“It is better to die”: experiences of traditional health practitioners within the HIV treatment as prevention trial communities in rural South Africa (ANRS 12249 TasP trial)

The ANRS 12249 Treatment-as-Prevention (TasP) cluster-randomized trial in rural South Africa uses a “test and treat” approach. Home-based testing services and antiretroviral treatment initiation satellite clinics were implemented in every cluster as part of the trial. A social science research agenda was nested within TasP with the aim of understanding the social, economic and contextual factors that affect individuals, households, communities and health systems with respect to TasP. Considering the rural nature of the trial setting, we sought to understand community perceptions and experiences of the TasP Trial interventions as seen through the eyes of traditional health practitioners (THPs). A qualitative study design was adopted using four repeat focus group discussions conducted with nine THPs, combined with community walks and photo-voice techniques, over a period of 18 months. A descriptive, interpretive and explanatory approach to analysis was adopted. Findings indicate that THPs engaged with the home-based testing services and HIV clinics established for TasP. Specifically, home-based testing services were perceived as relatively successful in increasing access to HIV testing. A major gap observed by THPs was linkage to HIV clinics. Most of their clients, and some of the THPs themselves, found it difficult to use HIV clinics due to fear of labelling, stigma and discrimination, and the ensuing personal implications of unsolicited disclosure. On the one hand, a growing number of patients diagnosed with HIV have found sanctuary with THPs as alternatives to clinics. On the other hand, THPs in turn have been struggling to channel patients suspected of HIV into clinics through referrals. Therefore, acceptability of the TasP test and treat approach by THPs is a major boost to the intervention, but further success can be achieved through strengthened ties with communities to combat stigma and effectively link patients into HIV care, including partnerships with THPs themselves

Влияние инфляции на взаимосвязь стабилизации и роста экономики некоторых стран Восточной Европы и бывшего СССР

In many countries, particularly in sub-Saharan Africa, Demographic and Health Surveys (DHSs) are the main way of estimating HIV prevalence nationally in the general population. Some DHSs record the longitude and latitude of the survey clusters.We present three methodological approaches for mapping spatial variations in HIV prevalence using the DHSs. These approaches are applied to simulated DHS samplings from a model country. The estimated surfaces are then compared with the model’s initial surface.We demonstrate that a method using kernel estimators with adaptive bandwidths size of equal number of persons observed can be used to estimate the main regional trends in epidemics. Application to Burkina Faso’s 2003 DHS data provides a plausible image of that country’s epidemiological situation

Factors associated with antiretroviral treatment initiation amongst HIV-positive individuals linked to care within a universal test and treat programme: early findings of the ANRS 12249 TasP trial in rural South Africa

Prompt uptake of antiretroviral treatment (ART) is essential to ensure the success of universal test and treat (UTT) strategies to prevent HIV transmission in high-prevalence settings. We describe ART initiation rates and associated factors within an ongoing UTT cluster-randomized trial in rural South Africa. HIV-positive individuals were offered immediate ART in the intervention arm vs. national guidelines recommended initiation (CD4≤350 cells/mm3) in the control arm. We used data collected up to July 2015 among the ART-eligible individuals linked to TasP clinics before January 2015. ART initiation rates at one (M1), three (M3) and six months (M6) from baseline visit were described by cluster and CD4 count strata (cells/mm3) and other eligibility criteria: ≤100; 100–200; 200–350; CD4>350 with WHO stage 3/4 or pregnancy; CD4>350 without WHO stage 3/4 or pregnancy. A Cox model accounting for covariate effect changes over time was used to assess factors associated with ART initiation. The 514 participants had a median [interquartile range] follow-up duration of 1.08 [0.69; 2.07] months until ART initiation or last visit. ART initiation rates at M1 varied substantially (36.9% in the group CD4>350 without WHO stage 3/4 or pregnancy, and 55.2–71.8% in the three groups with CD4≤350) but less at M6 (from 85.3% in the first group to 96.1–98.3% in the three other groups). Factors associated with lower ART initiation at M1 were a higher CD4 count and attending clinics with both high patient load and higher cluster HIV prevalence. After M1, having a regular partner was the only factor associated with higher likelihood of ART initiation. These findings suggest good ART uptake within a UTT setting, even among individuals with high CD4 count. However, inadequate staffing and healthcare professional practices could result in prioritizing ART initiation in patients with the lowest CD4 counts

Sources of variation in under-5 mortality across sub-Saharan Africa: a spatial analysis

SummaryBackgroundDetailed spatial understanding of levels and trends in under-5 mortality is needed to improve the targeting of interventions to the areas of highest need, and to understand the sources of variation in mortality. To improve this understanding, we analysed local-level information on child mortality across sub-Saharan Africa between 1980–2010.MethodsWe used data from 82 Demographic and Health Surveys in 28 sub-Saharan African countries, including the location and timing of 3·24 million childbirths and 393 685 deaths, to develop high-resolution spatial maps of under-5 mortality in the 1980s, 1990s, and 2000s. These estimates were at a resolution of 0·1 degree latitude by 0·1 degree longitude (roughly 10 km × 10 km). We then analysed this spatial information to distinguish within-country versus between-country sources of variation in mortality, to examine the extent to which declines in mortality have been accompanied by convergence in the distribution of mortality, and to study localised drivers of mortality differences, including temperature, malaria burden, and conflict.FindingsIn our sample of sub-Saharan African countries from the 1980s to the 2000s, within-country differences in under-5 mortality accounted for 74–78% of overall variation in under-5 mortality across space and over time. Mortality differed significantly across only 8–15% of country borders, supporting the role of local, rather than national, factors in driving mortality patterns. We found that by the end of the study period, 23% of the eligible children in the study countries continue to live in mortality hotspots—areas where, if current trends continue, the Sustainable Developent Goals mortality targets will not be met. In multivariate analysis, within-country mortality levels at each pixel were significantly related to local temperature, malaria burden, and recent history of conflict.InterpretationOur findings suggest that sub-national determinants explain a greater portion of under-5 mortality than do country-level characteristics. Sub-national measures of child mortality could provide a more accurate, and potentially more actionable, portrayal of where and why children are still dying than can national statistics.FundingThe Stanford Woods Institute for the Environment

HIV ascertainment through repeat home-based testing in the context of a treatment as prevention trial (ANRS 12249 TasP) in rural South Africa

International audienceBackgroundThe ANRS 12249 TasP cluster-randomised trial evaluates whether HIV testing of all members of a community, followed by immediate antiretroviral treatment (ART) for infected people, will prevent onward sexual transmission and reduce HIV incidence at population level. Ascertaining the HIV status of a high proportion of the population regularly and repeatedly is key to the success of any universal test and treat strategy, as the first step of the HIV cascade.MethodsBetween March 2012 and March 2014, we implemented three six-monthly rounds of home-based HIV counselling and testing in ten local communities (clusters). At each home visit, individual questionnaires were administered and a rapid HIV test offered to all trial participants. We report early results on rates of HIV ascertainment, defined as undergoing a rapid HIV test or HIV-positive self-report.ResultsOf 12,911 eligible individuals (resident in the trial area and ≥16 years), 10,007 were successfully contacted at least once. At first contact, HIV status was ascertained for 7,628 (76.2% [95% CI: 75.4-77.1]) individuals. At second contact, among the 5,885 individuals contacted a second time, HIV status was ascertained for 2,829 (85.0% [95% CI: 83.7-86.2]) of the 3,328 tested negative at first contact and for 543 (45.7% [95% CI: 42.9-48.6]) of the 1,188 who refused a rapid test at first contact. Overall, HIV ascertainment rate was 89.0% (5,239/5,885 [95% CI: 88.2-89.8]) among trial participants contacted twice.ConclusionsRepeat home-based HIV testing is acceptable and feasible in this rural area. Socio-demographic characteristics, behaviours, attitudes, household characteristics and experience of HIV infection and ART in the household will be explored for their association with HIV ascertainment uptake. This will inform whether this intervention reaches the individuals at higher risk in a rural South African region

Retention in care trajectories of HIV-positive individuals participating in a universal test and treat programme in rural South Africa (ANRS 12249 TasP trial)

Objective: To study retention in care (RIC) trajectories and associated factors in patients eligible for antiretroviral treatment (ART) in a universal test-and-treat setting (TasP trial, South Africa, 2012-2016). Design: A cluster-randomized trial whereby individuals identified HIV-positive after home-based testing were invited to initiate ART immediately (intervention) or following national guidelines (control). Methods: Exiting care was defined as ≥3 months late for a clinic appointment, transferring elsewhere, or death. Group-Based Trajectory Modelling was performed to estimate RIC trajectories over 18 months and associated factors in 777 ART-eligible patients. Results: Four RIC trajectory groups were identified: i) group 1 “remained” in care (reference, n=554, 71.3%), ii) group 2 exited care then “returned” after (median [interquartile range]) 4 [3-9] months (n=40, 5.2%), iii) group 3 “exited care rapidly” (after 4 [4-6] months, n=98, 12.6%), iv) group 4 “exited care later” (after 11 [9-13] months, n=85, 10.9%). Group 2 patients were less likely to have initiated ART within 1 month and more likely to be male, young (350 cells/mm3. Group 3 patients were more likely to be women without social support, newly diagnosed, young, and less likely to have initiated ART within 1 month. Group 4 patients were more likely to be newly diagnosed and aged ≤39 years. Conclusions: High CD4 counts at care initiation were not associated with a higher risk of exiting care. Prompt ART initiation and special support for young and newly diagnosed HIV-patients are needed to maximize RIC

Access to HIV care in the context of universal test and treat: challenges within the ANRS 12249 TasP cluster-randomized trial in rural South Africa

Introduction: We aimed to quantify and identify associated factors of linkage to HIV care following home-based HIV counselling and testing (HBHCT) in the ongoing ANRS 12249 treatment-as-prevention (TasP) cluster-randomized trial in rural KwaZulu-Natal, South Africa. Methods: Individuals ]16 years were offered HBHCT; those who were identified HIV positive were referred to cluster-based TasP clinics and offered antiretroviral treatment (ART) immediately (five clusters) or according to national guidelines (five clusters). HIV care was also available in the local Department of Health (DoH) clinics. Linkage to HIV care was defined as TasP or DoH clinic attendance within three months of referral among adults not in HIV care at referral. Associated factors were identified using multivariable logistic regression adjusted for trial arm. Results: Overall, 1323 HIV-positive adults (72.9% women) not in HIV care at referral were included, of whom 36.9% (n488) linked to care B3 months of referral (similar by sex). In adjusted analyses (n1222), individuals who had never been in HIV care before referral were significantly less likely to link to care than those who had previously been in care (B33% vs. 42%, pB0.001). Linkage to care was lower in students (adjusted odds-ratio [aOR] 0.47; 95% confidence interval [CI] 0.240.92) than in employed adults, in adults who completed secondary school (aOR0.68; CI 0.490.96) or at least some secondary school (aOR0.59; CI 0.410.84) versus 5 primary school, in those who lived at 1 to 2 km (aOR0.58; CI 0.440.78) or 25 km from the nearest TasP clinic (aOR0.57; CI 0.410.77) versus B1 km, and in those who were referred to clinic after ]2 contacts (aOR0.75; CI 0.580.97) versus those referred at the first contact. Linkage to care was higher in adults who reported knowing an HIV-positive family member (aOR1.45; CI 1.121.86) versus not, and in those who said that they would take ART as soon as possible if they were diagnosed HIV positive (aOR2.16; CI 1.134.10) versus not. Conclusions: Fewer than 40% of HIV-positive adults not in care at referral were linked to HIV care within three months of HBHCT in the TasP trial. Achieving universal test and treat coverage will require innovative interventions to support linkage to HIV care

Men who have sex with men (MSM) and factors associated with not using a condom at last sexual intercourse with a man and with a woman in Senegal

BACKGROUND: Men who have sex with other men (MSM) are a vulnerable population in Africa that has been insufficiently explored. Given the high rate of bisexuality among MSM (73% in the past year), it is important to understand their risk-taking behaviors regarding both men and women. METHODOLOGY/PRINCIPAL FINDINGS: A socio-behavioral survey was carried out in 2007 among 501 MSM recruited using the snowball sampling method. We explore in this article why a condom was not used during last sexual intercourse with a man and with a woman, taking into account the respondent's characteristics, type of relationship and the context of the sexual act. In the survey, 489 men reported that they had had sexual intercourse at least once with another man during the previous year, and 358 with a man and with a woman. The main risk factors for not using a condom at last sexual intercourse with another man were having sex in a public place (aOR = 6.26 [95%CI: 2.71–14.46]), non-participation in an MSM prevention program (aOR = 3.47 [95%CI: 2.12–5.69]), a 19 years old or younger partner (aOR = 2.6 [95%CI: 1.23–4.53]), being 24 years or younger (aOR = 2.07 [95%CI: 1.20–3.58]) or being 35 years or over (aOR = 3.08 [95%CI:1.11–8.53]) and being unemployed (aOR = 0.36 [95%CI: 0.10–1.25]). The last sexual intercourse with the respondent's wife was hardly ever protected (2%). With women, the other factors were a 15 years or younger partner (aOR = 6.45 [95%CI: 2.56–16.28]), being educated (primary: aOR = 0.45 [95%CI: 0.21–0.95], secondary or higher: aOR = 0.26 [95%CI: 0.11–0.62]), being a student (aOR = 2.20 [95%CI: 1.07–4.54]) or unemployed (aOR = 3.72 [95%CI: 1.31–10.61]) and having participated in a MSM prevention program (aOR = 0.57 [95%CI: 0.34–0.93]). CONCLUSION: Having participated in a prevention program specifically targeting MSM constitutes a major prevention factor. However, these programs targeting MSM must address their heterosexual practices and the specific risks involved