Sex differences in delayed antiretroviral therapy initiation among adolescents and young adults living with HIV in DR Congo

Background: In DR Congo, adolescent girls are disproportionately vulnerable to HIV. Nonetheless, females are often more engaged in the health-care system, including during antenatal care, when women enrolled on Option B+ for prevention of mother-to-child transmission of HIV initiate antiretroviral therapy (ART). We aimed to understand the extent of delayed ART initiation among adolescents and young adults newly enrolled in HIV care, and to assess whether there were any sex differences. Methods: Aggregate data from 365 ICAP-supported sites in Kinshasa and Haut-Katanga provinces in DR Congo from April 2016 to May 2017 were reviewed to describe delayed ART uptake among adolescents and young adults aged 15–24 years. Delayed uptake was defined as not beginning treatment within 1 month of enrolling in care among those eligible for ART. Pregnant and non-pregnant women were combined since available data did not disaggregate by pregnancy status. DR Congo began implementing “test and start” during the study period. All analyses used group-level data and were conducted using multivariable logistic regression, adjusting for setting and age group. Findings: Between April 2016 and May 2017, 861 adolescents and young adults (128 male and 733 female) enrolled in HIV care and treatment services. 21 (16%) males and 58 (8%) females had not begun treatment within 1 month of enrolling in care, despite eligibility for ART (odds ratio [OR] 2·28, 95% CI 1·33–3·92). The male predominance remained after controlling for setting (urban vs rural) and age group (15–19 years vs 20–24 years) (adjusted OR 2·03, 95% CI 1·17–3·53). Aggregate data did not allow for analysis of individual explanations, but reasons for delayed ART may include the need to stabilise patients before starting treatment and patients’ preferences. Interpretation: Despite being more vulnerable to HIV, female adolescents and young adults have faster ART initiation than males after enrolling in HIV treatment. It is likely that Option B+ expedites ART initiation for females. Going forwards, ICAP will strengthen its adolescent package of support with community-based adolescent-friendly interventions targeting males, with the goal to enrol all adolescents and young adults on ART in accordance with DRC's test and start guidelines. Funding: CDC/PEPFAR

Roll-out of first HIV pre-exposure prophylaxis services in the Democratic Republic of the Congo

Background: In the Democratic Republic of the Congo (DR Congo), HIV prevalence is highest in key populations, specifically female sex workers and men who have sex with men, with estimates of 7% and 18%, respectively, compared with 1·2% in the general population. Pre-exposure prophylaxis (PrEP) is an evidence-based intervention to reduce HIV incidence in populations who are at substantial risk of acquiring HIV. Building the capacity of clinics and outreach programmes serving key populations is a critical first step in scaling-up PrEP services. Here, we describe a programme from the DR Congo's National AIDS Control Programme, US Centers for Disease Control and Prevention (CDC), and ICAP at Columbia University to initiate 350 clients from key population on PrEP in 2018. Methods: With support from the National AIDS Control Programme and CDC, ICAP facilitated PrEP implementation at seven HIV care and treatment facilities in DR Congo. Capacity-building activities included: guidance on national planning; establishment of a national PrEP technical working group; and the development of PrEP training material for multidisciplinary facility teams to provide and monitor PrEP services. Training addressed: PrEP eligibility screening, initiation, and follow-up; PrEP retention and follow-up activities; and monitoring and evaluation of PrEP services. ICAP also provided ongoing on-site mentorship of clinic staff, and continuous evaluation of clinic procedures to ensure standardised PrEP service delivery across all facilities. Findings: By February, 2018, 38 clinical staff and 48 peer outreach workers had completed a 6-day PrEP training course using ICAP's PrEP training curriculum; participant and facilitator manuals; job aids; and monitoring, evaluation, and reporting tools. Following the training, four sites in Kinshasa and three sites in Lubumbashi initiated PrEP services for the first time, resulting in successful achievement of the national PrEP targets. Interpretation: Collaboration between national and global stakeholders resulted in the successful introduction of PrEP in DR Congo. PrEP implementation required extensive clinic training, tailoring of existing outreach activities to improve PrEP retention, inclusion of peer workers to help educate patients about PrEP, comprehensive monitoring and evaluation reporting, and ongoing mentoring of clinic staff. Lessons learned in DR Congo will be shared with other programmes in African countries that work with populations at risk of HIV. Project findings will also support the endorsement of national PrEP guidelines and the scale-up of PrEP in DR Congo. Funding: US Centers for Disease Control and Prevention