United Nations Programme On HIV/AIDS Research Articles

PIN38 Cost-Effectiveness of Expanded HIV Screening Among Adult Population in Italy

The global targets set out by the Joint United Nations Programme on HIV/AIDS (UNAIDS) for 2020 are to diagnose 90% of all HIV-positive people, provide antiretroviral therapy for 90% of those diagnosed, and achieve viral suppression for 90% of those treated (known as 90-90-90 targets). In Italy, there is no uniform HIV screening strategy across the country. Our study aimed to assess the cost-effectiveness of expanded HIV screening among adult population (25-50 years). A decision tree was combined with a previously published Markov model for evaluate the management of HIV-infected patients in Italy. The model was informed by epidemiological and cost estimates taken from different sources (literature and real-world data). The cohort of new HIV diagnosed patients effectively linked to care in Italy (2,847 patients) was followed over a 30-year time horizon evaluating different scenarios for new HIV diagnoses due to the expanded HIV screening. The analysis was conducted from the National Health Service perspective and both costs and QALYs were discounted at an annual rate of 3%. Deterministic and probabilistic sensitivity analysis were conducted to evaluate parameter uncertainty. Our preliminary analysis showed that with an increase of 10% of new HIV linked to care patients, HIV screening strategy resulted in an increment of about 2,466 QALYs and in an increment of about € 73.8 million compared to the status quo from the Italian NHS perspective. The ICER was equal to € 29,943/QALY. Probabilistic sensitivity analysis confirmed that the expanded HIV screening would be cost-effective for > 51% of simulations at a minimum willingness-to-pay threshold of € 30,000 per QALY gained. In Italy there is an urgent need to apply HIV screening strategies to increase awareness of the risks of the disease. Our analysis indicates that the expanded HIV screening in adult population would be cost-effective.

THE INTERNATIONAL GOVERNMENT ORGANIZATIONS ROLE IN GLOBAL HEALTH

International government organizations with a global outreach are working on global health issues to achieve the objective of Health for All. The key actors in global health working on global health problems are the United Nations Educational, Scientific and Cultural Organization (UNESCO) and the Joint United Nations Program on HIV/AIDS (UNAIDS) (Johnson, Stotskopt, & Shi, 2018). These international organizations participate in generating and sharing knowledge, engage in advocacy,provide global funds for health efforts. Our paper will analyze the structure, goals, and processes of global health organizations, UNESCO and UNAIDS.

Assessing barriers to treatment for all: an analysis of resources for PLHA in Cayo and Stann Creek Districts of Belize

Background The Joint United Nations Programme on HIV/AIDS (UNAIDS) launched a global campaign, 90:90:90, which aims to ensure that by 2030: 90% of the people living with HIV will know their HIV status, 90% of those diagnosed with HIV will receive sustained ART, and 90% of those on ART will have durable viral suppression. Belize is striving towards completing this goal and contributing to international efforts for eliminating HIV globally. In order to successfully reach 90% of the population receiving sustained ART, barriers to care that decrease retention rates must be addressed. To combat barriers to care for Persons Living with HIV/AIDS (PLHA), resources must serve to eliminate the obstacles negatively affecting adherence to treatment. Methods This study aimed to (a) assess treatment and care resources in Cayo and Stann Creek districts and (b) pose questions to key informants to gain deeper understanding of HIV services and patient utilization. The study was conducted from May to July 2016 and focused in Belmopan, San Ignacio, and Dangriga to produce an HIV services inventory for the Cayo and Stann Creek districts. Results Our participants composed of 50% civil society and 50% government organizations. 50% of the locations worked less than 45 hours per week and most commonly served the community by providing training, health fairs, and posters. Resources with the lowest number of facility participation were directly observed therapy (DOT), HIV support group (HSG), and prescriptions. The emerging themes from the key informants were (a) concern with patients’ needs, (b) unsustainable resources, and (c) inadequate quality of treatment and care beyond the provider’s control. Results convey the gap between the needs of PLHA and what is being offered by the organizations in the community. In addition, key informants note the unsustainable resources that may contribute to the current climate. Conclusions The final product of this study included a report based on the data produced, a patient-friendly brochure in English listing resources available, and an infographic summarizing the findings of this study.

Written at the closing year of the "three 90%" strategic goal for AIDS prevention and treatment

In 2014, Joint United Nations Programme on HIV/AIDS (UNAIDS) put forward the goal of ending HIV epidemic by 2030 at the International AIDS Conference and proposed the strategic goal of achieving "three 90%" by 2020. This year is the closing year of this strategic goal, and all regions have begun to evaluate the progress of implementing the goal. This article discussed the progress of the implementation of the "three 90%", and scientifically interpreted the strategic goal. It is proposed that the goal is a relative and dynamic concept, and only if we sieze the opportunity to achieve the strategic goal and continuously enhance comprehensive prevention and control, can the HIV epidemic be better controlled.

Time for HIV self-testing in Canada: a vision and an action plan

KEY POINTS In 2020, compared against the Joint United Nations Programme on HIV/AIDS (UNAIDS) 95-95-95 targets for HIV elimination (95% tested for HIV, 95% treated and 95% retained in treatment), Canada stands at 86% tested, 81% treated, 91% retained in treatment.[1][1] Despite the availability of

Not yet 90-90-90: A quality improvement approach to human immunodeficiency virus viral suppression in paediatric patients in the rural Eastern Cape, South Africa.

BackgroundA strategy implemented by the South African Department of Health to manage the high burden of human immunodeficiency virus (HIV) has been to task-shift services to primary health care clinics. Outcomes of paediatric patients with HIV are poorer than those of adults, particularly in rural areas. Viral suppression in paediatric patients at the feeder clinics of a rural South African hospital was anecdotally far below the aim of the Joint United Nations Programme on HIV/AIDS (UNAIDS) of 90%.MethodsA quality improvement approach was used to conduct a baseline assessment of HIV viral suppression in paediatric patients and other process measures, implement a clinical mentorship intervention and evaluate its effectiveness.ResultsAn initial audit of 235 clinical folders of paediatric patients with HIV revealed a viral suppression of 55.3%. Other poor measures included prescription accuracy, viral loads performed within schedule and response to successive high viral loads. A clinical mentorship intervention using dedicated doctor outreach was implemented and the audit repeated after 12 months (263 folders). Viral suppression improved to 67.4%, as did most other process measures.ConclusionThe quality improvement approach regarding the aim to significantly improve viral suppression in paediatric patients through the implementation of clinical mentorship was successful.

Non-uptake of viral load testing among people receiving HIV treatment in Gomba district, rural Uganda

BackgroundViral load (VL) testing is the gold-standard approach for monitoring human immunodeficiency virus (HIV) treatment success and virologic failure, but uptake is suboptimal in resource-limited and rural settings. We conducted a cross-sectional study of risk factors for non-uptake of VL testing in rural Uganda.MethodsWe conducted a cross-sectional analysis of uptake of VL testing among randomly selected people with HIV (PWH) receiving anti-retroviral treatment (ART) for at least 6 months at all eight primary health centers in Gomba district, rural Uganda. Socio-demographic and clinical data were extracted from medical records for the period January to December 2017. VL testing was routinely performed 6 months after ART initiation and 12 months thereafter for PWH stable on ART. We used descriptive statistics and multivariable logistic regression to evaluate factors associated with non-uptake of VL testing (the primary outcome).ResultsOf 414 PWH, 60% were female, and the median age was 40 years (interquartile range [IQR] 31–48). Most (62.3%) had been on ART > 2 years, and the median duration of treatment was 34 months (IQR 14–55). Thirty three percent did not receive VL testing: 36% of women and 30% of men. Shorter duration of ART (≤2 years) (adjusted odds ratio [AOR] 2.38; 95% CI:1.37–4.12; p = 0.002), younger age 16–30 years (AOR 2.74; 95% CI:1.44–5.24; p = 0.002) and 31–45 years (AOR 1.92; 95% CI 1.12–3.27; p = 0.017), and receipt of ART at Health Center IV (AOR 2.85; 95% CI: 1.78–4.56; p < 0.001) were significantly associated with non-uptake of VL testing.ConclusionsOne-in-three PWH on ART missed VL testing in rural Uganda. Strategies to improve coverage of VL testing, such as VL focal persons to flag missed tests, patient education and demand creation for VL testing are needed, particularly for recent ART initiates and younger persons on treatment, in order to attain the third Joint United Nations Program on HIV/AIDS (UNAIDS) 95–95-95 target – virologic suppression for 95% of PWH on ART.

Human Immunodeficiency Virus Continuum of Care in 11 European Union Countries at the End of 2016 Overall and by Key Population: Have We Made Progress?

BackgroundHigh uptake of antiretroviral treatment (ART) is essential to reduce human immunodeficiency virus (HIV) transmission and related mortality; however, gaps in care exist. We aimed to construct the continuum of HIV care (CoC) in 2016 in 11 European Union (EU) countries, overall and by key population and sex. To estimate progress toward the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target, we compared 2016 to 2013 estimates for the same countries, representing 73% of the population in the region.MethodsA CoC with the following 4 stages was constructed: number of people living with HIV (PLHIV); proportion of PLHIV diagnosed; proportion of those diagnosed who ever initiated ART; and proportion of those ever treated who achieved viral suppression at their last visit.ResultsWe estimated that 87% of PLHIV were diagnosed; 92% of those diagnosed had ever initiated ART; and 91% of those ever on ART, or 73% of all PLHIV, were virally suppressed. Corresponding figures for men having sex with men were: 86%, 93%, 93%, 74%; for people who inject drugs: 94%, 88%, 85%, 70%; and for heterosexuals: 86%, 92%, 91%, 72%. The proportion suppressed of all PLHIV ranged from 59% to 86% across countries.ConclusionsThe EU is close to the 90-90-90 target and achieved the UNAIDS target of 73% of all PLHIV virally suppressed, significant progress since 2013 when 60% of all PLHIV were virally suppressed. Strengthening of testing programs and treatment support, along with prevention interventions, are needed to achieve HIV epidemic control.

Towards achieving the 90\u201390\u201390 HIV targets: results from the south African 2017 national HIV survey

BackgroundMeasuring progress towards the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90–90–90 treatment targets is key to assessing progress towards turning the HIV epidemic tide. In 2017, the UNAIDS model estimated that 75% of people living with HIV (PLHIV) globally knew their HIV positive status, 79% of those who knew their status were on antiretroviral therapy (ART), and 81% of those who knew their HIV status and were on ART had a suppressed viral load. The fifth South African national HIV sero-behavioural survey collected nationally representative data that enabled the empirical estimation of these 90–90–90 targets for the country stratified by a variety of key factors.MethodsTo evaluate progress towards achievement of the 90–90–90 targets for South Africa, data obtained from a national, representative, cross-sectional population-based multi-stage stratified cluster random survey conducted in 2017 were analysed. The Fifth South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (SABSSM V), collected behavioural and biomarker data from individuals residing in households from 1000 randomly selected Small Area Layers (SALs), across all nine provinces of the country. Structured questionnaires were used to collect socio-demographic data, knowledge and perceptions about HIV, and related risk behaviours. Blood samples were collected to test for HIV infection, antiretroviral use, and viral suppression (defined as < 1000 copies/ml). Weighted proportions of study participants aged 15 years and older who tested HIV positive were computed for those who reported awareness of their status (1st 90), and among these, those who were currently on ART (2nd 90) and of these, those who were virally suppressed (3rd 90).ResultsAmong persons 15 years and older who were HIV positive, 84.8% were aware of their HIV positive status, of whom 70.7% were currently on ART, with 87.4% of these estimated to have suppressed viral load at the time of the survey. These estimates varied by sex, age, and geo-location type. Relatively higher percentages across all three indicators for women compared to men were observed: 88.7% versus 78.2% for those aware of their status, 72.3% versus 67.7% for on ART, and 89.8% versus 82.3% for viral suppression. Knowing one’s positive HIV status increased with age: 74.0, 85.8, and 88.1% for age groups 15–24 years old, 25–49 years old and 50–64 years old, although for those 65 years and older, 78.7% knew their HIV positive status. A similar pattern was observed for the 2nd 90, among those who knew their HIV positive status, 51.7% of 15 to 24 year olds, 70.5% of those aged 25–49 years old, 82.9% of those aged 50–64 years old and 82.4% of those aged 65 years or older were currently on ART. Viral suppression for the above mentioned aged groups, among those who were on ART was 85.2, 87.2, 89.5, and 84.6% respectively. The 90–90–90 indicators for urban areas were 87.7, 66.5, and 87.2%, for rural settings was 85.8, 79.8, and 88.4%, while in commercial farming communities it was 56.2, 67.6 and 81.4%.ConclusionsSouth Africa appears to be on track to achieve the first 90 indicator by 2020. However, it is behind on the second 90 indicator with ART coverage that was ~ 20-percentage points below the target among people who knew their HIV status, this indicates deficiencies around linkage to and retention on ART. Overall viral suppression among those on ART is approaching the target at 87.4%, but this must be interpreted in the context of low reported ART coverage as well as with variation by age and sex. Targeted diagnosis, awareness, and treatment programs for men, young people aged 15–24 years old, people who reside in farming communities, and in specific provinces are needed. More nuanced 90–90–90 estimates within provinces, specifically looking at more granular sub-national level (e.g. districts), are needed to identify gaps in specific regions and to inform provincial interventions.

Data-driven HIV programming to maximise health benefits

From the perspective of the ongoing COVID-19 pandemic, where evidence on effective prevention and treatment interventions for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections is limited, the near perfect efficacy of antiretroviral therapy (ART) for HIV treatment is enviable. ART prevents individual level HIV-associated morbidity and mortality, restoring life expectancy to near normal,1 and prevents transmissions by decreasing viral load to undetectable levels.2 To translate ART efficacy to population level health benefits, the Joint United Nations Programme on HIV/AIDS (UNAIDS) set goals to diagnose 90% of people living with HIV, link 90% of those diagnosed to ART, and achieve 90% viral suppression among people on ART by 2020.

Mapping male circumcision for HIV prevention efforts in sub-Saharan Africa

BackgroundHIV remains the largest cause of disease burden among men and women of reproductive age in sub-Saharan Africa. Voluntary medical male circumcision (VMMC) reduces the risk of female-to-male transmission of HIV by 50–60%. The World Health Organization (WHO) and Joint United Nations Programme on HIV/AIDS (UNAIDS) identified 14 priority countries for VMMC campaigns and set a coverage goal of 80% for men ages 15–49. From 2008 to 2017, over 18 million VMMCs were reported in priority countries. Nonetheless, relatively little is known about local variation in male circumcision (MC) prevalence.MethodsWe analyzed geo-located MC prevalence data from 109 household surveys using a Bayesian geostatistical modeling framework to estimate adult MC prevalence and the number of circumcised and uncircumcised men aged 15–49 in 38 countries in sub-Saharan Africa at a 5 × 5-km resolution and among first administrative level (typically provinces or states) and second administrative level (typically districts or counties) units.ResultsWe found striking within-country and between-country variation in MC prevalence; most (12 of 14) priority countries had more than a twofold difference between their first administrative level units with the highest and lowest estimated prevalence in 2017. Although estimated national MC prevalence increased in all priority countries with the onset of VMMC campaigns, seven priority countries contained both subnational areas where estimated MC prevalence increased and areas where estimated MC prevalence decreased after the initiation of VMMC campaigns. In 2017, only three priority countries (Ethiopia, Kenya, and Tanzania) were likely to have reached the MC coverage target of 80% at the national level, and no priority country was likely to have reached this goal in all subnational areas.ConclusionsDespite MC prevalence increases in all priority countries since the onset of VMMC campaigns in 2008, MC prevalence remains below the 80% coverage target in most subnational areas and is highly variable. These mapped results provide an actionable tool for understanding local needs and informing VMMC interventions for maximum impact in the continued effort towards ending the HIV epidemic in sub-Saharan Africa.

Characteristics and outcomes of older people on antiretroviral therapy in Tlokwe Clinics, South Africa.

BackgroundSouth Africa (SA) has a large human immunodeficiency virus (HIV) epidemic but little is known of its effect on those ≥ 60 years of age viz. ‘older-persons’ living with HIV (OPLWH). Numbers in this age group are increasing and are expected to place a greater strain on existing resources.ObjectivesTo describe the demographic features and the co-morbidities of OPLWH in Tlokwe. This included an assessment of viral load (VL) suppression and the identification of associations between patient characteristics and clinical outcomes.MethodsA retrospective file review was undertaken to cover the period 01 May 2017 to 30 April 2018. Descriptive statistics were applied to demographic and clinical data and to treatment outcomes. Statistically significant associations were subjected to logistic regression analysis.ResultsOf the 191 participants, 111/191 (58.1%) were female and 167/191 (87.4%) were 60 –70 years of age. Of the participants, 154/191 (81.9%) were virally suppressed (< 400 copies/mL). Hypertension (n = 106/191, 55.5%) was the most frequently identified co-morbidity. A CD4 cell count of ≥ 350 cells/mm3 at last assessment correlated positively with VL suppression (odds ratio 2.3, confidence interval 1.05–5.02, p = 0.037).ConclusionAlthough the level of VL suppression in this cohort was high, greater effort is required to bring this in line with the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommendations viz. 90% viral suppression in PLWH by 2030. Further research is needed to define the evolving long-term needs of OPLWH and to facilitate entry into care of those currently not in care.

Monitoring progress towards the first UNAIDS 90-90-90 target in key populations living with HIV in Norway

BackgroundIn line with the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target, Norway aims for at least 90% of people living with HIV (PLHIV) to know their HIV-status. We produced current estimates of the number of PLHIV and undiagnosed population in Norway, overall and for six key subpopulations: Norwegian-born men who have sex with men (MSM), migrant MSM, Norwegian-born heterosexuals, migrant Sub-Saharan Africa (SSA)-born heterosexuals, migrant non-SSA-born heterosexuals and people who inject drugs.MethodsWe used the European Centre for Disease Prevention and Control (ECDC) HIV Modelling Tool on Norwegian HIV surveillance data through 2018 to estimate incidence, time from infection to diagnosis, PLHIV, and the number and proportion undiagnosed. As surveillance data on CD4 count at diagnosis were not collected in Norway, we ran two models; using default model CD4 assumptions, or a proxy for CD4 distribution based on Danish national surveillance data. We also generated alternative overall PLHIV estimates using the Spectrum AIDS Impact Model, to compare with those obtained from the ECDC tool.ResultsEstimates of the overall number of PLHIV in 2018 using different modelling approaches aligned at approximately 5000. In both ECDC models, the overall number undiagnosed decreased continuously from 2008. The proportion undiagnosed in 2018 was lower using default model CD4 assumptions (7.1% [95%CI: 5.3–8.9%]), than the Danish CD4 proxy (10.2% [8.3–12.1%]). This difference was driven by results for heterosexual migrants. Estimates for Norwegian-born MSM, migrant MSM and Norwegian-born heterosexuals were similar in both models. In these three subpopulations, incidence in 2018 was < 30 new infections, and the number undiagnosed had decreased in recent years. Norwegian-born MSM had the lowest estimated number of undiagnosed infections (45 [30–75], using default CD4 assumptions) and undiagnosed fraction (3.6% [2.4–5.7%], using default CD4 assumptions) in 2018.ConclusionsResults allow cautious confidence in concluding that Norway has achieved the first UNAIDS 90–90-90 target, and clearly highlight the success of prevention strategies among MSM. Estimates for subpopulations strongly influenced by migration remain less clear, and future modelling should appropriately account for all-cause mortality and out-migration, and adjust for time of in-migration.

Survival and HIV-Free Survival Among Children Aged ≤3 Years - Eight Sub-Saharan African Countries, 2015-2017.

Although mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) is preventable through antiretroviral treatment (ART) during pregnancy and postpartum, the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that 160,000 new HIV infections occurred among children in 2018 (1). Child survival and HIV-free survival rates* are standard measures of progress toward eliminating MTCT† (2). Nationally representative Population-based HIV Impact Assessment (PHIA)§ survey data, pooled from eight sub-Saharan African countries¶ were used to calculate survival probability among children aged ≤3 years by maternal HIV status during pregnancy and HIV-free survival probability among children aged ≤3 years born to women with HIV infection, stratified by maternal ART** status during pregnancy. Survival probability was significantly lower among children born to women with HIV infection (94.7%) than among those born to women without HIV infection (97.6%). HIV-free survival probability of children born to women with HIV infection differed significantly by the timing of initiation of maternal ART: 93.0% among children whose mothers received ART before pregnancy, 87.8% among those whose mothers initiated ART during pregnancy, and 53.4% among children whose mothers did not receive ART during pregnancy. Focusing on prevention of HIV acquisition and, among women of reproductive age with HIV infection, on early diagnosis of HIV infection and ART initiation when applicable, especially before pregnancy, can improve child survival and HIV-free survival.

HIV testing and treatment coverage achieved after 4 years across 14 urban and peri-urban communities in Zambia and South Africa: An analysis of findings from the HPTN 071 (PopART) trial.

BackgroundIn 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) set the 90-90-90 targets: that 90% of people living with HIV know their HIV status, that 90% of those who know their HIV-positive status are on antiretroviral therapy (ART), and that 90% of those on treatment are virally suppressed. The aim was to reach these targets by 2020. We assessed the feasibility of achieving the first two targets, and the corresponding 81% ART coverage target, as part of the HIV Prevention Trials Network (HPTN) 071 Population Effects of Antiretroviral Therapy to Reduce HIV Transmission (PopART) community-randomized trial.Methods and findingsThe study population was individuals aged ≥15 years living in 14 urban and peri-urban “PopART intervention” communities in Zambia and South Africa (SA), with a total population of approximately 600,000 and approximately 15% adult HIV prevalence. Community HIV care providers (CHiPs) delivered the PopART intervention during 2014–2017. This was a combination HIV prevention package including universal home-based HIV testing, referral of HIV-positive individuals to government HIV clinic services that offered universal ART (Arm A) or ART according to national guidelines (Arm B), and revisits to HIV-positive individuals to support linkage to HIV care and retention on ART. The intervention was delivered in 3 “rounds,” each about 15 months long, during which CHiPs visited all households and aimed to contact all individuals aged ≥15 years at least once.In Arm A in Round 3 (R3), 67% (41,332/61,402) of men and 86% (56,345/65,896) of women in Zambia and 56% (17,813/32,095) of men and 71% (24,461/34,514) of women in SA participated in the intervention, among 193,907 residents aged ≥15 years. Following participation, HIV status was known by 90% of men and women in Zambia and by 78% of men and 85% of women in SA. The median time from CHiP referral of HIV-positive individuals to ART initiation was approximately 3 months. By the end of R3, an estimated 95% of HIV-positive women and 85% of HIV-positive men knew their HIV status, and among these individuals, approximately 90% of women and approximately 85% of men were on ART. ART coverage among all HIV-positive individuals was approximately 85% in women and approximately 75% in men, up from about 45% at the start of the study. ART coverage was lowest among men aged 18 to 34 and women aged 15 to 24 years, and among mobile individuals/in-migrants. Findings from Arm B were similar. The main limitations to our study were that estimates of testing and treatment coverage among men relied on considerable extrapolation because, in each round, approximately one-third of men did not participate in the PopART intervention; that our findings are for a service delivery model that was relatively intensive; and that we did not have comparable data from the 7 “standard-of-care” (Arm C) communities.ConclusionsOur study showed that very high HIV testing and treatment coverage can be achieved through persistent delivery of universal testing, facilitated linkage to HIV care, and universal treatment services. The ART coverage target of 81% was achieved overall, after 4 years of delivery of the PopART intervention, though important gaps remained among men and young people. Our findings are consistent with previously reported findings from southern and east Africa, extending their generalisability to urban settings with high rates of in-migration and mobility and to Zambia and SA.Trial registrationClinicalTrials.gov NCT01900977.

Long-term Experience and Outcomes of Programmatic Antiretroviral Therapy for Human Immunodeficiency Virus Type 2 Infection in Senegal, West Africa.

Programmatic treatment outcome data for people living with human immunodeficiency virus type 2 (HIV-2) in West Africa, where the virus is most prevalent, are scarce. Adults with HIV-2 initiating or receiving antiretroviral therapy (ART) through the Senegalese national AIDS program were invited to participate in this prospective, longitudinal observational cohort study. We analyzed HIV-2 viral loads, CD4 cell counts, antiretroviral drug resistance, loss to follow-up, and mortality. We also examined changes in treatment guidelines over time and assessed progress toward the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets for HIV-2. We enrolled 291 participants at 2 sites for 926.0 person-years of follow-up over 13 years. Median follow-up time was 2.2 years per participant. There were 21 deaths reported (7.2%), and 117 individuals (40.2%) were lost to follow-up, including 43 (14.7%) who had an initial visit but never returned for follow-up. CD4 counts and HIV-2 viral suppression (< 50 copies/mL) at enrollment increased over calendar time. Over the study period, 76.7% of plasma viral loads for participants receiving ART were suppressed, and median CD4 gain was 84 cells/μL in participants' first 2 years on study. Since the UNAIDS 90-90-90 strategy was published, 88.1% of viral loads were suppressed. Fifteen percent of patients experienced virologic failure with no known resistance mutations, while 56% had evidence of multiclass drug resistance. Participants in the Senegalese national AIDS program are initiating ART earlier in the course of disease, and more modern therapeutic regimens have improved outcomes among those receiving therapy. Despite these achievements, HIV-2 treatment remains suboptimal, and significant challenges to improving care remain.

The HIV epidemic in Latin America: a time to reflect on the history of success and the challenges ahead.

The HIV epidemic in Latin America: a time to reflect on the history of success and the challenges ahead.

Financial education for HIV-vulnerable youth, orphans, and vulnerable children: A systematic review of outcome evidence.

According to Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization, HIV is the leading cause of youth mortality in Africa, and the second cause of death among young people worldwide. Global commitments to reverse the HIV epidemic will only be achieved if strategies prioritize children and youth. Relevant evidence reviews found mixed evidence that HIV prevention may be addressed through economic strengthening activities such as financial education for youth. There was some evidence related to the potential for plural interventions that include both financial and sexual, reproductive health education. However, there is limited quality evidence that focused on HIV vulnerable youth in low- and middle-income countries (LMICs). This systematic review assessed the scope and strength of evidence for financial education and plural interventions aimed at reducing HIV vulnerability for youth, orphans and vulnerable children (OVC) in LMICs. Standard methodological procedures expected of systematic reviews were used. Six scientific and 24 grey literature sites were searched for relevant studies in English, French, Spanish and Arabic published between 1990 and 2016. Experimental and quasi-experimental research methods were considered where data was gathered at baseline and at least 6 months after the end of the intervention. Mixed-methods studies were considered provided they demonstrated validity in terms of randomization, appropriate sampling and controls, and minimization of bias errors and attrition. Evidence was then analysed and mapped to show types of financial and plural interventions by outcome type, direction and strength of evidence through qualitative assessments by the team. In addition, meta-analysis of odds ratios was conducted to validate the strength of evidence. This analysis illustrated the relative effect or weight of interventions on HIV-related outcomes based on confidence levels and sample sizes. Of 5,216 records, 16 moderate to higher quality studies representing 10 interventions were identified, mostly focusing on HIV-vulnerable girls in Sub-Saharan Africa. More than half of the interventions were plural and included access to finance and counselling or supports to improve confidence, negotiating ability and social conditions. Most studies used an experimental design. Only 11 of the 16 studies had comparable enough measures to be validated with meta-analysis of odds ratios. The strongest evidence showed plural education interventions with self-efficacy supports, with and without savings to have positive effects on HIV-related outcomes. These outcomes included improved knowledge, attitudes and reduced sexual risk-taking behaviour. Evidence also showed improved self-efficacy from plural interventions, the changes in confidence, negotiating ability and social conditions that enable people to act on knowledge. Self-efficacy seems important as both a set of conditions to support reduced vulnerabilities and a way to measure them in terms of outcomes. While positive effects were also observed related to increased savings and improved attitudes toward saving, generally interventions showed mixed effects on financial and economic outcomes. This systematic review supports emerging evidence that plural interventions are associated with positive health and economic outcomes for vulnerable youth and children in LMIC. Even so, as a body of evidence, it is not clear which components are effective at producing favourable outcomes. Therefore, asset theories linking financial education and asset building with favourable outcomes for vulnerable youth are not as clear as may be commonly assumed. Quality evidence is needed in more settings separating out economic, health and self-efficacy components to better understand pathways and effects on outcomes. Segmentation in quantitative studies will enhance our understanding of asset, capability and self-efficacy theories for greater impact. Mixed methods and qualitative studies will be important complements to enhance our understanding of contextual conditions and how to build assets and self-efficacy in HIV vulnerable youth and OVC.

Limitations of the UNAIDS 90-90-90 metrics: a simulation-based comparison of cross-sectional and longitudinal metrics for the HIV care continuum.

Objectives:The Joint United Nations Programme on HIV/AIDS (UNAIDS) 90–90–90 and other cross-sectional metrics can lead to potentially counterintuitive conclusions when used to evaluate health systems’ performance. This study demonstrates how time and population dynamics impact UNAIDS 90–90–90 metrics in comparison with a longitudinal analogue.Design:A simplified simulation representing a hypothetical population was used to estimate and compare inference from UNAIDS 90–90–90 metrics and longitudinal metrics based on Kaplan–Meier-estimated 2-year probability of transition between stages.Methods:We simulated a large cohort over 15 years. Everyone started out at risk for HIV, and then transitioned through the HIV care continuum based on fixed daily probabilities of acquiring HIV, learning status, entering care, initiating antiretroviral therapy (ART), and becoming virally suppressed, or dying. We varied the probability of ART initiation over three five-year periods (low, high, and low). We repeated the simulation with an increased probability of death.Results:The cross-sectional probability of being on ART among persons who were diagnosed responded relatively slowly to changes in the rate of ART initiation. Increases in ART initiation rates caused apparent declines in the cross-sectional probability of being virally suppressed among persons who had initiated ART, despite no changes in the rate of viral suppression. In some cases, higher mortality resulted in the cross-sectional metrics implying improved healthcare system performance. The longitudinal continuum was robust to these issues.Conclusion:The UNAIDS 90–90–90 care continuum may lead to incorrect inference when used to evaluate health systems performance. We recommend that evaluation of HIV care delivery include longitudinal care continuum metrics wherever possible.

Estimating the population size of female sex workers and transgender women in Sri Lanka.

We implemented population size estimation of female sex workers (FSW) and transgender women (TGW) in Sri Lanka in 2018 using several approaches (geographical mapping, service and unique object multiplier and a modified Delphi method during the stakeholder consensus meeting). Mapping was done in 49 randomly selected Divisional Secretariats, which provided a basis for extrapolation of size estimates to the national level. Two types of adjustments were applied on the mean (minimum-maximum) population estimate obtained during mapping: (1) an adjustment for mobility to reduce double counting of FSW and TGW frequenting multiple spots, obtained during mapping; (2) an adjustment for "a hidden population", obtained from surveys among FSW and TGW. For the multiplier method, we used data from services of non-governmental organisations that FSW and TGW were in contact with, and surveys based on respondent-driven sampling. Surveys were carried out in the cities of Colombo (FSW, TGW), Kandy (FSW), Galle (FSW) and Jaffna (TGW). We estimated that there are 30,000 FSWs in Sri Lanka, with a plausible range of 20,000-35,000, which implies a prevalence of FSW of 0.56% (0.37-0.65%) among adult females. This study provided baseline estimates of 2,200 TGW in the country, with a plausible range of 2,000-3,500, which is 0.04% (0.04-0.07%) of adult male population. Our estimates of the proportional contribution of the FSW and TGW populations among the adult population in Sri Lanka are consistent with the The Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended estimates for Asia and the Pacific. The results provide an important point for macro- and micro-level planning of HIV services, allocating programme resources and assessing programme coverage and quality.