, where the lower-bound cost assumed that all sexual partners tested were HIV-negative and the upper-bound cost assumed that all sexual partners were HIV-positive. All costs were undiscounted and reported separately for the task-shifting scenarios. Appendix I outlines the assumptions regarding the patient workload and the number of providers available to do aPS in Kisumu County. Appendices II & III are the assumptions for calculating HIV testing costs and budget impact respectively. Appendix IV is the decision trees for determining expected costs for antiretroviral therapy, clinic visits and hospitalization visits. For the pilot of the surveillance system, we revised the national HTC data collection tool to include specific questions on whether clients testing for HIV were doing so due to an exposure from an HIV-infected partner. Results: The study enrolled 1119 index cases from 18 different clusters (550 in the intervention arm and 569 in the control arm) who mentioned 1872 sexual partners. Of the sexual partners, 1292 (69%), [620 in the intervention arm and 672 in the control arm] were enrolled. Enrollment and follow-up data were available for 579 (63%) of sexual partners mentioned in the immediate arm and enrollment data available for 672 (70%) in the delayed arm. 388 in the immediate arm during enrolment and within the study after enrollment, and 118 in the delayed arm in the preceding two months before enrollment (Incidence Rate Ratio (IRR) 3.78, 95% CI: 3.08-4.65). The incidence rate ratio comparing rates of new testing for HIV between the immediate and delayed groups was 11.50 (95% CI: 5.56-23.78). Immediate aPS also increased the number testing positive and those enrolled in HIV care, IRR 3.22 (95% CI: 2.26-4.61) and 3.95 (95% CI: 2.48-6.28) respectively. The number of index cases needed to interview (NNTI) to identify an HIV infection in the partners was 4.08, and that to identify a newly testing partner was 3.34. No study-related intimate partner violence was reported. The average annual aPS costs are US$1,092,161 and US$ 753,547 for Kisumu County using nurses and CHWs, respectively. The weighted average cost of scaling up aPS over a five period using nurses was 45% higher compared to CHWs (US$5,460,837 and US$ 3,767,738 respectively). Overall, the differences between the upper and lower bound costs were 8.7% for nurse-based aPS and 2.5% for the CHW-based approach. Over the time horizon, the total budget impact of nurse-model was US$1,726,832, 69.2$ 1,184,640, 68.6% lower than the nurse-based model. Proportional distribution of impact across budget categories was similar in the two models, although CHWs model had lower aPS related impact The weighted unit costs of HIV testing across the three levels of facilities for HIV-infected index clients using nurses were US$25.36 and US$ 17.86 using CHWs. Costs for testing sexual partners of infected index clients were higher overall, with an HIV test costing US$19.18 per person if all tests were negative and US$31.07 per person if all tests were positive for nurses and US$11.74 per person and US$ 14.14 per person for CHWS respectively. Median time for data capture using the HTC form was 4 minutes (IQR: 3-15), with a longer duration for HIV-infected participants, and there was no reported data loss. Interpretation: aPS is safe, effective and feasible at the population level and should be implemented as part of HIV Testing and Counseling (HTC delivery). In addition to early ART initiation, aPS may have considerable effect on HIV transmission at the population level. Furthermore, aPS is affordable although not cost-saving and routine Health Information Systems (HIS) may be used to monitor aPS outcomes

Assisted partner notification services to augment HIV testing and linkage to care in Kenya: study protocol for a cluster randomized trial

Abstract Background HIV case-finding and linkage to care are critical for control of HIV transmission. In Kenya, >50% of seropositive individuals are unaware of their status. Assisted partner notification is a public health strategy that provides HIV testing to individuals with sexual exposure to HIV and are at risk of infection and disease. This parallel, cluster-randomized controlled trial will evaluate the effectiveness, cost-effectiveness, and feasibility of implementing HIV assisted partner notification services at HIV testing sites (clusters) in Kenya. Methods/design Eighteen sites were selected among health facilities in Kenya with well-established, high-volume HIV testing programs, to reflect diverse communities and health-care settings. Restricted randomization was used to balance site characteristics between study arms (n = 9 per arm). Sixty individuals testing HIV positive (‘index partners’) will be enrolled per site (inclusion criteria: ≥18 years, positive HIV test at a study site, willing to disclose sexual partners, and never enrolled for HIV care; exclusion criteria: pregnancy or high risk of intimate partner violence). Index partners provide names and contact information for all sexual partners in the past 3 years. At intervention sites, study staff immediately contact sexual partners to notify them of exposure, offer HIV testing, and link to care if HIV seropositive. At control sites, passive partner referral is performed according to national guidelines, and assisted partner notification is delayed by 6 weeks. Primary outcomes, assessed 6 weeks after index partner enrollment and analyzed at the cluster level, are the number of partners accepting HIV testing and number of HIV infections diagnosed and linked to care per index partner. Secondary outcomes are the incremental cost-effectiveness of partner notification and the costs of identifying >1 partner per index case. Participants are closely monitored for adverse outcomes, particularly intimate partner violence. The study is unblinded due to practical limitations. Discussion This rigorously designed trial will inform policy decisions regarding implementation of HIV partner notification services in Kenya, with possible application to other parts of sub-Saharan Africa. Examination of effectiveness and cost-effectiveness in diverse settings will enable targeted application and define best practices. Trial registration ClinicalTrials.gov NCT01616420