Looking beyond facilities to eliminate vertical transmission

In The Lancet HIV , Goodluck Willey Lyatuu and colleagues present large-scale estimates of vertical HIV transmission in Dar es Salaam, Tanzania. The authors prospectively follow a cohort of women who presented for antenatal care from 2015 to 2017 and estimate vertical transmission rates in their infants up to 18-months post-partum. Of 13,251 women followed over this period, 159 infants were diagnosed with HIV, representing an impressively low vertical transmission rate of 1·4%. Factors related to poor care-seeking and adherence behaviours were most strongly associated with vertical transmission: late presentation to antenatal care, lack of previous ART use, advanced HIV disease, and use of second-line ART regimens

Assessing the Prevention Impact of HIV Counseling and Testing in the South African Context

HIV counseling and testing (HCT) is rapidly being brought to scale in South Africa, yet its impact on sexual behavior and HIV incidence is not well understood. The purpose of Aim 1 was to assess whether HIV-infected persons in HIV-discordant couples were less likely to engage in unprotected sex after HCT. Self-reported behavioral data from 500 HIV-infected South Africans enrolled in Partners in Prevention HSV/HIV Transmission Study was used. The sexual behavior of two groups was compared: HIV-infected persons who had just learned their HIV status from HCT ( 30 days before baseline). Among those tested 30 days before baseline the predicted probability of unprotected sex was lower at baseline (0.26), declined futher by month one (0.14) and remained lower at month twelve (0.19). These findings suggest HCT lead to substantial reductions in unprotected sex. In Aim 2, the effect of HCT on future HIV acquisition among HIV-uninfected youth was assessed. A retrospective cohort study of 3959 HIV-uninfected youth 15-24 years-old was conducted using a demographic and health surveillance from KwaZulu-Natal, South Africa (2006-2011). Young persons who reported knowing their HIV status from HCT were compared to those who reported not knowing their HIV status from HCT for time to HIV seroconversion using marginal structural Cox proportional hazards models. In these models, after weighting for confounding and censoring, HCT was protective [HR: 0.59, 95% CI: 0.44, 0.78], underscoring the importance of HCT for youth. In Aim 3 a framework was developed to describe nine awareness patterns within HIV-discordant dyads considering both HCT and HIV disclosure together. It was hypothesized that different types of HCT lead to different awareness patterns and that certain patterns are more strongly associated with uptake of and adherence to behavioral and biomedical HIV prevention strategies. Better understandings of these associations may inform how to optimize HCT delivery for prevention.Doctor of Philosoph

The effect of HIV counselling and testing on HIV acquisition in sub-Saharan Africa: a systematic review

Annually, millions of people in sub-Saharan Africa (SSA) receive HIV counselling and testing (HCT), a service designed to inform persons of their HIV status and, if HIV-uninfected, reduce HIV acquisition risk. However, the impact of HCT on HIV acquisition has not been systematically evaluated. We conducted a systematic review to assess this relationship in SSA

Hidden costs: The ethics of cost-effectiveness analyses for health interventions in resource-limited settings

Cost-effectiveness analysis (CEA) is an increasingly appealing tool for evaluating and comparing health-related interventions in resource-limited settings. The goal is to inform decision-makers regarding the health benefits and associated costs of alternative interventions, helping guide allocation of limited resources by prioritizing interventions that offer the most health for the least money. Although only one component of a more complex decision-making process, CEAs influence the distribution of healthcare resources, directly influencing morbidity and mortality for the world’s most vulnerable populations. However, CEA-associated measures are frequently setting-specific valuations, and CEA outcomes may violate ethical principles of equity and distributive justice. We examine the assumptions and analytical tools used in CEAs that may conflict with societal values. We then evaluate contextual features unique to resource-limited settings, including the source of health-state utilities and disability weights; implications of CEA thresholds in light of economic uncertainty; and the role of external donors. Finally, we explore opportunities to help align interpretation of CEA outcomes with values and budgetary constraints in resource-limited settings. The ethical implications of CEAs in resource-limited settings are vast. It is imperative that CEA outcome summary measures and implementation thresholds adequately reflect societal values and ethical priorities in resource-limited settings

The Role of Acute and Early HIV Infection in the Sexual Transmission of HIV

Acute HIV infection (AHI), the earliest period after HIV acquisition, is only a few weeks in duration. In this brief period, the concentration of HIV in blood and genital secretions is extremely high, increasing the probability of HIV transmission. Although a substantial role of AHI in the sexual transmission of HIV is biologically plausible, the significance of AHI in the epidemiological spread of HIV remains uncertain

What interventions are effective in improving uptake and retention of HIV-positive pregnant and breastfeeding women and their infants in prevention of mother to child transmission care programmes in low-income and middle-income countries? A systematic review and meta-analysis

Objective This review was conducted to identify interventions effective in improving uptake and retention of HIV-positive mothers and their infants in prevention of mother to child transmission (PMTCT) services in low-income and middle-income countries (LMICs) in order to inform programme planning. Methods We conducted a systematic review of studies comparing usual care with any intervention to improve uptake and retention of HIV-positive pregnant or breastfeeding women and their children from birth to 2 years of age in PMTCT services in LMICs. Twenty-two electronic databases were searched from inception to 15 January 2018, for randomised, quasi-randomised and non-randomised controlled trials, and interrupted time series studies; reference lists of included articles were searched for relevant articles. Risk of bias was assessed using the Cochrane Effective Practice and Organisation of Care group criteria. Random-effects meta-analysis was conducted for studies reporting similar interventions and outcomes. Results We identified 29 837 articles, of which 18 studies were included in our review. Because of heterogeneity in interventions and outcome measures, only one meta-analysis of two studies and one outcome was conducted; we found a statistically significant increase in antiretroviral therapy (ART) use during pregnancy for integration of HIV and antenatal care relative to standard non-integrated care (pooled AOR=2.69; 95% CI 1.25 to 5.78, p=0.0113). The remaining studies assessing other patient, provider or health system interventions were synthesised narratively, with small effects seen across intervention categories for both maternal and infant PMTCT outcomes based predominately on evidence with moderate to high risk of bias. Conclusions Evidence on the effectiveness of interventions to improve uptake and retention of mothers and infants in PMTCT care is lacking. Our findings suggest that integration of HIV and antenatal care may improve ART use during pregnancy. Future studies to replicate promising approaches are needed. Improved reporting of key methodological criteria will facilitate interpretation of findings and improve the utility of evidence to PMTCT programme planners

How can we better identify early HIV infections?

Detection of early HIV infections (EHIs), including acute HIV infection (AHI), is important for individual health, prevention of HIV transmission, and measurement of HIV incidence. We describe markers of EHI, diagnostic strategies for detecting these markers, and ways to incorporate these strategies into diagnostic and HIV incidence algorithms

Female adherence self-efficacy before and after couple HIV testing and counseling within Malawi's Option B+ program

Adherence self-efficacy, belief in one’s ability to adhere to daily medication, is strongly associated with antiretroviral therapy (ART) adherence and preventing mother-to-child HIV transmission. Couple-based interventions could enhance self-efficacy and adherence. We assessed the relationship between couple HIV testing and counseling (cHTC) and adherence self-efficacy using a 100-point culturally-adapted adherence self-efficacy scale (ASES). Secondarily, we explored the relationship between ASES and ART adherence. Ninety HIV-positive pregnant women at an antenatal clinic in Lilongwe, Malawi were enrolled in an observational cohort study. They were assessed with ASES immediately before and one month after receiving cHTC. Median ASES scores were 100 (IQR 95, 100) before and 100 (IQR 99, 100) after cHTC; there was a significant median difference (p = 0.02) for participants before and after cHTC. This change in ASES scores was associated with the odds of self-reported ART adherence in the full population (OR 1.1, p = 0.01), and there was a trend in the same direction for participants with imperfect baseline ASES scores (OR 1.1, p = 0.2). In our population, adherence self-efficacy and ART adherence were both quite high, and those who had room to improve in self-efficacy may have benefited from cHTC, which in turn could impact ART adherence and ultimately mother-to-child transmission

Index case finding facilitates identification and linkage to care of children and young persons living with HIV/AIDS in Malawi

OBJECTIVES: Evaluation of a novel index case finding and linkage-to-care programme to identify and link HIV-infected children (1-15 years) and young persons (>15-24 years) to care. METHODS: HIV-infected patients enrolled in HIV services were screened and those who reported untested household members (index cases) were offered home- or facility-based HIV testing and counselling (HTC) of their household by a community health worker (CHW). HIV-infected household members identified were enrolled in a follow-up programme offering home and facility-based follow-up by CHWs. RESULTS: Of the 1567 patients enrolled in HIV services, 1030 (65.7%) were screened and 461 (44.8%) identified as index cases; 93.5% consented to HIV testing of their households and of those, 279 (64.7%) reported an untested child or young person. CHWs tested 711 children and young persons, newly diagnosed 28 HIV-infected persons (yield 4.0%; 95% CI: 2.7-5.6), and identified an additional two HIV-infected persons not enrolled in care. Of the 30 HIV-infected persons identified, 23 (76.6%) were linked to HIV services; 18 of the 20 eligible for ART (90.0%) were initiated. Median time (IQR) from identification to enrolment into HIV services was 4 days (1-8) and from identification to ART start was 6 days (1-8). CONCLUSIONS: Almost half of HIV-infected patients enrolled in treatment services had untested household members, many of whom were children and young persons. Index case finding, coupled with home-based testing and tracked follow-up, is acceptable, feasible and facilitates the identification and timely linkage to care of HIV-infected children and young persons

Individual, Partner, and Couple Predictors of HIV Infection among Pregnant Women in Malawi: A Case-Control Study

We aimed to understand drivers of HIV-infection in pregnant women in Malawi. The study was conducted in antenatal and labor and delivery wards. HIV-infected women and their partners (cases) were frequency matched in a 1:2 ratio based on age and screening location to HIV-uninfected women and their partners (controls) in a prevalent case–control study. Characteristics associated with female HIV infection were assessed using logistic regression modeling. At screening, HIV-infected women were more likely to have partners outside Lilongwe than HIV-uninfected women (24% vs. 0%, p < 0.0001). Case females were more likely to have HIV-infected study partners than control females (75% vs. 4%, p < 0.0001). The odds of female HIV-infection were higher if either couple member reported ≥ 2 lifetime marriages (OR 9.0, CI 2.6–30.9) or ≥ 3 lifetime partners (OR 18.0, CI 3.1–103.6) and lower if either reported past couple HIV testing and counseling (OR 0.1, CI 0.04–0.3). Targeting women with migrating partners, promoting couple HIV testing and counseling, and limiting partners could slow HIV transmission