Population-based HIV Survey Research Articles

DYnamics of Contraception in Eswatini (DYCE): protocol for a high-frequency, longitudinal cell phone survey

IntroductionBy 2030, an estimated 42% of the world’s adolescent girls and young women (AGYW) will live in sub-Saharan Africa (SSA), where a quarter of AGYW pregnancies are undesired and AGYW...

Individual and household factors associated with non-disclosure of positive HIV status in a population-based HIV serosurvey.

Non-disclosure of positive HIV status in population-based surveys causes underestimation of national HIV diagnosis and biases inferences about engagement in the care continuum. This study investigated individual and household factors associated with HIV non-disclosure to survey interviewers in Nigeria. Secondary analysis of a cross sectional population-based household HIV survey. We analyzed data from adults aged 15-64 years who tested positive for HIV and had antiretroviral drugs (ARVs) in their blood from a nationally representative HIV sero-survey conducted in Nigeria in 2018. We considered ARV use as a proxy for knowledge of HIV diagnosis; thus, respondents who self-reported to be unaware of their HIV status were classified as non-disclosers. We estimated the associations between non-disclosure and various sociodemographic, clinical, and household characteristics using weighted logistic regression. Among 1266 respondents living with HIV who were taking ARVs, 503 (40%) did not disclose their HIV status to interviewers. In multivariable statistical analyses, the adjusted odds of non-disclosure were highest among respondents aged 15-24 years, those with less than a primary school education, and those who were the only person living with HIV in their household. Non-disclosure of positive HIV status to survey personnel is common among adults who are receiving treatment in Nigeria. These findings highlight the importance of validating self-reported HIV status in surveys using biomarkers of ARV use. Meanwhile, it is crucial to improve disclosure by strengthening interview procedures and tailoring strategies towards groups that are disproportionately likely to underreport HIV diagnoses.

Correcting for selection bias in HIV prevalence estimates: an application of sample selection models using data from population-based HIV surveys in seven sub-Saharan African countries.

IntroductionPopulation‐based biomarker surveys are the gold standard for estimating HIV prevalence but are susceptible to substantial non‐participation (up to 30%). Analytical missing data methods, including inverse‐probability weighting (IPW) and multiple imputation (MI), are biased when data are missing‐not‐at‐random, for example when people living with HIV more frequently decline participation. Heckman‐type selection models can, under certain assumptions, recover unbiased prevalence estimates in such scenarios.MethodsWe pooled data from 142,706 participants aged 15–49 years from nationally representative cross‐sectional Population‐based HIV Impact Assessments in seven countries in sub‐Saharan Africa, conducted between 2015 and 2018 in Tanzania, Uganda, Malawi, Zambia, Zimbabwe, Lesotho and Eswatini. We compared sex‐stratified HIV prevalence estimates from unadjusted, IPW, MI and selection models, controlling for household and individual‐level predictors of non‐participation, and assessed the sensitivity of selection models to the copula function specifying the correlation between study participation and HIV status.ResultsIn total, 84.1% of participants provided a blood sample to determine HIV serostatus (range: 76% in Malawi to 95% in Uganda). HIV prevalence estimates from selection models diverged from IPW and MI models by up to 5% in Lesotho, without substantial precision loss. In Tanzania, the IPW model yielded lower HIV prevalence estimates among males than the best‐fitting copula selection model (3.8% vs. 7.9%).ConclusionsWe demonstrate how HIV prevalence estimates from selection models can differ from those obtained under missing‐at‐random assumptions. Further benefits include exploration of plausible relationships between participation and outcome. While selection models require additional assumptions and careful specification, they are an important tool for triangulating prevalence estimates in surveys with substantial missing data due to non‐participation.

A Comparison of Bayesian Spatial Models for HIV Mapping in South Africa.

Despite making significant progress in tackling its HIV epidemic, South Africa, with 7.7 million people living with HIV, still has the biggest HIV epidemic in the world. The Government, in collaboration with developmental partners and agencies, has been strengthening its responses to the HIV epidemic to better target the delivery of HIV care, treatment strategies and prevention services. Population-based household HIV surveys have, over time, contributed to the country’s efforts in monitoring and understanding the magnitude and heterogeneity of the HIV epidemic. Local-level monitoring of progress made against HIV and AIDS is increasingly needed for decision making. Previous studies have provided evidence of substantial subnational variation in the HIV epidemic. Using HIV prevalence data from the 2016 South African Demographic and Health Survey, we compare three spatial smoothing models, namely, the intrinsically conditionally autoregressive normal, Laplace and skew-t (ICAR-normal, ICAR-Laplace and ICAR-skew-t) in the estimation of the HIV prevalence across 52 districts in South Africa. The parameters of the resulting models are estimated using Bayesian approaches. The skewness parameter for the ICAR-skew-t model was not statistically significant, suggesting the absence of skewness in the HIV prevalence data. Based on the deviance information criterion (DIC) model selection, the ICAR-normal and ICAR-Laplace had DIC values of 291.3 and 315, respectively, which were lower than that of the ICAR-skewed t (348.1). However, based on the model adequacy criterion using the conditional predictive ordinates (CPO), the ICAR-skew-t distribution had the lowest CPO value. Thus, the ICAR-skew-t was the best spatial smoothing model for the estimation of HIV prevalence in our study.

Is Interview Length Associated With Blood Test Participation? Evidence From Three Population-Based HIV Impact Assessment Surveys Conducted From 2016 to 2017.

High response rates in surveys are critical to ensuring that findings are unbiased and representative of the target population. Questionnaire length affects response rates, with long interviews associated with partially complete surveys, higher item nonresponse ("don't know" and "refuse" responses), and willingness to participate in future surveys. Our aim is to determine the impact of questionnaire length on blood test participation in population-based HIV surveys. Data are from population-based HIV impact assessments conducted in Zambia, Eswatini, and Lesotho in 2016-2017. The population-based HIV impact assessments consist of an interview followed by a blood draw. Consent for blood draw was obtained before the interview in Eswatini and after the interview in Zambia and Lesotho. Interview length was measured by the survey tablet as the time to complete the survey (interview duration) and the number of questions answered by the participant (questionnaire length). We assessed the effects of questionnaire length and interview duration on blood test participation using logistic regression. Across all 3 surveys, the median interview duration was 16 minutes and the median number of questions was 77. In adjusted analyses, there was a negative impact of interview duration on blood draw consent for individuals with unknown status in Lesotho and a positive relationship between questionnaire length and blood draw consent in Zambia for those with HIV-negative and unknown status. Although interview length is an important consideration to reduce respondent burden, a longer questionnaire does not necessarily result in lower consent rates for blood testing.

The Burden of HIV, Hepatitis B and Hepatitis C by Armed Conflict Setting: The Nigeria AIDS Indicator and Impact Survey, 2018.

Background:Against a background of security challenges, Nigeria conducted recently the largest population-based HIV survey in the world to ascertain the burden of the HIV disease in the country.Objective:We evaluated the main outcomes of the survey and the level of success using participation/response indicators.Methods:The survey was conducted from July–December 2018 by over 6,000 field staff across Nigeria in six consecutive webs, using two-stage cluster sampling. We estimated the prevalence of HIV, hepatitis B and hepatitis C in the entire country and by conflict zone status. Adjusted odds ratios (OR) and 95% confidence intervals (CI) from survey logistic regression models were used to compare the likelihood of test positivity for the three infections between zones.Findings:A total of 186,405 adults were interviewed from 97,250 households in 3,848 census enumeration areas. The overall HIV, hepatitis B and hepatitis C positivity rates were 1.55%, 7.63% and 1.73%, respectively. The prevalence of HIV, hepatitis B and C infection was significantly greater in conflict than non-conflict zones (HIV: 1.75% versus 1.0%; hepatitis B: 9.9% versus 7.3%; and hepatitis C: 3.2% versus 0.3%; p < 0.01 in all cases). Individuals living in conflict zones were about three times as likely to test positive for HIV (OR = 2.80, 95% CI = 2.08, 3.60) and nearly six times as likely to test positive for hepatitis C (OR = 5.90, 95% CI = 2.17, 16.67).Conclusion:Large population-based surveys are feasible, even in armed conflict settings. The burden of HIV, hepatitis B and hepatitis C was significantly higher in areas of conflict in Nigeria, highlighting the need for reinforced public health control measures in these settings in order to attain UNAIDS’ 95-95-95 targets of controlling the HIV epidemic in sub-Saharan Africa by 2030.

Prevalence of self-reported HIV testing and associated factors among adolescent girls and young women in South Africa: Results from a 2017 nationally representative population-based HIV survey

ObjectivesThis article estimated the prevalence of self-reported HIV testing and identified associated factors among sexually active adolescent girls and young women (AGYW), aged 15–24 years, in South Africa. Study designThis is a secondary data analysis of a nationally representative population-based cross-sectional multi-stage cluster survey of households in South Africa conducted in 2017. MethodsDescriptive statistics were used to describe AGYW characteristics and the multivariable logistic regression model was used to determine factors associated with HIV testing. All analyses were adjusted for unequal sampling probabilities using survey weights. ResultsFrom the 1360 AGYW analysed (70.3% aged 20–24 years, 89.0% Black African, 95.5% unmarried, 88.7% unemployed), 1154 (estimate 85.8% (95% Confidence Interval (CI): 83.0 to 88.1)) had ever tested for HIV. In adjusted analysis, AGYW who had been pregnant in the past 24 months (adjusted Odds Ratio [aOR] 3.67, 95%CI: 1.68 to 8.02), were older (20–24 years: aOR 3.13, 95%CI: 1.86 to 5.28), or did not use condoms consistently compared to using them every time (almost every time: aOR 3.31, 95%CI: 1.07 to 10.22; sometimes: aOR 2.54, 95%CI: 1.29 to 4.98) had significantly higher odds of ever testing for HIV. ConclusionsThis research identified an unmet need for HIV testing among AGYW and increasing awareness of HIV counselling and testing among AGYW in South Africa is recommended.

Cohort Profile Update: Africa Centre Demographic Information System (ACDIS) and population-based HIV survey.

Cohort Profile Update: Africa Centre Demographic Information System (ACDIS) and population-based HIV survey.

The Burden of HIV, Hepatitis B and Hepatitis C by Armed Conflict Setting the Nigeria Aids Indicator and Impact Survey, 2018

Background: Against a background of security challenges, Nigeria conducted recently the largest population-based HIV survey in the world to ascertain the burden of the HIV disease in the country. We evaluated the main outcomes of the survey and the level of success using participation/response indicators. Methods: The survey was conducted from July 2018 to December 2018 by over 6,000 field staff across Nigeria in six consecutive webs, using two-stage cluster sampling. This analysis was restricted to adults (15-64 years old) from randomly selected households. We estimated the prevalence of HIV, hepatitis B and hepatitis C in the entire country and by conflict zone status. Adjusted odds ratios (OR) and 95% confidence intervals (CI) from survey logistic regression models were used to compare the likelihood of test positivity for the three infections between zones. Findings: A total of 186,405 adults were interviewed from 97,250 households in 3,848 census enumeration areas. Although household response rate was lower in conflict compared to non-conflict areas (68·76% versus 89·83%; p < 0·01), rates of interview response (92·43% versus 91·61%) and blood draw acceptance (94·71% versus 92·91%) were higher in conflict zones. The overall HIV, hepatitis B and hepatitis C positivity rates were 1·55%, 7·63% and 1·73%, respectively. The prevalence of HIV, hepatitis B and C infection was significantly greater in conflict than non-conflict zones (HIV: 1·75% versus 1·0%; hepatitis B: 9·9% versus 7·3%; and hepatitis C: 3·2% versus 0·3%; p < 0·01 in all cases). Individuals living in conflict zones were about three times as likely to test positive for HIV (OR = 2·80, 95% CI = 2·08,3·60) and nearly six times as likely to test positive for hepatitis C (OR = 5·90, 95% CI = 2·17,16·67). Interpretation: Large population-based surveys are feasible, even in armed conflict settings. The burden of HIV, hepatitis B and hepatitis C was significantly higher in areas of conflict in Nigeria, highlighting the need for reinforced public health control measures in these settings in order to attain UNAIDS’ 95-95-95 targets of controlling the HIV epidemic in sub-Saharan Africa by 2030. Funding Statement: President’s Emergency Plan for AIDS Relief (PEPFAR), The US Centers for Disease Control and Prevention, The Global Fund. Declaration of Interests: All authors attest that there is no conflict of interest to be declared Ethics Approval Statement: The protocol for the survey was approved by the Nigeria National Health Research Ethics Committee (NHREC) and the Institutional Review Boards at the CDC and the University of Maryland.

Where are the positives? HIV testing in sub-Saharan Africa in the era of test and treat.

Where are the positives? HIV testing in sub-Saharan Africa in the era of test and treat.

Correlates of Undiagnosed HIV Infection and Retesting Among Voluntary HIV Testing Clients at Mildmay Clinic, Uganda.

Increasing HIV diagnosis is important for combatting HIV. We invited individuals aged ≥ 13years seeking voluntary HIV testing at Mildmay Clinic in Uganda to undertake a computer or audio-computer-assisted self-interview to facilitate post-test counseling. We evaluated first-visit data from 12,233 consenting individuals between January 2011 and October 2013. HIV prevalence was 39.0%. Of those with HIV, 37.2% already knew they were infected. Undiagnosed infection was associated with not being single, screening positive for depression (aOR 1.16, 95% CI 1.04-1.28), and screening for harmful drinking behavior (aOR 1.23, 95% CI 1.10-1.39). The odds of retesting subsequent to HIV diagnosis were lower for males (aOR 0.80, 95% CI 0.70-0.92) and those screening positive for harmful drinking behavior (aOR 0.77, 95% CI 0.66-0.88). Retesting was also associated with higher education and perceived social status below 'better off'. Our findings reiterate the value of population-based HIV surveys to provide estimates of testing coverage.

Population-level HIV incidence estimates using a combination of synthetic cohort and recency biomarker approaches in KwaZulu-Natal, South Africa.

IntroductionThere is a notable absence of consensus on how to generate estimates of population-level incidence. Incidence is a considerably more sensitive indicator of epidemiological trends than prevalence, but is harder to estimate. We used a novel hybrid method to estimate HIV incidence by age and sex in a rural district of KwaZulu-Natal, South Africa.MethodsOur novel method uses an ‘optimal weighting’ of estimates based on an implementation of a particular ‘synthetic cohort’ approach (interpreting the age/time structure of prevalence, in conjunction with estimates of excess mortality) and biomarkers of ‘recent infection’ (combining Lag-Avidity, Bio-Rad Avidity and viral load results to define recent infection, and adapting the method for age-specific incidence estimation). Data were obtained from a population-based cross-sectional HIV survey conducted in Mbongolwane and Eshowe health service areas in 2013.ResultsUsing the combined method, we find that age-specific HIV incidence in females rose rapidly during adolescence, from 1.33 cases/100 person-years (95% CI: 0.98,1.67) at age 15 to a peak of 5.01/100PY (4.14,5.87) at age 23. In males, incidence was lower, 0.34/100PY (0.00-0.74) at age 15, and rose later, peaking at 3.86/100PY (2.52-5.20) at age 30. Susceptible population-weighted average incidence in females aged 15-29 was estimated at 3.84/100PY (3.36-4.40), in males aged 15-29 at 1.28/100PY (0.68-1.50) and in all individuals aged 15-29 at 2.55/100PY (2.09-2.76). Using the conventional recency biomarker approach, we estimated HIV incidence among females aged 15-29 at 2.99/100PY (1.79-4.36), among males aged 15-29 at 0.87/100PY (0.22-1.60) and among all individuals aged 15-59 at 1.66/100PY (1.13-2.27).DiscussionHIV incidence was very high in women aged 15-30, peaking in the early 20s. Men had lower incidence, which peaked at age 30. The estimates obtained from the hybrid method are more informative than those produced by conventional analysis of biomarker data, and represents a more optimal use of available data than either the age-continuous biomarker or synthetic cohort methods alone. The method is mainly useful at younger ages, where excess mortality is low and uncertainty in the synthetic cohort estimates is reasonably small.ConclusionApplication of this method to large-scale population-based HIV prevalence surveys is likely to result in improved incidence surveillance over methods currently in wide use. Reasonably accurate and precise age-specific estimates of incidence are important to target better prevention, diagnosis and care strategies.

Is the prevalence of HIV wrongly estimated in Nigeria? Some insights from a 2017 World AIDS day experience from a Nigerian Non-Governmental Organisation

Introduction : HIV is still a major public health challenge, especially in resource-limited settings. In Nigeria, it is estimated that over 50% of those infected with HIV do not know their status. With the recent Nigerian governmental approval of a Test and Start Strategy, we embarked on HIV testing and services in four defined locations to mark 2017 World AIDS Day. The aim of this report is to document the process and outcome of the exercise. Methods : four teams led by senior clinical associates implemented the services and were mandated to test at least 100 persons per location. At each location, we carried out the following activities: (1) short advocacy to community leaders, (2) HIV testing and counselling, (3) disclosure of results, post-test counselling and healthy life-style education and (4) distribution of free male condoms and Information, Education and Communication (IEC) material. Results : a total of 237 people (male 195, female 42) were tested, the majority of whom were between 19 and 49 years (93.7%). Two people were found to be positive, giving a 0.84% positivity rate. Informal interactions between service providers and the people tested revealed that people were aware of HIV as a public health problem, and people positively received HIV services. Although there is a selection bias, as those tested will not be truly representative of the population, the current positively rate of less than 1% is low compared to previous Nigerian estimates, which are based on antenatal testing. However, the exercise showed a willingness to be tested and fair knowledge of HIV as a problem. Population-based data from across Nigeria should be aggregated to determine community prevalence pending the National population-based HIV survey in 2018. Such information will inform evidence-based decisions on the necessity of such large-scale surveys in future years. Conclusion : there is an urgent need to define the real prevalence of HIV in Nigeria through a well planned and executed community based survey.

Returning HIV‐1 viral load results to participant‐selected health facilities in national Population‐based HIV Impact Assessment (PHIA) household surveys in three sub‐Saharan African Countries, 2015 to 2016

IntroductionLogistical complexities of returning laboratory test results to participants have precluded most population‐based HIV surveys conducted in sub‐Saharan Africa from doing so. For HIV positive participants, this presents a missed opportunity for engagement into clinical care and improvement in health outcomes. The Population‐based HIV Impact Assessment (PHIA) surveys, which measure HIV incidence and the prevalence of viral load (VL) suppression in selected African countries, are returning VL results to health facilities specified by each HIV positive participant within eight weeks of collection. We describe the performance of the specimen and data management systems used to return VL results to PHIA participants in Zimbabwe, Malawi and Zambia.MethodsConsenting participants underwent home‐based counseling and HIV rapid testing as per national testing guidelines; all confirmed HIV positive participants had VL measured at a central laboratory on either the Roche CAP/CTM or Abbott m2000 platform. On a bi‐weekly basis, a dedicated data management team produced logs linking the VL test result with the participants’ contact information and preferred health facility; project staff sent test results confidentially via project drivers, national courier systems, or electronically through an adapted short message service (SMS). Participants who provided cell phone numbers received SMS or phone call alerts regarding availability of VL results.Results and discussionFrom 29,634 households across the three countries, 78,090 total participants 0 to 64 years in Zimbabwe and Malawi and 0 to 59 years in Zambia underwent blood draw and HIV testing. Of the 8391 total HIV positive participants identified, 8313 (99%) had VL tests performed and 8245 (99%) of these were returned to the selected health facilities. Of the 5979 VL results returned in Zimbabwe and Zambia, 85% were returned within the eight‐week goal with a median turnaround time of 48 days (IQR: 33 to 61). In Malawi, where exact return dates were unavailable all 2266 returnable results reached the health facilities by 11 weeks.ConclusionsThe first three PHIA surveys returned the vast majority of VL results to each HIV positive participant's preferred health facility within the eight‐week target. Even in the absence of national VL monitoring systems, a system to return VL results from a population‐based survey is feasible, but it requires developing laboratory and data management systems and dedicated staff. These are likely important requirements to strengthen return of results systems in routine clinical care.

The HIV Epidemic in Sub-Saharan Africa is Aging: Evidence from the Demographic and Health Surveys in Sub-Saharan Africa.

We use the individual-level data from all available Demographic and Health Surveys (DHS) from 27 sub-Saharan African countries conducted between 2003 and 2012 (40 population-based and nationally representative surveys in total) to calculate HIV testing consent rates and HIV prevalence for each country separately, as well as for the pooled sample. The pooled sample comprised of 427,130 individuals. In most countries HIV prevalence in adults aged 45years and above is higher than in the total population. We further show that over the past decade HIV prevalence has increased in older age groups, while it has decreased in younger ones. While the age patterns of HIV consent rates vary across the 27 countries included in our sample, analysis of the pooled sample across all countries reveals a u-shaped relationship with lowest consent rates around age 35years and higher consent rates among younger and older people. We argue that future DHS and other population-based HIV surveys should offer HIV testing to all adults without age limits.

Adjusting HIV prevalence estimates for non-participation: an application to demographic surveillance.

IntroductionHIV testing is a cornerstone of efforts to combat the HIV epidemic, and testing conducted as part of surveillance provides invaluable data on the spread of infection and the effectiveness of campaigns to reduce the transmission of HIV. However, participation in HIV testing can be low, and if respondents systematically select not to be tested because they know or suspect they are HIV positive (and fear disclosure), standard approaches to deal with missing data will fail to remove selection bias. We implemented Heckman-type selection models, which can be used to adjust for missing data that are not missing at random, and established the extent of selection bias in a population-based HIV survey in an HIV hyperendemic community in rural South Africa.MethodsWe used data from a population-based HIV survey carried out in 2009 in rural KwaZulu-Natal, South Africa. In this survey, 5565 women (35%) and 2567 men (27%) provided blood for an HIV test. We accounted for missing data using interviewer identity as a selection variable which predicted consent to HIV testing but was unlikely to be independently associated with HIV status. Our approach involved using this selection variable to examine the HIV status of residents who would ordinarily refuse to test, except that they were allocated a persuasive interviewer. Our copula model allows for flexibility when modelling the dependence structure between HIV survey participation and HIV status.ResultsFor women, our selection model generated an HIV prevalence estimate of 33% (95% CI 27–40) for all people eligible to consent to HIV testing in the survey. This estimate is higher than the estimate of 24% generated when only information from respondents who participated in testing is used in the analysis, and the estimate of 27% when imputation analysis is used to predict missing data on HIV status. For men, we found an HIV prevalence of 25% (95% CI 15–35) using the selection model, compared to 16% among those who participated in testing, and 18% estimated with imputation. We provide new confidence intervals that correct for the fact that the relationship between testing and HIV status is unknown and requires estimation.ConclusionsWe confirm the feasibility and value of adopting selection models to account for missing data in population-based HIV surveys and surveillance systems. Elements of survey design, such as interviewer identity, present the opportunity to adopt this approach in routine applications. Where non-participation is high, true confidence intervals are much wider than those generated by standard approaches to dealing with missing data suggest.

Modelling HIV incidence and survival from age-specific seroprevalence after antiretroviral treatment scale-up in rural South Africa

Objective:Our study uses sex-specific and age-specific HIV prevalence data from an ongoing population-based demographic and HIV survey to infer HIV incidence and survival in rural KwaZulu-Natal between 2003 and 2011, a period when antiretroviral treatment (ART) was rolled out on a large scale.Design:Catalytic mathematical model for estimating HIV incidence and differential survival in HIV-infected persons on multiple rounds of HIV seroprevalence.Methods:We evaluate trends of HIV incidence and survival by estimating parameters separately for women and men aged 15–49 years during three calendar periods (2003–2005, 2006–2008, 2009–2011) reflecting increasing ART coverage. We compare model-based estimates of HIV incidence with observed cohort-based estimates from the longitudinal HIV surveillance.Results:Median survival after HIV infection increased significantly between 2003–2005 and 2009–2011 from 10.0 [95% confidence interval (CI) 8.8–11.2] to 14.2 (95% CI 12.6–15.8) years in women (P < 0.001) and from 10.0 (95% CI 9.2–10.8) to 14.0 (95% CI 10.6–17.4) years in men (P = 0.02). Our model suggests no statistically significant reduction of HIV incidence in the age-group 15–49 years in 2009–2011 compared with 2003–2005. Age-specific and sex-specific model-based HIV incidence estimates were in good agreement with observed cohort-based estimates from the ongoing HIV surveillance.Conclusion:Our catalytic modelling approach using cross-sectional age-specific HIV prevalence data could be useful to monitor trends of HIV incidence and survival in other African settings with a high ART coverage.

Human papillomavirus seropositivity and subsequent risk of HIV acquisition in rural South African women.

This study aimed to provide a population-based estimate of human papillomavirus (HPV) seropositivity for women in a rural African context and to evaluate the impact of HPV serostatus on subsequent acquisition of HIV outside a clinical setting. A random sample of women participating in a longitudinal, population-based HIV survey combined with a case-control study. Blood samples of women participating in a single round of population-based HIV surveillance (N = 1049) in a rural South African population were used to measure vaccine-preventable HPV seropositivity (types 6, 11, 16, and 18) in the general population in 2010. Using results from the repeat HIV surveys, a case-control analysis was then performed comparing HPV sero-status in samples taken from HIV sero-converting women (prior to infection with HIV) against samples from HIV-uninfected, sexually-active controls matched 1:1 according to 5-year age band (377:377). Unconditional multivariable logistic regression with multiple imputations was used to control for sociodemographic and behavioral variables associated with HIV acquisition. Human papillomavirus seropositivity in the population-based sample of women was 20.8% (95% confidence interval [CI], 18.3-23.4), and HIV prevalence was 27.6% (95% CI, 24.9-30.4). In the case-control analysis, allowing for variables known to be associated with HIV incidence, HPV seropositivity was associated with nearly 2.5 times the odds of subsequent acquisition of HIV (adjusted odds ratio, 2.33 [95% CI, 1.61-3.39]; P < 0.001). These results suggest that HPV vaccination before or soon after sexual debut could lower HIV infection risk. Randomized trials that quantify the impact of HPV vaccination in girls on the risk of acquiring HIV are urgently required.

Home-based voluntary HIV counselling and testing found highly acceptable and to reduce inequalities

BackgroundLow uptake of voluntary HIV counselling and testing (VCT) in sub-Saharan Africa is raising acceptability concerns which might be associated with ways by which it is offered. We investigated the acceptability of home-based delivery of counselling and HIV testing in urban and rural populations in Zambia where VCT has been offered mostly from local clinics.MethodsA population-based HIV survey was conducted in selected communities in 2003 (n = 5035). All participants stating willingness to be HIV tested were offered VCT at home and all counselling was conducted in the participants' homes. In the urban area post-test counselling and giving of results were done the following day whereas in rural areas this could take 1-3 weeks.ResultsOf those who indicated willingness to be HIV tested, 76.1% (95%CI 74.9-77.2) were counselled and received the test result. Overall, there was an increase in the proportion ever HIV tested from 18% before provision of home-based VCT to 38% after. The highest increase was in rural areas; among young rural men aged 15-24 years up from 14% to 42% vs. for urban men from 17% to 37%. Test rates by educational attainment changed from being positively associated to be evenly distributed after home-based VCT.ConclusionsA high uptake was achieved by delivering HIV counselling and testing at home. The highest uptakes were seen in rural areas, in young people and groups with low educational attainment, resulting in substantial reductions in existing inequalities in accessing VCT services.

Impact of HIV infection on self-rated health in a high-prevalence popolation with low awareness of own HIV status

Background: Self-rated global health status has been found to be a sensitive marker of declining health and to operate as an independent predictor of survival. This study examines the effect of HIV infection on self-rated health in a population with high prevalence of HIV infection and low awareness of own status of HIV infection. Methods: The data stem from a comprehensive population-based HIV survey conducted in selected urban and rural populations in Zambia in 1996. A total of 1951 males and 2158 females of age more than 14 years were interviewed of which 6% refused to be tested for HIV infection. A logistic regression model was used assuming socio-demographic factors, mental distress and health care use to be associated both with HIV infection and self-rated health. Results: The proportion of persons judging their health status as poor was higher in the rural than in the urban population. Generally no major difference in the proportions of persons rating their health status as poor was observed between sexes. The proportion of poor self-rated health status increased linearly with age. Use of health care services, mental distress and self-perceived risk of HIV infection were negatively associated with self-rated health. Both males and females living in an urban area and males living in a rural area of age more than 24 years who were infected with HIV were about twice as likely to rate their health status as poor compared to respondents who were not infected with HIV. Conclusion: HIV infection had a strong independent negative effect on self-rated health in persons of age greater than 24 years. This measure of people’s subjective health may be used as a valuable “diagnostic” tool in HIV-related care and support programmes, and should be evaluated for use in such services.