Antiretroviral Therapy to Prevent HIV Acquisition in Serodiscordant Couples in a Hyperendemic Community in Rural South Africa

Oldenburg, Catherine E.; Bärnighausen, Till; Tanser, Frank; Iwuji, Collins; Gruttola, Victor De; Seage, George R.; Mimiaga, Matthew J.; Mayer, Kenneth H.; Pillay, Deenan; Harling, Guy

doi:10.1093/cid/ciw335

Cited by 31 publications

(26 citation statements)

References 41 publications

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“…3 Accelerated ART in all men 85% reduction in risk of transmission for a person on ART relative to others [18][19][20]. intervention is in addition to this background "late" ART and is for those with higher CD4 counts, with active outreach to engage them in services.…”

Section: The Order Of Roll Out Of Strategiesmentioning

confidence: 99%

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HIV prevention where it is needed most: comparison of strategies for the geographical allocation of interventions

et al. 2017

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IntroductionA strategic approach to the application of HIV prevention interventions is a core component of the UNAIDS Fast Track strategy to end the HIV epidemic by 2030. Central to these plans is a focus on high‐prevalence geographies, in a bid to target resources to those in greatest need and maximize the reduction in new infections. Whilst this idea of geographical prioritization has the potential to improve efficiency, it is unclear how it should be implemented in practice. There are a range of prevention interventions which can be applied differentially across risk groups and locations, making allocation decisions complex. Here, we use mathematical modelling to compare the impact (infections averted) of a number of different approaches to the implementation of geographical prioritization of prevention interventions, similar to those emerging in policy and practice, across a range of prevention budgets.MethodsWe use geographically specific mathematical models of the epidemic and response in 48 counties and major cities of Kenya to project the impact of the different geographical prioritization approaches. We compare the geographical allocation strategies with a nationally uniform approach under which the same interventions must be applied across all modelled locations.ResultsWe find that the most extreme geographical prioritization strategy, which focuses resources exclusively to high‐prevalence locations, may substantially restrict impact (41% fewer infections averted) compared to a nationally uniform approach, as opportunities for highly effective interventions for high‐risk populations in lower‐prevalence areas are missed. Other geographical allocation approaches, which intensify efforts in higher‐prevalence areas whilst maintaining a minimum package of cost‐effective interventions everywhere, consistently improve impact at all budget levels. Such strategies balance the need for greater investment in locations with the largest epidemics whilst ensuring higher‐risk groups in lower‐priority locations are provided with cost‐effective interventions.ConclusionsOur findings serve as a warning to not be too selective in the application of prevention strategies. Further research is needed to understand how decision‐makers can find the right balance between the choice of interventions, focus on high‐risk populations, and geographical targeting to ensure the greatest impact of HIV prevention.

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Section: The Order Of Roll Out Of Strategiesmentioning

confidence: 99%

“…Accelerated ART in all women 85% reduction in risk of transmission for a person on ART relative to others [18][19][20].…”

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confidence: 99%

HIV prevention where it is needed most: comparison of strategies for the geographical allocation of interventions

et al. 2017

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“…2 Expanded ART availability has altered dramatically the health and quality of life of people living with HIV/AIDS, with an estimated life expectancy gain of 11.3 years between 2003 and 2011 due to ART 3 and a 77% decrease in HIV transmission among serodiscordant couples. 4 However, the rapid scale-up of the national ART program has put tremendous pressure on the limited resources of a public health sector that is hurrying to meet immense need. The positive impact of life expectancy gains and improved health through expanded ART availability will only be realized if eligible individuals access care, remain in care and adhere to treatment.…”

Section: Introductionmentioning

confidence: 99%

Mobility and Clinic Switching Among Postpartum Women Considered Lost to HIV Care in South Africa

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Vermund

Maskew

et al. 2017

JAIDS Journal of Acquired Immune Deficiency Syndromes

105

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Objective Retention in HIV care, particularly among postpartum women, is a challenge to national antiretroviral therapy (ART) programs. Retention estimates may be underestimated due to unreported transfers. We explored mobility and clinic switching among patients considered lost to follow-up (LTFU). Design Observational cohort study. Methods Of 788 women initiating ART during pregnancy at six public clinics in Johannesburg, South Africa, 300 (38.1%) were LTFU (no visit ≥3 months). We manually searched for these women in the South African National Health Laboratory Services database to assess continuity of HIV care. We used geographic information systems tools to map mobility to new facilities. Results Over one–third (37.6%) of women showed evidence of continued HIV care after LTFU. Of these, 67.0% continued care in the same province as the origin clinic. Compared to those who traveled outside of the province for care, these same-province “clinic shoppers” stayed out-of-care longer [median 373 days (IQR: 175–790) vs. 175.5 days (IQR: 74–371)] and had a lower CD4+ cell count upon re-entry [median 327 cells/µL (IQR: 196–576) vs. 493 cells/µL (IQR: 213–557). When considering all women with additional evidence of care as engaged in care, cohort LTFU dropped from 38.1% to 25.0%. Conclusions We found evidence of continued care after LTFU and identified local and national clinic mobility among postpartum women. Laboratory records do not show all clinic visits and manual matching may have been under- or overestimated. A national health database linked to a unique identifier is necessary to improve reporting and patient care among highly mobile populations.

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“…The impact of ART on HIV transmission at the community-level has also been observed in South Africa’s generalized HIV epidemic during the early stages of scaling up ART (Tanser, Barnighausen, Grapsa, Zaidi, & Newell, 2013). However, early observations have not translated to community-level reductions in HIV infections (Oldenburg et al, 2016). The outcomes of one large community-level trial of administering early ART as prevention in South Africa demonstrated high-levels of uptake and viral suppression, but failed to show significant impacts on new HIV infections (Iwuji et al, 2016).…”

Section: Introductionmentioning

confidence: 99%

Diminishing Perceived Threat of AIDS and Increasing Sexual Risks of HIV Among Men Who Have Sex with Men, 1997–2015

et al. 2017

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Community-wide awareness that ART provides protection against HIV has the potential to increase perceived safety and thereby increase condomless anal sex among men who have sex with men (MSM). Furthermore, reductions in condom use can increase exposure to sexually transmitted infections, which in turn can reduce the protective effects of ART on HIV transmission. The current study extends previous community-based behavioral surveillance research on beliefs regarding use of ART for HIV prevention and sexual practices among MSM. Anonymous cross-sectional community surveys were collected from 1831 men at the same Gay pride event in Atlanta, GA four times over nearly two decades; 1997, 2005–2006 (the 2006 survey over-sampled African Americans to diversify the study), and 2015. Results indicate clear and consistent trends of increasing beliefs that HIV treatments reduce HIV transmission risks, reflecting the dissemination of HIV prevention research findings. Changes in treatment beliefs coincide with increased rates of condomless anal intercourse. Increased beliefs that treatments prevent HIV and increased condomless anal sex were observed for both HIV positive men and men who had not tested HIV positive. Results illustrate the emergence of an era where ART is the focus of HIV prevention and community-held beliefs and behaviors regarding definitions of risk create a new and potentially problematic environment for HIV transmission.

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Antiretroviral Therapy to Prevent HIV Acquisition in Serodiscordant Couples in a Hyperendemic Community in Rural South Africa

Cited by 31 publications

References 41 publications

HIV prevention where it is needed most: comparison of strategies for the geographical allocation of interventions

HIV prevention where it is needed most: comparison of strategies for the geographical allocation of interventions

Mobility and Clinic Switching Among Postpartum Women Considered Lost to HIV Care in South Africa

Diminishing Perceived Threat of AIDS and Increasing Sexual Risks of HIV Among Men Who Have Sex with Men, 1997–2015

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