ART Coverage Research Articles

Experiences and challenges of nurses in initiating antiretroviral drugs among adolescents living with HIV and AIDS in Thaba-Tseka, Lesotho

Background: Lesotho has the second-highest HIV and AIDS prevalence globally and is the country’s second leading cause of death. Despite increasing ART coverage, adolescents remain left behind and face high mortality because of delayed ART initiation. This study aimed to explore the experiences and challenges of nurses when initiating adolescents living with HIV on ART in Thaba-Tseka, Lesotho. Methods: A qualitative descriptive research design and twelve in-depth interviews were conducted among nurses from a hospital in the Thaba-Tseka district. Participants were selected purposively until data saturation was reached. Data were transcribed verbatim and analysed manually using the thematic analysis approach. The findings were presented in themes and sub-themes. Individual face-to-face interviews were conducted in English and Sesotho from May to August 2021. Results: The key findings in this study involved adolescents’ attendance at the health care facility, ART initiation process, HIV stigma influencing the uptake of ART, poor ART follow-up and socio-economic factors affecting adherence to ART. Conclusion: The themes uncovered in this study provide valuable insights into the gaps in ART initiation, and highlight the challenges encountered by nurses during this process among adolescents in Lesotho. The experiences and obstacles shared by nurses during ART initiation cover a range of issues, collectively demonstrating their engagement in HIV and ART care. These findings emphasise the critical role of policymakers and health care providers in devising customised ART initiation interventions for adolescents. Addressing these challenges will be crucial for enhancing ART uptake and adherence among adolescents living with HIV in Lesotho.

Impact of natural disasters on HIV risk behaviors, seroprevalence, and virological supression in a hyperendemic fishing village in Uganda.

Understanding the impact of natural disasters on the HIV epidemic in populations with high HIV burden is critical for the effective delivery of HIV control efforts. We assessed HIV risk behaviors, seroprevalence, and viral suppression in a high HIV prevalence Lake Victoria fishing community before and after COVID-19 emergence and lockdown and a severe lake flooding event, both of which occurred in 2020. We used data from the largest Lake Victoria fishing community in the Rakai Community Cohort Study, an open population-based HIV surveillance cohort in south-central Uganda. The data were collected both prior to (September-December 2018) and after (October-December 2021) COVID-19 emergence and a severe flooding event. Households impacted by flooding were identified via drone data and through consulting village community health workers. The entire study population was subject to extensive COVID-19-related lockdowns in the first half of 2020. Differences in HIV-related outcomes before and after COVID, and between residents of flooded and non-flooded households, were assessed using a difference-in-differences statistical modeling approach. A total of 1,226 people participated in the pre- and post-COVID surveys, of whom 506 (41%) were affected by flooding. HIV seroprevalence in the initial period was 37% in flooded and 36.8% in non-flooded households. After the COVID-19 pandemic and lockdown, we observed a decline in HIV-associated risk behaviors: transactional sex declined from 29.4% to 24.8% (p = 0.011), and inconsistent condom use with non-marital partners declined from 41.6% to 37% (p = 0.021). ART coverage increased from 91.6% to 97.2% (p<0.001). There was 17% decline in transactional sex (aPR = 0.83, 95% CI: 0.75-0.92) and 28% decline in the overall HIV risk score (aPR = 0.83, 95% CI: 0.75-0.92) among HIV-seronegative participants. We observed no statistically significant differences in changes of HIV risk behavior, seroprevalence, or viral suppression outcomes when comparing those affected by floods to those not affected by floods, in the periods before and after COVID-19, based on difference-in-differences analyses. Despite a high background burden of HIV, the COVID-19 pandemic, and severe flooding, we observed no adverse impact on HIV risk behaviors, seroprevalence, or virologic outcomes. This may be attributed to innovative HIV programming during the period and/or population resilience. Understanding exactly what HIV programs and personal or community-level strategies worked to maintain good public health outcomes despite extreme environmental and pandemic conditions may help improve HIV epidemic control during future natural disaster events.

Projected impact of fast-tracking of anti-retroviral treatment coverage on vertical transmission of HIV in India.

One of the five high-level goals under Phase V of the National AIDS and STD Control Programme (NACP) of the Government of India is the elimination of vertical transmission of HIV. In this paper, we estimate the potential impact of maintaining and enhancing the anti-retroviral treatment under the NACP in terms of averting new infections and vertical transmission rates vis-à-vis no intervention scenario. We used India's HIV Estimates 2022 models to create treatment coverage scenarios of no interventions, status quo, business as usual, on-track and fast-track scenarios from 2023 to 2030. Our analysis indicates that fast-tracking scale-up of treatment services would avert almost 41000 child infections from 2023 to 2030 leading to a vertical transmission rate of around 7.70% in 2030 vis-a-vis no interventions scenario. Higher and sustained ART coverage would not only take the country closer to the elimination goals but would also prevent thousands of vertical transmissions, thus bringing a lot of benefits to HIV-positive pregnant women and their families. Supported by efforts for the prevention of new infections in the general population, India is on track for the attainment of elimination of vertical transmission of HIV by 2030.

Trends in body mass index for people with and without HIV: Pooled analysis of nationally-representative health surveys from 10 countries and 173,800 adults in Africa.

It remains unclear if and how body mass index (BMI) levels have changed over time in HIV endemic regions. We described trends in mean BMI and prevalence of overweight between 2003-2019 in 10 countries in Africa including people living with (PLWH) and without (PLWoH) HIV. We pooled Demographic and Health Surveys (DHS) from countries where ≥2 surveys >4 years apart were available with height/weight measurements and HIV tests. HIV status was ascertained with a finger-prick dried blood spot (DBS) specimen tested in a laboratory. The DBS is taken as part of the regular DHS procedures. We summarized age and socioeconomic status standardized sex-specific mean BMI (kg/m2) and prevalence of overweight (BMI ≥25 kg/m2) by HIV status. We fitted country-level meta-regressions to ascertain if changes in ART coverage were correlated with changes in BMI. Before 2011, women LWH (22.9 [95% CI: 22.2-23.6]) and LWoH (22.6 [95% CI: 22.3-22.8]) had similar mean BMI. Over time, mean BMI increased more in women LWH (+0.8 [95% CI: 0.7-0.8] BMI units) than LWoH (+0.2 [95% CI: 0.2-0.3]). Before 2013, the mean BMI was similar between men LWH (21.1 (95% CI: 20.3-21.9)) and LWoH (20.8 (95% CI: 20.6-21.1)). Over time, mean BMI increased more in men LWoH (+0.3 [95% CI: 0.3-0.3]) than LWH (+0.1 [95% CI: 0.1-0.1]). The same profile was observed for prevalence of overweight. ART coverage was not strongly associated with BMI changes. Mean BMI and prevalence of overweight were similar in PLWH and PLWoH, yet in some cases the estimates for PWLH were on track to catch up with those for PLWoH. BMI monitoring programs are warranted in PLWH to address the rising BMI trends.

Guidance for triangulating data and estimates of HIV prevalence among pregnant women and coverage of PMTCT using the Spectrum AIDS Impact Module.

Most countries use the Spectrum AIDS Impact Module (Spectrum-AIM), antenatal care routine HIV testing, and antiretroviral treatment data to estimate HIV prevalence among pregnant women. Non-representative programme data may lead to inaccurate estimates HIV prevalence and treatment coverage for pregnant women. 154 countries and subnational locations across 126 countries. Using 2023 UNAIDS HIV estimates, we calculated three ratios: (1) HIV prevalence among pregnant women to all women 15-49y (prevalence), (2) ART coverage before pregnancy to women 15-49y ART coverage (ART pre-pregnancy), and (3) ART coverage at delivery to women 15-49y ART coverage (PMTCT coverage). We developed an algorithm to identify and adjust inconsistent results within regional ranges in Spectrum-AIM, illustrated using Burkina Faso's estimates. In 2022, the mean regional ratio of prevalence among pregnant women to all women ranged from 0.68 to 0.95. ART coverage pre-pregnancy ranged by region from 0.40 to 1.22 times ART coverage among all women. Mean regional PMTCT coverage ratios ranged from 0.85 to 1.51. The prevalence ratio in Burkina Faso was 1.59, above the typical range 0.62-1.04 in western and central Africa. Antenatal clinics reported more PMTCT recipients than estimated HIV-positive pregnant women from 2015 to 2019. We adjusted inputted PMTCT programme data to enable consistency of HIV prevalence among pregnant women from programmatic routine HIV testing at antenatal clinics with values typical for Western and central Africa. These ratios offer Spectrum-AIM users a tool to gauge the consistency of their HIV prevalence and treatment coverage estimates among pregnant women with other countries in the region.

Explaining inequity in knowledge, attitude, and services related to HIV/AIDS: a systematic review

BackgroundEquitable service provision and coverage are important responses to end the threat of the HIV/AIDS pandemic. Understanding inequity supports policies and programmes to deliver tailored interventions. There is continuous evidence generation on inequity in HIV/AIDS services. However, there was a lack of evidence on the global picture of inequity in behavioural and biomedical services related to HIV/AIDS. This systematic review assessed inequities in knowledge, attitude, HIV testing, and ART coverage across individual-level social groups and multiple (dis)advantage categories.MethodsThis review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline, with a PROSPERO registration number CRD42024521247. The risk of bias was assessed by using Hoy et al’s and Joanna Brigg’s quality appraisal checklists for cross-sectional quantitative and qualitative studies, respectively. The search date was from inception to the final database search date (May 29, 2023). The included articles were either quantitative or qualitative studies. We used mixed-methods approach to analyse the data from the review articles. Quantitative descriptive analysis was conducted to estimate frequency of articles published from different countries around the world. Qualitative content analysis of the findings from the original studies was conducted using the PROGRESS plus framework which stands for: place of residence, occupation or employment status, gender, religion, education status, socioeconomic status, and social capital.ResultsOut of 6,029 articles that were accessed and screened, only 72 articles met the inclusion criteria. More articles on HIV-related equity in knowledge, attitude, testing, and ART were published in developed countries than in developing countries. Individuals from higher-income households had better knowledge about HIV/AIDS. Unfavourable attitudes towards people living with HIV and HIV/AIDS-associated stigma were common among women. HIV/AIDS service coverage (HIV testing or ART coverage) was higher among richer and urban residents. HIV/AIDS-associated stigma and lower levels of knowledge about HIV/AIDS were observed among multiple disadvantageous groups due to the intersection of two or more identities.ConclusionsThe current review revealed that there have been disparities in HIV/AIDS services between social classes. Ending service disparity towards the global threat of HIV/AIDS demands tailored interventions based on socially disadvantaged groups (e.g., poor, rural dwellers, and women) and intersectional determinants. There is a need to understand the deep-rooted causes of inequity and the challenges that an equity-oriented system faces over time. More studies on inequity are needed, including intersectional inequity, which has been rarely studied in developing countries.

Lower Prevalence Countries Outside of South-Eastern Africa Now Have the Fastest Growing HIV Epidemic.

The United Nations Program on HIV/AIDS (UNAIDS) targets aim to reduce new HIV infections below 370 000 annually by 2025. However, there were 1.3 million new HIV infections worldwide in 2022. We collected and analyzed data for key variables of the HIV epidemic from UNAIDS and supplemented by PUBMED/EMBASE searches and national reports. A total of 53% of the HIV infections worldwide were in 14 high-prevalence countries in Southern/East Africa-where most of the funding for treatment and prevention is allocated-versus 47% in 54 low-prevalence countries. In 2022, there were more new HIV infections (770 000 vs 468 000), more HIV-related deaths (383 000 vs 225 000), higher rates of mother-to-child transmissions (16% vs 9%) and lower antiretroviral therapy coverage (67% vs 83%) in low-prevalence countries versus high-prevalence countries. To achieve UNAIDS annual new infections target for 2025, ART coverage needs to be optimized worldwide, and preexposure prophylaxis coverage expanded to 74 million people, versus 2.5 million currently treated.

Guidance for triangulating data and estimates of HIV prevalence among pregnant women and coverage of PMTCT using the Spectrum AIDS Impact Module.

Most countries use the Spectrum AIDS Impact Module (Spectrum-AIM), antenatal care routine HIV testing, and antiretroviral treatment data to estimate HIV prevalence among pregnant women. Non-representative programme data may lead to inaccurate estimates HIV prevalence and treatment coverage for pregnant women. 154 locations in 126 countries. Using 2023 UNAIDS HIV estimates, we calculated three ratios: (1) HIV prevalence among pregnant women to all women 15-49y (prevalence), (2) ART coverage before pregnancy to women 15-49y ART coverage (ART pre-pregnancy), and (3) ART coverage at delivery to women 15-49y ART coverage (PMTCT coverage). We developed an algorithm to identify and adjust inconsistent results within regional ranges in Spectrum-AIM, illustrated using Burkina Faso's estimates. In 2022, the mean regional ratio of prevalence among pregnant women to all women ranged from 0.68 to 0.95. ART coverage pre-pregnancy ranged by region from 0.40 to 1.22 times ART coverage among all women. Mean regional PMTCT coverage ratios ranged from 0.85 to 1.51. The prevalence ratio in Burkina Faso was 1.59, above the typical range 0.62-1.04 in western and central Africa. Antenatal clinics reported more PMTCT recipients than estimated HIV-positive pregnant women from 2015 to 2019. We adjusted inputted PMTCT programme data to enable consistency of HIV prevalence among pregnant women from programmatic routine HIV testing at antenatal clinics with values typical for Western and central Africa. These ratios offer Spectrum-AIM users a tool to gauge the consistency of their HIV prevalence and treatment coverage estimates among pregnant women with other countries in the region.

ART coverage and viral suppression among female sex workers living with HIV in eThekwini, South Africa: Baseline findings from the Siyaphambili study.

In South Africa >60% of female sex workers (FSW) are living with HIV, the majority of whom are not virally suppressed. Identifying multi-level determinants of viral suppression is central to developing implementation strategies to promote retention in HIV care and viral suppression among FSW with unmet treatment needs. Adult cisgender FSW living with HIV for ≥6 months, conducting sex work as their primary source of income, and residing in Durban (South Africa) were enrolled into the Siyaphambili Study, a sequential multiple assignment randomized trial. Baseline viral load and CD4 were assessed, and an interviewer-administered survey was conducted, capturing socio-demographic, reproductive and sexual history and behaviors, vulnerabilities, substance use, mental health, and stigma. We assessed baseline determinants of viral suppression (<50 copies/mL) using bivariate and multivariable robust poisson regression, considering associations across the individual, network, environmental and macrostructural levels. From June 2018 -March 2020, 1,644 women were screened, with 1,391 eligible FSW living with HIV enrolled. The analyses were conducted among the 1,373 participants with baseline data. Overall, 65% (889/1,373) of participants were reported to be on antiretroviral therapy and 38% (520/1,373) were virally suppressed. In the multivariable model, FSW who experienced a lack of housing in the prior six months were less likely to be virally suppressed (aPR: 0.72, 95%CI 0.56-0.91), while older FSW (aPR: 1.46 95%CI: 1.16-1.83 for 30-39 years old vs. 18-29 years old; aPR: 2.15 95%CI: 1.64-2.80 for 40+ years vs. 18-29 years old) and FSW reporting hormonal or long-acting contraception use were more likely to be virally suppressed (aPR: 1.19 95% CI: 1.00-1.43). We found vulnerability to be high among FSW living with HIV in South Africa and identified individual and structural determinants associated with viral suppression. Taken together these results suggest optimizing HIV treatment outcomes necessitates supporting younger sex workers and addressing housing instability. Trial registration: NCT03500172.

Trends of the HIV Epidemic in North Eastern Uganda

The purpose of this study was to investigate the trends of the HIV pandemic in North Eastern Uganda to assess the current status and guide future programs aimed at ending HIV as a public health threat in this region by 2030. The study established that awareness about HIV was at 75% among the adolescents in the region and that only 63% of the population in the region had tested for HIV. These levels are below the desired target of 95%. Overall HIV prevalence was found to be 3.7%, which is below the national average of 5.8%. ART coverage was 53.6% among men and 69.9% among women living with HIV in the region; this too is below the desired target of 95%. Viral Load Suppression was found to be at an average of 78%, which is significantly lower than the target of at least 95%. 36% of the people living with HIV felt significant levels of stigma and discrimination, thus reducing their quality of life. Overall, the study found that most of the key HIV indicators had stagnated in the region, with some heading away from, rather than towards the targets for HIV epidemic control. Recommendations for improvement include reviving HIV prevention and awareness programming for young people, as well as addressing the multiple obstacles hampering HIV control efforts in the region.

A quantitative assessment of the consistency of projections from five mathematical models of the HIV epidemic in South Africa: a model comparison study

BackgroundMathematical models are increasingly used to inform HIV policy and planning. Comparing estimates obtained using different mathematical models can test the robustness of estimates and highlight research gaps. As part of a larger project aiming to determine the optimal allocation of funding for HIV services, in this study we compare projections from five mathematical models of the HIV epidemic in South Africa: EMOD-HIV, Goals, HIV-Synthesis, Optima, and Thembisa.MethodsThe five modelling groups produced estimates of the total population, HIV incidence, HIV prevalence, proportion of people living with HIV who are diagnosed, ART coverage, proportion of those on ART who are virally suppressed, AIDS-related deaths, total deaths, and the proportion of adult males who are circumcised. Estimates were made under a “status quo” scenario for the period 1990 to 2040. For each output variable we assessed the consistency of model estimates by calculating the coefficient of variation and examining the trend over time.ResultsFor most outputs there was significant inter-model variability between 1990 and 2005, when limited data was available for calibration, good consistency from 2005 to 2025, and increasing variability towards the end of the projection period. Estimates of HIV incidence, deaths in people living with HIV, and total deaths displayed the largest long-term variability, with standard deviations between 35 and 65% of the cross-model means. Despite this variability, all models predicted a gradual decline in HIV incidence in the long-term. Projections related to the UNAIDS 95–95-95 targets were more consistent, with the coefficients of variation below 0.1 for all groups except children.ConclusionsWhile models produced consistent estimates for several outputs, there are areas of variability that should be investigated. This is important if projections are to be used in subsequent cost-effectiveness studies.

Temporal trend analysis of the HIV/AIDS burden before and after the implementation of antiretroviral therapy at the population level from 1990 to 2020 in Ghana

BackgroundAntiretroviral therapy (ART) has helped reduce the burden of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) in the majority of countries. Its contribution to the HIV/AIDS burden in Ghana is still understudied. This study examined HIV/AIDS trends in Ghana before (1990–2004) and after (2004–2020) the implementation and expansion of ART.MethodsWe obtained HIV/AIDS epidemiology and treatment data for the years 1990–2020 from the United Nations Programme on HIV/AIDS. We investigated the impact of the ART rollout on HIV/AIDS in Ghana using Joinpoint regression models.ResultsThe HIV incidence, prevalence, and AIDS-related deaths decreased significantly after 2004, as ART coverage increased from 1% to 2004 to 60% in 2020. The HIV incidence decreased by approximately 3% (AAPC = -2.6%; 95% CI: -3.2, -1.9) per year from 1990 to 2004 and approximately 5% (AAPC = -4.5%; 95% CI: -4.9, -4.2) per year from 2004 to 2020. Between 1990 and 2004, the HIV prevalence increased by approximately 5% (AAPC = 4.7%; 95% CI: 3.6, 5.8) per year but decreased by 2% (AAPC = -1.9%; 95% CI: -2.1, -1.6) per year between 2004 and 2020. Between 1990 and 2004, the annual increase in AIDS-related mortality was 14% (AAPC = 13.8%; 95% CI: 12.6, 15.0), but between 2004 and 2020, it decreased at nearly a 4% (AAPC= -3.6%; 95% CI: -4.7, -2.5) annual rate.ConclusionsWe found trends indicating progress in Ghana’s fight against HIV/AIDS. However, the most significant declines occurred after the introduction of ART, suggesting that the scale-up of ART may have contributed to the decline in HIV/AIDS in Ghana. We advocate for the rapid expansion of ART in Ghana.

Achieving the “Ending the HIV Epidemic in the U.S.” incidence reduction goals among at-risk populations in the South

IntroductionAntiretroviral medication coverage remains sub-optimal in much of the United States, particularly the Sothern region, and Non-Hispanic Black or African American persons (NHB) continue to be disproportionately impacted by the HIV epidemic. The “Ending the HIV Epidemic in the U.S.” (EHE) initiative seeks to reduce HIV incidence nationally by focusing resources towards the most highly impacted localities and populations. This study evaluates the impact of hypothetical improvements in ART and PrEP coverage to estimate the levels of coverage needed to achieve EHE goals in the South.MethodsWe developed a stochastic, agent-based network model of 500,000 individuals to simulate the HIV epidemic and hypothetical improvements in ART and PrEP coverage.ResultsNew infections declined by 78.6% at 90%/40% ART/PrEP and 94.3% at 100%/50% ART/PrEP. Declines in annual incidence rates surpassed 75% by 2025 with 90%/40% ART/PrEP and 90% by 2030 with 100%/50% ART/PrEP coverage. Increased ART coverage among NHB MSM was associated with a linear decline in incidence among all MSM. Declines in incidence among Hispanic/Latino and White/Other MSM were similar regardless of which MSM race group increased their ART coverage, while the benefit to NHB MSM was greatest when their own ART coverage increased. The incidence rate among NHB women declined by over a third when either NHB heterosexual men or NHB MSM increased their ART use respectively. Increased use of PrEP was associated with a decline in incidence for the groups using PrEP. MSM experienced the largest absolute declines in incidence with increasing PrEP coverage, followed by NHB women.ConclusionsOur analysis indicates that it is possible to reach EHE goals. The largest reductions in HIV incidence can be achieved by increasing ART coverage among MSM and all race groups benefit regardless of differences in ART initiation by race. Improving ART coverage to > 90% should be prioritized with a particular emphasis on reaching NHB MSM. Such a focus will reduce the largest number of incident cases, reduce racial HIV incidence disparities among both MSM and women, and reduce racial health disparities among persons with HIV. NHB women should also be prioritized for PrEP outreach.

Improving Health Staff Performance Using Standardized Performance Management Systems in Bunyangabu District Health Facilities in Western Uganda

Introduction: The performance management concept is not new but has undergone a relatively slow development in the Ugandan health sector and lacks documented proof of practice. Performance management is a continuous process of identifying, measuring and developing the performance of individuals and aligning performance with the strategic goals of the organization. Aim of the study: The study aimed to improve the performance of health workers through established performance management practices in health facilities of Bunyangabu district in order to inform and benchmark interventions. Methodology: A before and after study design was employed to conduct this study. Both qualitative and quantitative research methods were used to collect data from selected health facilities in Bunyangabu district, interventions which included, training, support supervision and mentor-ship were used. Pre and post intervention data was collected and analyzed using excel, stata, and epi info computer software . Findings: The baseline analysis showed that up to 25% of the health managers were not aware of the recommended performance management practices, 45% able to set performance targets, 20% had job descriptions, 30%had conducted appraisals and only 15% knew about the rewards and sanctions. 85% could not state the vision or mission of the organizations.The interventions applied during the study including training in performance management improved the level of awareness among participants from 75% to 95% in six months, knowledge on target setting from 15-80%, knowledge on Job description from 20-62%, knowledge in performance appraisal from 30-70%, and knowledge in rewards and sanctions from 15 – 70%. The raise in knowledge was associated with an improvement in key health service delivery indicators; staff attendance 62-88%, eMTCT retention on ART 79-88%, PNC at 6weeks 26-53%, HTS linkage 89-97%, and ART coverage 92.5 – 99.7%.The study of associations indicated that the performance management was associated with health facility performance as follows performance planning (r=.757; P = 0.001), performance monitoring (r=.692) ; P=0.001), and functional rewards and sanctions committees (r=.66843); P=0.000). Conclusion: The study concludes that there is a knowledge gap among health facility managers about performance management.The study also concludes that inclusion of performance management in routine support supervision is associated with improved quality of health services and Continuous monitoring and mentor-ships influence performance among health workers. Keywords: health staff, individual performance management, standardized staff performance management systems, accredited facilities, performance planning, performance monitoring, performance appraisal, rewards and sanctions DOI: 10.7176/PPAR/13-3-04 Publication date: April 30 th 2023

HIV, sexual violence, and termination of pregnancy among adolescent and adult female sex workers in Malawi: A respondent-driven sampling study.

Female Sex Workers (FSWs) are a hard-to-reach and understudied population, especially those who begin selling sex at a young age. In one of the most economically disadvantaged regions in Malawi, a large population of women is engaged in sex work surrounding predominantly male work sites and transport routes. A cross-sectional study in February and April 2019 in Nsanje district used respondent driven sampling (RDS) to recruit women ≥13 years who had sexual intercourse (with someone other than their main partner) in exchange for money or goods in the last 30 days. A standardized questionnaire was filled in; HIV, syphilis, gonorrhea, and chlamydia tests were performed. CD4 count and viral load (VL) testing occurred for persons living with HIV (PLHIV). Among 363 study participants, one-quarter were adolescents 13-19 years (25.9%; n = 85). HIV prevalence was 52.6% [47.3-57.6] and increased with age: from 14.7% (13-19 years) to 87.9% (≥35 years). HIV status awareness was 95.2% [91.3-97.4], ART coverage was 98.8% [95.3-99.7], and VL suppression 83.2% [77.1-88.0], though adolescent FSWs were less likely to be virally suppressed than adults (62.8% vs. 84.4%). Overall syphilis prevalence was 29.7% [25.3-43.5], gonorrhea 9.5% [6.9-12.9], and chlamydia 12.5% [9.3-16.6]. 72.4% had at least one unwanted pregnancy, 17.9% had at least one abortion (40.1% of which were unsafe). Half of participants reported experiencing sexual violence (SV) (47.6% [42.5-52.7]) and more than one-tenth (14.2%) of all respondents experienced SV perpetrated by a police officer. Our findings show high levels of PLHIV-FSWs engaged in all stages of the HIV cascade of care. The prevalence of HIV, other STIs, unwanted pregnancy, unsafe abortion, and sexual violence remains extremely high. Peer-led approaches contributed to levels of ART coverage and HIV status awareness similar to those found in the general district population, despite the challenges and risks faced by FSWs.

Impact of COVID-19 on the Belgian HIV epidemic: slowdown of HIV transmission and testing and adaptation of care

BackgroundTo gain insight into the impact of the COVID-19 pandemic and containment measures on the HIV epidemic and services, this study aims to describe HIV trends in 2020 and compare them with previous years.MethodsBelgian national HIV surveillance data 2017–2020 were analysed for trends in HIV testing, HIV diagnoses, VL measurements, ART uptake and PrEP purchase. Descriptive statistics from 2020 are compared to annual averages from 2017 to 2019 (proportional difference, %).ResultsIn 2020, 725 HIV infections were diagnosed in Belgium (− 21.5% compared to 2019). The decline was most pronounced during the first lockdown in April–May but also present in July–December. The number of HIV tests performed decreased by 17.6% in 2020, particularly in March–May and October–December (− 57.5% in April and -25.4% in November 2020 compared to monthly 2017–19 numbers). Diagnosis of acute HIV infections decreased by 47.1% in 2020 (n = 27) compared to 2019 (n = 51). Late HIV diagnoses decreased by 24.7% (95% CI [− 40.7%; -9.7%]) in 2020 compared to 2019. Of patients in care in 2019, 11.8% interrupted HIV care in 2020 compared to 9.1% yearly in the 3 previous years. The number of HIV patients with VL monitoring per month dropped in March–May 2020, whilst proportions of VL suppression and ART coverage remained above 86% and 98.5% respectively in 2020. PrEP purchases, number of purchasers and starters dropped during April–May 2020 (respectively − 45.7%, − 47.4%, − 77.9% in April compared to February 2020).ConclusionsThe significant decrease in HIV diagnoses in Belgium in 2020 coincided with the COVID-19 pandemic and following containment measures, particularly in April–May during the first lockdown. A slowdown of HIV transmission due to reduced HIV risk exposure is suggested by the halving in diagnosis of acute HIV infections in March-December 2020 compared to the previous year, and the adaptive decrease in PrEP use and PrEP initiation from April onwards. Despite a slight increase in HIV care interruptions, the indicators of quality of HIV care remained stable. Access to prevention, testing and care for all people living with HIV and at risk of acquiring HIV is a priority during and after times of pandemic.

Pre-treatment HIV-1 drug resistance in antiretroviral therapy-naive adults in Eastern Africa: a systematic review and meta-analysis.

Pre-treatment HIV drug resistance (PDR) may result in increased risk of virological failure and acquisition of new resistance mutations. With recently increasing ART coverage and periodic modifications of the guidelines for HIV treatment, there is a need for an updated systematic review to assess the levels of the PDR among adults newly initiating ART in Eastern Africa. We conducted a systematic search for studies published between 1 January 2017 and 30 April 2022 in the MEDLINE Complete and CINAHL Complete, searched simultaneously using EBSCOhost, and Web of Science. To determine the overall PDR prevalence estimates, we extracted data from eligible articles and analysed prevalence estimates using Stata 14.2. A total of 22 eligible observation studies were selected. The studies included a total of 5852 ART-naive people living with HIV. The overall pooled prevalence of PDR was 10.0% (95% CI: 7.9%-12.0%, I2 = 88.9%) and 9.4% (95% CI: 7.0%-11.9%, I2 = 90.4%) for NNRTIs, 2.6% (95% CI: 1.8%-3.4%, I2 = 69.2%) for NRTIs and 0.7% (95% CI: 0.3%-1.2%, I2 = 29.0%) for PIs. No major integrase strand transfer inhibitors (INSTI)-related mutations were identified. We observed a moderate overall PDR prevalence among new ART initiators in this study. PDR to NNRTIs is more prevalent, underscoring the importance of the current WHO recommendation for replacement of NNRTIs by INSTIs. PDR to NRTIs was low but notable, which warrants continuous surveillance of pre-existing resistance to the dolutegravir co-administered NRTI in Eastern Africa.

The Role of HIV Partner Services in the Modern Biomedical HIV Prevention Era: A Network Modeling Study.

HIV partner services can accelerate the use of antiretroviral-based HIV prevention tools (antiretroviral therapy [ART] and preexposure prophylaxis [PrEP]), but its population impact on long-term HIV incidence reduction is challenging to quantify with traditional partner services metrics of partner identified or HIV screened. Understanding the role of partner services within the portfolio of HIV prevention interventions, including using it to efficiently deliver antiretrovirals, is needed to achieve HIV prevention targets. We used a stochastic network model of HIV/sexually transmitted infection transmission for men who have sex with men, calibrated to surveillance-based estimates in the Atlanta area, a jurisdiction with high HIV burden and suboptimal partner services uptake. Model scenarios varied successful delivery of partner services cascade steps (newly diagnosed "index" patient and partner identification, partner HIV screening, and linkage or reengagement of partners in PrEP or ART care) individually and jointly. At current levels observed in Atlanta, removal of HIV partner services had minimal impact on 10-year cumulative HIV incidence, as did improving a single partner services step while holding the others constant. These changes did not sufficiently impact overall PrEP or ART coverage to reduce HIV transmission. If all index patients and partners were identified, maximizing partner HIV screening, partner PrEP provision, partner ART linkage, and partner ART reengagement would avert 6%, 11%, 5%, and 18% of infections, respectively. Realistic improvements in partner identification and service delivery were estimated to avert 2% to 8% of infections, depending on the combination of improvements. Achieving optimal HIV prevention with partner services depends on pairing improvements in index patient and partner identification with maximal delivery of HIV screening, ART, and PrEP to partners if indicated. Improving the identification steps without improvement to antiretroviral service delivery steps, or vice versa, is projected to result in negligible population HIV prevention benefit.

Status of the HIV epidemic in Manicaland, east Zimbabwe prior to the outbreak of the COVID-19 pandemic.

BackgroundManicaland province in eastern Zimbabwe has a high incidence of HIV. Completion of the seventh round of the Manicaland Survey in 2018–2019 provided the opportunity to assess the state of the epidemic prior to the start of the COVID-19 pandemic. The study aims were to: a) estimate HIV seroprevalence and assess whether prevalence has declined since the last round of the survey (2012–2013), b) describe and analyse the socio-demographic and behavioural risk factors for HIV infection and c) describe the HIV treatment cascade.MethodsParticipants were administered individual questionnaires collecting data on socio-demographic characteristics, sexual relationships, HIV prevention methods and treatment access, and were tested for HIV. Descriptive analyses were followed by univariate and multivariate analyses of risk factors for HIV seropositvity using logistic regression modelling based on the proximate-determinants framework.ResultsHIV prevalence was 11.3% [95% CI; 10.6–12.0] and was higher in females than males up to 45–49 years. Since 2012–2013 HIV prevalence has significantly declined in 30–44 year-olds in males, and 20–44 year-olds in females. The HIV epidemic has aged since 2012–2013, with an increase in the mean age of HIV positive persons from 38 to 41 years. Socio-demographic determinants of HIV prevalence were church denomination in males, site-type, wealth-status, employment sector and alcohol use in females, and age and marital status in both sexes. Behavioural determinants associated with increased odds of HIV were a higher number of regular sexual partners (lifetime), non-regular sexual partners (lifetime) and condom use in both sexes, and early sexual debut and concomitant STIs in females; medical circumcision was protective in males. HIV status awareness among participants testing positive in our study was low at 66.2%. ART coverage amongst all participants testing positive for HIV in our study was 65.0% and was lower in urban areas than rural areas, particularly in males.ConclusionsPrevalence has declined, and ART coverage increased, since 2012–2013. Majority of the associations with prevalence hypothesised by the theoretical framework were not observed in our data, likely due to underreporting of sexual risk behaviours or the treatment-as-prevention effect of ART curtailing the probability of transmission despite high levels of sexual risk behaviour. Further reductions in HIV incidence require strengthened primary prevention, HIV testing and linkage to risk behaviour counselling services. Our results serve as a valuable baseline against which to measure the impact of the COVID-19 pandemic on HIV prevalence and its determinants in Manicaland, Zimbabwe, and target interventions appropriately.

Undiagnosed HIV Infections May Drive HIV Transmission in the Era of "Treat All": A Deep-Sampling Molecular Network Study in Northeast China during 2016 to 2019.

Universal antiretroviral therapy (ART, “treat all”) was recommended by the World Health Organization in 2015; however, HIV-1 transmission is still ongoing. This study characterizes the drivers of HIV transmission in the “treat all” era. Demographic and clinical information and HIV pol gene were collected from all newly diagnosed cases in Shenyang, the largest city in Northeast China, during 2016 to 2019. Molecular networks were constructed based on genetic distance and logistic regression analysis was used to assess potential transmission source characteristics. The cumulative ART coverage in Shenyang increased significantly from 77.0% (485/630) in 2016 to 93.0% (2598/2794) in 2019 (p < 0.001). Molecular networks showed that recent HIV infections linked to untreated individuals decreased from 61.6% in 2017 to 28.9% in 2019, while linking to individuals with viral suppression (VS) increased from 9.0% to 49.0% during the same time frame (p < 0.001). Undiagnosed people living with HIV (PLWH) hidden behind the links between index cases and individuals with VS were likely to be male, younger than 25 years of age, with Manchu nationality (p < 0.05). HIV transmission has declined significantly in the era of “treat all”. Undiagnosed PLWH may drive HIV transmission and should be the target for early detection and intervention.