Antiretroviral therapy for HIV prevention: many concerns and challenges, but are there ways forward in sub-Saharan Africa?

Zachariah, Rony; Harries, Anthony; Philips, Mit; Arnould, Line; Sabapathy, Kalpana; O’Brien, D. P.; Ferreyra, Cecilia; Balkan, Suna

doi:10.1016/j.trstmh.2010.01.004

Cited by 18 publications

(15 citation statements)

References 19 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…3, 4 These advances have ignited debate about how best to use ART in efforts to further reduce HIV incidence. 5 An approach combining multiple biomedical and behavioral interventions will be required, 6 and policy makers are currently debating the criteria used to target interventions, including TasP and PrEP.…”

Section: Introductionmentioning

confidence: 99%

Extra-couple HIV transmission in sub-Saharan Africa: a mathematical modelling study of survey data

et al. 2013

View full text Add to dashboard Cite

Summary Background The proportion of heterosexual HIV transmission in Sub-Saharan Africa that occurs within cohabiting partnerships, as opposed to among single people, or in extra-couple relationships, is a subject of active debate. This question is of immediate importance. As plans to use antiretroviral drugs as a strategy for population-level prevention progress, understanding the importance of different transmission routes is critical to targeting intervention efforts. Methods We built a mechanistic HIV transmission model using data from Demographic and Health Surveys covering 27,201 cohabiting couples from 18 sub-Saharan African countries with information on couple duration, age at sexual debut, and HIV serostatus. We combined this model with estimates of HIV survival times and country-specific estimates of HIV prevalence and ART coverage. We then estimated the proportion of observed infections in surveyed cohabiting couples that occurred prior to couple formation, between couple members, and through extra-couple intercourse. Findings We estimate that extra-couple transmission accounts for between 27-61% and 21-51% of all infected males and females, respectively, in surveyed couples, with the ranges given reflecting inter-country variation. We project that over the next year extra-couple transmission will account for 30-65% and 10-47% of new incident HIV infections in males and females, respectively, in cohabiting couples. Our results also suggest that the directionality of transmission within couples is largely from males to females; however, females experience a very high-risk period prior to couple formation. Interpretation Due to the large contribution of extra-couple transmission, HIV prevention interventions should target the general sexually active population, and not just serodiscordant couples.

show abstract

Section: Introductionmentioning

confidence: 99%

Extra-couple HIV transmission in sub-Saharan Africa: a mathematical modelling study of survey data

et al. 2013

View full text Add to dashboard Cite

show abstract

“…A study from Rakai, Uganda, reported that there were no instances of HIV transmission between sero-discordant couples when serum HIV RNA levels in the infected partner were ≤1500 copies/ml [13]. These results led to increased interest in the potential benefits of ART in HIV prevention [16,17,18,19,20]. The HPTN 052 trial [21] of sero-discordant couples found that the risk of HIV infection in the sero-negative partner was reduced by 96% when the HIV infected partner received ART.…”

Section: Introductionmentioning

confidence: 99%

Community Viral Load and CD4 Count Distribution Among People Living With HIV in a South African Township

Kranzer

Lawn

Johnson

et al. 2013

JAIDS Journal of Acquired Immune Deficiency Syndromes

View full text Add to dashboard Cite

Introduction The goals of scale-up of antiretroviral therapy (ART) have expanded from prevention of morbidity and death to include prevention of transmission. Morbidity and mortality risk are associated with CD4 counts; transmission risk depends on plasma viral load (VL). This study aimed to describe CD4 count and VL distributions among HIV-infected individuals in a South African township to gain insights into the potential impact of ART scale-up on community HIV transmission risk. Methods A random sample of 10% of the adult population was invited to attend an HIV testing service. Study procedures included a questionnaire, HIV testing, CD4 count and VL testing. Results 1144 (88.0%) of 1300 randomly selected individuals participated in the study. 260 tested positive, giving an HIV prevalence of 22.7% (95%CI:20.3-25.3). A third of all HIV-infected individuals (33.5%, 95%CI:27.8-39.6) reported taking ART. The median CD4 count was 417 cells/μl (IQR:285-627); 33 (12.7%, 95%CI:8.9-17.4) had a CD4 count of ≤200 cells/μL. VL measurements were available for 219 (84.2%) individuals and were undetectable in 72 (33.9%), >1500 copies/ml in 127 (58.0%) and >10,000 copies/ml in 96 (43.8%). Of those reporting they were receiving ART, 30.4% had a VL>1500 copies/ml compared to 58.0% of those reporting they were not receiving ART. Conclusion A small proportion of those living with HIV in this community had a CD4 count <200 cells/μl; more than half had a VL high enough to be associated with considerable transmission risk. A substantial proportion of HIV-infected individuals remained at risk of transmitting HIV even after starting ART.

show abstract

“…However, policy-makers must be obliged to act in the interest of social justice by devising strategies that account for the potential complexities that HIV/(DR-)TB co-infected individuals may encounter. Given the diverse social, cultural, economic and ecological settings in SSA, careful consideration of local contexts is essential, and community motivation and support is vital (Zachariah et al, 2010). Treatment guidelines with regards to HIV/DR-TB co-infections in any targeted subpopulation must be developed and adequately backed with funding and support services to ensure a rights-aware and effective service delivery strategy.…”

Section: Global Public Healthmentioning

confidence: 99%

Programmatic and ethical challenges in the implementation of treatment-as-prevention in the context of HIV and drug-resistant tuberculosis co-infection in sub-Saharan Africa

Melesse

Becker

McClarty

et al. 2014

Global Public Health

View full text Add to dashboard Cite

There is limited literature on programmatic challenges in the implementation of a treatment-as-prevention (TasP) strategy among human immunodeficiency virus (HIV) and drug-resistant tuberculosis (DR-TB) co-infected individuals in sub-Saharan Africa (SSA). This paper highlights specific programmatic challenges surrounding the implementation of this strategy among HIV and DR-TB co-infected populations in SSA. In SSA, limitations in administrative, human and financial resources and poor health infrastructure, as well as increased duration and complexity of providing long-term treatment for HIV individuals co-infected with DR-TB, pose substantial challenges to the implementation of a TasP strategy and warrant further investigation. A comprehensive approach must be devised to implement TasP strategy, with special attention paid to the sizable HIV and DR-TB co-infected populations. We suggest that evidence-informed and human rights-based guidelines for participant protection and strategies for programme delivery must be developed and tailored to maximise the benefits to those most at risk of developing HIV and DR-TB co-infection. Assessing regional circumstances is crucial, and TasP programmes in the region should be complemented by combined prevention strategies to achieve the intended goals.

show abstract

Antiretroviral therapy for HIV prevention: many concerns and challenges, but are there ways forward in sub-Saharan Africa?

Cited by 18 publications

References 19 publications

Extra-couple HIV transmission in sub-Saharan Africa: a mathematical modelling study of survey data

Extra-couple HIV transmission in sub-Saharan Africa: a mathematical modelling study of survey data

Community Viral Load and CD4 Count Distribution Among People Living With HIV in a South African Township

Programmatic and ethical challenges in the implementation of treatment-as-prevention in the context of HIV and drug-resistant tuberculosis co-infection in sub-Saharan Africa

Contact Info

Product

Resources

About