It takes two: The dyadic and gendered context of HIV testing, risk assessment, and partner communication in Kisarawe, Tanzania

Background: Sexual transmission of HIV takes place between two people, yet dyads are rarely the focus of HIV-related interventions. Given the increasing importance of HIV testing, understanding how dyads influence each other’s motivations for HIV testing and what drives partner communication could help create effective interventions that leverage partner testing. This dissertation seeks to understand the dyadic and gendered context of partner communication and sexual risk in influencing decisions surrounding HIV testing in Kisarawe, Tanzania. Methods: Manuscript 1 examines factors associated with prior HIV testing, stratified by gender, to better understand what drives HIV testing behavior using Social Action Theory. Manuscript 2 uses Categorization and Regression Tree analysis (CaRT) to create risk assessment tools for men and women to use during testing so that high-risk individuals can be identified and encouraged to discuss HIV testing with their sexual partners. Given the emphasis on partner communication as the referral mechanism discussed in Manuscript 2, Manuscript 3 explores factors related to partner communication about HIV using the Theory of Gender and Power. Results: Correlates of HIV testing, partner communication, and HIV-related risk differed by gender across analyses. HIV testing rates were lower for men and young people. Having had prior conversations about HIV was positively correlated with prior testing among men. At the dyadic level, knowing if a sexual partner had tested for HIV was associated with recent testing among men. As a means to foster partner referral for HIV testing, we developed a 6- and 10-item risk assessment questionnaire for men and women, respectively, to classify individuals at heightened risk of infection using simple behavioral predictors. Regarding factors related to partner communication, both men and women had higher odds of communication if they had more progressive gender norms, more favorable social norms toward HIV prevention, and were socially engaged. Conclusions: Our findings help understand the specific pathways through which gender norms and social-level factors influence dyadic behavior in relation to HIV testing and partner communication. Gender-specific, proactive interventions are needed to increase testing uptake, especially for young people and men. Interventions that encourage sexual partners to test could facilitate uptake of HIV testing services but would require increased partner communication. Drivers of partner communication are inherently socially and structurally-based. Creating change will require interventions at multiple levels—from interventions to improve individual and dyadic-level communication and negotiation skills to interventions at the social-level to increase community dialogue

Service delivery interventions to increase uptake of voluntary medical male circumcision for HIV prevention: A systematic review.

BackgroundVoluntary medical male circumcision (VMMC) remains an essential component of combination HIV prevention services, particularly in priority countries in sub-Saharan Africa. As VMMC programs seek to maximize impact and efficiency, and to support World Health Organization guidance, specific uptake-enhancing strategies are critical to identify.MethodsWe systematically reviewed the literature to evaluate the impact of service delivery interventions (e.g., facility layout, service co-location, mobile outreach) on VMMC uptake among adolescent and adult men. For the main effectiveness review, we searched for publications or conference abstracts that measured VMMC uptake or uptake of HIV testing or risk reduction counselling within VMMC services. We synthesized data by coding categories and outcomes. We also reviewed studies assessing acceptability, values/preferences, costs, and feasibility.ResultsFour randomized controlled trials and five observational studies were included in the effectiveness review. Studies took place in South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. They assessed a range of service delivery innovations, including community-, school-, and facility-based interventions. Overall, interventions increased VMMC uptake; some successfully improved uptake among age-specific subpopulations, but urban-rural stratification showed no clear trends. Interventions that increased adult men's uptake included mobile services (compared to static facilities), home-based testing with active referral follow-up, and facility-based HIV testing with enhanced comprehensive sexual education. Six acceptability studies suggested interventions were generally perceived to help men choose to get circumcised. Eleven cost studies suggested interventions create economies-of-scale and efficiencies. Three studies suggested such interventions were feasible, improving facility preparedness, service quality and quantity, and efficiencies.ConclusionsInnovative changes in male-centered VMMC services can improve adult men's and adolescent boys' VMMC uptake. Limited evidence on interventions that enhance access and acceptability show promising results, but evidence gaps persist due to inconsistent intervention definition and delivery, due in part to contextual relevance and limited age disaggregation

Economic compensation interventions to increase uptake of voluntary medical male circumcision for HIV prevention: A systematic review and meta-analysis.

BackgroundEconomic compensation interventions may help support higher voluntary medical male circumcision (VMMC) coverage in priority sub-Saharan African countries. To inform World Health Organization guidelines, we conducted a systematic review of economic compensation interventions to increase VMMC uptake.MethodsEconomic compensation interventions were defined as providing money or in-kind compensation, reimbursement for associated costs (e.g. travel, lost wages), or lottery entry. We searched five electronic databases and four scientific conferences for studies examining the impact of such interventions on VMMC uptake, HIV testing and safer-sex/risk-reduction counseling uptake within VMMC, community expectations about compensation, and potential coercion. We screened citations, extracted data, and assessed risk of bias in duplicate. We conducted random-effects meta-analysis. We also reviewed studies examining acceptability, values/preferences, costs, and feasibility.ResultsOf 2484 citations identified, five randomized controlled trials (RCTs) and three non-randomized controlled trials met our eligibility criteria. Studies took place in Kenya, Malawi, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. Meta-analysis of four RCTs showed significant impact of any economic compensation on VMMC uptake (relative risk: 5.23, 95% CI: 3.13 to 8.76). RCTs of food/transport vouchers and conditional cash transfers generally showed increases in VMMC uptake, but lotteries, subsidized VMMC, and receiving a gift appeared somewhat less effective. Three non-randomized trials showed mixed impact. Six additional studies suggested economic compensation interventions were generally acceptable, valued for addressing key barriers, and motivating to men. However, some participants felt they were insufficiently motivating or necessary; one study suggested they might raise community suspicions. One study from South Africa found a program cost of US$91 per additional circumcision and US$450-$1350 per HIV infection averted.ConclusionsEconomic compensation interventions, particularly transport/food vouchers, positively impacted VMMC uptake among adult men and were generally acceptable to potential clients. Carefully selected economic interventions may be a useful targeted strategy to enhance VMMC coverage

Effectiveness and safety of oral HIV preexposure prophylaxis for all populations.

ObjectivePreexposure prophylaxis (PrEP) offers a promising new approach to HIV prevention. This systematic review and meta-analysis evaluated the evidence for use of oral PrEP containing tenofovir disoproxil fumarate as an additional HIV prevention strategy in populations at substantial risk for HIV based on HIV acquisition, adverse events, drug resistance, sexual behavior, and reproductive health outcomes.DesignRigorous systematic review and meta-analysis.MethodsA comprehensive search strategy reviewed three electronic databases and conference abstracts through April 2015. Pooled effect estimates were calculated using random-effects meta-analysis.ResultsEighteen studies were included, comprising data from 39 articles and six conference abstracts. Across populations and PrEP regimens, PrEP significantly reduced the risk of HIV acquisition compared with placebo. Trials with PrEP use more than 70% demonstrated the highest PrEP effectiveness (risk ratio = 0.30, 95% confidence interval: 0.21-0.45, P < 0.001) compared with placebo. Trials with low PrEP use did not show a significantly protective effect. Adverse events were similar between PrEP and placebo groups. More cases of drug-resistant HIV infection were found among PrEP users who initiated PrEP while acutely HIV-infected, but incidence of acquiring drug-resistant HIV during PrEP use was low. Studies consistently found no association between PrEP use and changes in sexual risk behavior. PrEP was not associated with increased pregnancy-related adverse events or hormonal contraception effectiveness.ConclusionPrEP is protective against HIV infection across populations, presents few significant safety risks, and there is no evidence of behavioral risk compensation. The effective and cost-effective use of PrEP will require development of best practices for fostering uptake and adherence among people at substantial HIV risk

Country adherence to WHO recommendations to improve the quality of HIV diagnosis: a global policy review.

INTRODUCTION: Ensuring a correct and timely HIV diagnosis is critical. WHO publishes guidelines on HIV testing strategies that maximise the likelihood of correctly determining one's HIV status. A review of national HIV testing policies in 2014 found low adherence to WHO guidelines. We updated this review to determine adherence to current recommendations. METHODS: We conducted a comprehensive policy review through April 2018. We extracted data on HIV testing strategies, recommendations on HIV retesting prior to antiretroviral therapy (ART) initiation and pre-exposure prophylaxis (PrEP)-related HIV testing information. Descriptive analyses disaggregated by region were conducted to ascertain adherence to recommendations and to describe testing strategy characteristics. RESULTS: Of 91 policies included, 26% (n=24/91) adhered to WHO recommendations. Having a two-assay testing strategy to rule-in HIV infection as opposed to the recommended three-assay testing strategy was a major reason for non-adherence. Of 72 country policies providing sufficient information, 31% (n=22) recommended retesting for HIV prior to initiating ART. Of 25 countries and two regions reporting PrEP-related HIV testing guidelines, almost all recommended testing prior to initiating PrEP and every 3 months during PrEP use. CONCLUSIONS: Global adherence to WHO recommendations for HIV testing strategies have improved since 2014 but remain low. We found adherence existed on a continuum. Such a system provides insights into how countries can move towards adherence by making relatively minor changes to testing strategies. Guidance from WHO on the role of new HIV testing technologies within testing algorithms and identifying ways to simplify testing guidance is warranted

It takes two: The dyadic and gendered context of HIV testing, risk assessment, and partner communication in Kisarawe, Tanzania

Background: Sexual transmission of HIV takes place between two people, yet dyads are rarely the focus of HIV-related interventions. Given the increasing importance of HIV testing, understanding how dyads influence each other’s motivations for HIV testing and what drives partner communication could help create effective interventions that leverage partner testing. This dissertation seeks to understand the dyadic and gendered context of partner communication and sexual risk in influencing decisions surrounding HIV testing in Kisarawe, Tanzania. Methods: Manuscript 1 examines factors associated with prior HIV testing, stratified by gender, to better understand what drives HIV testing behavior using Social Action Theory. Manuscript 2 uses Categorization and Regression Tree analysis (CaRT) to create risk assessment tools for men and women to use during testing so that high-risk individuals can be identified and encouraged to discuss HIV testing with their sexual partners. Given the emphasis on partner communication as the referral mechanism discussed in Manuscript 2, Manuscript 3 explores factors related to partner communication about HIV using the Theory of Gender and Power. Results: Correlates of HIV testing, partner communication, and HIV-related risk differed by gender across analyses. HIV testing rates were lower for men and young people. Having had prior conversations about HIV was positively correlated with prior testing among men. At the dyadic level, knowing if a sexual partner had tested for HIV was associated with recent testing among men. As a means to foster partner referral for HIV testing, we developed a 6- and 10-item risk assessment questionnaire for men and women, respectively, to classify individuals at heightened risk of infection using simple behavioral predictors. Regarding factors related to partner communication, both men and women had higher odds of communication if they had more progressive gender norms, more favorable social norms toward HIV prevention, and were socially engaged. Conclusions: Our findings help understand the specific pathways through which gender norms and social-level factors influence dyadic behavior in relation to HIV testing and partner communication. Gender-specific, proactive interventions are needed to increase testing uptake, especially for young people and men. Interventions that encourage sexual partners to test could facilitate uptake of HIV testing services but would require increased partner communication. Drivers of partner communication are inherently socially and structurally-based. Creating change will require interventions at multiple levels—from interventions to improve individual and dyadic-level communication and negotiation skills to interventions at the social-level to increase community dialogue

Mapping of Pro-Equity Interventions Proposed by Immunisation Programs in Gavi Health Systems Strengthening Grants

Reaching zero-dose (ZD) children, operationally defined as children who have not received a first dose of the diphtheria, tetanus, and pertussis (DTP1) vaccine, is crucial to increase equitable immunisation coverage and access to primary health care. However, little is known about the approaches already taken by countries to improve immunisation equity. We reviewed all Health System Strengthening (HSS) proposals submitted by Gavi-supported countries from 2014 to 2021 inclusively and extracted information on interventions favouring equity. Pro-equity interventions were mapped to an analytical framework representing Gavi 5.0 programmatic guidance on reaching ZD children and missed communities. Data from keyword searches and manual screening were extracted into an Excel database. Open format responses were analysed using inductive and deductive thematic coding. Data analysis was conducted using Excel and R. Of the 56 proposals included, 51 (91%) included at least one pro-equity intervention. The most common interventions were conducting outreach sessions, tailoring the location of service delivery, and partnerships. Many proposals had “bundles” of interventions, most often involving outreach, microplanning and community-level education activities. Nearly half prioritised remote-rural areas and only 30% addressed gender-related barriers to immunisation. The findings can help identify specific interventions on which to focus future evidence syntheses, case studies and implementation research and inform discussions on what may or may not need to change to better reach ZD children and missed communities moving forward