Journal Article > ResearchFull Text
Malar J. 2022 September 9; Volume 21 (Issue 1); 261.; DOI:10.1186/s12936-022-04280-w
Lynch E, Jensen TO, Assao B, Chihana ML, Turuho T, et al.
Malar J. 2022 September 9; Volume 21 (Issue 1); 261.; DOI:10.1186/s12936-022-04280-w
BACKGROUND
Rapid diagnostic tests (RDT) for malaria are the primary tool for malaria diagnosis in sub-Saharan Africa but the utility of the most commonly used histidine-rich protein 2 (HRP2) antigen-based tests is limited in high transmission settings due to the long duration of positivity after successful malaria treatment. HRP2 tests are also threatened by the emergence of Plasmodium that do not carry pfhrp2 or pfhrp 3 genes. Plasmodium lactate dehydrogenase (pLDH)-based tests are promising alternatives, but less available. This study assessed the performances of HRP2 and pLDH(pan) tests under field conditions.
METHODS
The study performed a prospective facility-based diagnostic evaluation of two malaria RDTs in Aweil, South Sudan, during the high transmission season. Capillary blood by fingerprick was collected from 800 children under 15 years of age with fever and no signs of severity. SD Bioline HRP2 and CareStart pLDH(pan) RDTs were performed in parallel, thick and thin smears for microscopy were examined, and dried blood was used for PCR testing.
RESULTS
Using microscopy as the gold standard, the sensitivity of both tests was estimated at > 99%, but the specificity of each was lower: 55.0% for the pLDH test and 61.7% for the HRP2 test. When using PCR as the gold standard, the sensitivity of both tests was lower than the values assessed using microscopy (97.0% for pLDH and 96.5% for HRP2), but the specificity increased (65.1% for pLDH and 72.9% for HRP2). Performance was similar across different production lots, sex, and age. Specificity of both the pLDH and HRP2 tests was significantly lower in children who reported taking a therapeutic course of anti-malarials in the 2 months prior to enrollment. The prevalence of pfhrp2/3 deletions in the study population was 0.6%.
CONCLUSIONS
The low specificity of the pLDH RDT in this setting confirms previous results and suggests a problem with this specific test. The prevalence of pfhrp2/3 deletions in the study area warrants continued monitoring and underscores the relevance of assessing deletion prevalence nationally. Improved malaria RDTs for high-transmission environments are needed.
Rapid diagnostic tests (RDT) for malaria are the primary tool for malaria diagnosis in sub-Saharan Africa but the utility of the most commonly used histidine-rich protein 2 (HRP2) antigen-based tests is limited in high transmission settings due to the long duration of positivity after successful malaria treatment. HRP2 tests are also threatened by the emergence of Plasmodium that do not carry pfhrp2 or pfhrp 3 genes. Plasmodium lactate dehydrogenase (pLDH)-based tests are promising alternatives, but less available. This study assessed the performances of HRP2 and pLDH(pan) tests under field conditions.
METHODS
The study performed a prospective facility-based diagnostic evaluation of two malaria RDTs in Aweil, South Sudan, during the high transmission season. Capillary blood by fingerprick was collected from 800 children under 15 years of age with fever and no signs of severity. SD Bioline HRP2 and CareStart pLDH(pan) RDTs were performed in parallel, thick and thin smears for microscopy were examined, and dried blood was used for PCR testing.
RESULTS
Using microscopy as the gold standard, the sensitivity of both tests was estimated at > 99%, but the specificity of each was lower: 55.0% for the pLDH test and 61.7% for the HRP2 test. When using PCR as the gold standard, the sensitivity of both tests was lower than the values assessed using microscopy (97.0% for pLDH and 96.5% for HRP2), but the specificity increased (65.1% for pLDH and 72.9% for HRP2). Performance was similar across different production lots, sex, and age. Specificity of both the pLDH and HRP2 tests was significantly lower in children who reported taking a therapeutic course of anti-malarials in the 2 months prior to enrollment. The prevalence of pfhrp2/3 deletions in the study population was 0.6%.
CONCLUSIONS
The low specificity of the pLDH RDT in this setting confirms previous results and suggests a problem with this specific test. The prevalence of pfhrp2/3 deletions in the study area warrants continued monitoring and underscores the relevance of assessing deletion prevalence nationally. Improved malaria RDTs for high-transmission environments are needed.
Journal Article > ResearchFull Text
Trop Med Int Health. 2021 October 12; Volume 26 (Issue 12); 1609-1615.; DOI:10.1111/tmi.13688
Conan N, Badawi M, Chihana ML, Wanjala S, Kingwara L, et al.
Trop Med Int Health. 2021 October 12; Volume 26 (Issue 12); 1609-1615.; DOI:10.1111/tmi.13688
Français
BACKGROUND
HIV-positive individuals who maintain an undetectable viral load cannot transmit the virus to others. In 2012, an HIV population-based survey was conducted in Ndhiwa sub-county (Kenya) to provide information on the HIV local epidemic. We carried out a second survey 6 years after the first one, to assess progress in HIV diagnosis and care and differences in the HIV prevalence and incidence between the two surveys.
METHODS
A cross-sectional, population-based survey using cluster sampling and geospatial random selection was implemented in 2018, using the same design as 2012. Consenting participants aged 15-59 years were interviewed and tested for HIV at home. HIV-positive individuals received viral load testing (viral suppression defined as <1000 copies/ml) and Lag-Avidity EIA assay (to measure recent infection). The 90-90-90 UNAIDS indicators were also assessed.
RESULTS
Overall, 6029 individuals were included in 2018. HIV prevalence was 16.9%. Viral suppression among all HIV-positive was 88.3% in 2018 (vs. 39.9% in 2012, p < 0.001). HIV incidence was 0.75% in 2018 vs. 1.90% in 2012 (p = 0.07). In 2018, the 90-90-90 indicators were 93%-97%-95% (vs. 60%-68%-83% in 2012).
CONCLUSIONS
A two-fold increase in the HIV viral load suppression rate along with a decreasing trend in incidence was observed over 6 years in Ndhiwa sub-county. Achieving high rates of viral suppression in HIV populations that can lead to reducing HIV transmission in sub-Saharan contexts is feasible. Nevertheless, we will need further efforts to sustain this progress.
HIV-positive individuals who maintain an undetectable viral load cannot transmit the virus to others. In 2012, an HIV population-based survey was conducted in Ndhiwa sub-county (Kenya) to provide information on the HIV local epidemic. We carried out a second survey 6 years after the first one, to assess progress in HIV diagnosis and care and differences in the HIV prevalence and incidence between the two surveys.
METHODS
A cross-sectional, population-based survey using cluster sampling and geospatial random selection was implemented in 2018, using the same design as 2012. Consenting participants aged 15-59 years were interviewed and tested for HIV at home. HIV-positive individuals received viral load testing (viral suppression defined as <1000 copies/ml) and Lag-Avidity EIA assay (to measure recent infection). The 90-90-90 UNAIDS indicators were also assessed.
RESULTS
Overall, 6029 individuals were included in 2018. HIV prevalence was 16.9%. Viral suppression among all HIV-positive was 88.3% in 2018 (vs. 39.9% in 2012, p < 0.001). HIV incidence was 0.75% in 2018 vs. 1.90% in 2012 (p = 0.07). In 2018, the 90-90-90 indicators were 93%-97%-95% (vs. 60%-68%-83% in 2012).
CONCLUSIONS
A two-fold increase in the HIV viral load suppression rate along with a decreasing trend in incidence was observed over 6 years in Ndhiwa sub-county. Achieving high rates of viral suppression in HIV populations that can lead to reducing HIV transmission in sub-Saharan contexts is feasible. Nevertheless, we will need further efforts to sustain this progress.
Journal Article > ResearchFull Text
PLOS One. 2022 December 30; Volume 17 (Issue 12); e0279692.; DOI:10.1371/journal.pone.0279692
Bossard C, Chihana ML, Nicholas S, Mauambeta D, Weinstein D, et al.
PLOS One. 2022 December 30; Volume 17 (Issue 12); e0279692.; DOI:10.1371/journal.pone.0279692
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.
Journal Article > ResearchFull Text
PLOS One. 2018 November 26; Volume 13 (Issue 11); e0207656.; DOI:10.1371/journal.pone.0207656
Chihana ML, Huerga H, Van Cutsem G, Ellman T, Wanjala S, et al.
PLOS One. 2018 November 26; Volume 13 (Issue 11); e0207656.; DOI:10.1371/journal.pone.0207656
Background
Latest WHO guidelines recommend starting HIV-positive individuals on antiretroviral therapy treatment (ART) regardless of CD4 count. We assessed additional impact of adopting new WHO guidelines.
Methods
We used data of individuals aged 15–59 years from three HIV population surveys conducted in 2012 (Kenya) and 2013 (Malawi and South Africa). Individuals were interviewed at home followed by rapid HIV and CD4 testing if tested HIV-positive. HIV-positive individuals were classified as “eligible for ART” if (i) had ever been initiated on ART or (ii) were not yet on ART but met the criteria for starting ART based on country’s guidelines at the time of the survey (Kenya–CD4< = 350 cells/µl and WHO Stage 3 or 4 disease, Malawi as for Kenya plus lifelong ART for all pregnant and breastfeeding women, South Africa as for Kenya plus ART for pregnant and breastfeeding women until cessation of breastfeeding).
Findings
Of 18,991 individuals who tested, 4,113 (21.7%) were HIV-positive. Using country’s ART eligibility guidelines at the time of the survey, the proportion of HIV-infected individuals eligible for ART was 60.0% (95% CI: 57.2–62.7) (Kenya), 73.4% (70.8–75.8) (South Africa) and 80.1% (77.3–82.6) (Malawi). Applying WHO 2013 guidelines (eligibility at CD4< = 500 and Option B+ for pregnant and breastfeeding women), the proportions eligible were 82.0% (79.8–84.1) (Kenya), 83.7% (81.5–85.6) (South Africa) and 87.6% (85.0–89.8) (Malawi). Adopting “test and treat” would mean a further 18.0% HIV-positive individuals (Kenya), 16.3% (South Africa) and 12.4% (Malawi) would become eligible. In all countries, about 20% of adolescents (aged 15–19 years), became eligible for ART moving from WHO 2013 to “test and treat” while no differences by sex were observed.
Conclusion
Countries that have already implemented 2013 WHO recommendations, the burden of implementing “test and treat” would be small. Youth friendly programmes to help adolescents access and adhere to treatment will be needed.
Go to:
Introduction
HIV remains one of the biggest contributors to mortality and morbidity in the world with most deaths occurring in the Sub-Saharan Africa (SSA)[1]. Despite freely available treatment for HIV/AIDS over the past decade, only (66.0%) of people living with HIV in eastern and southern part of SSA were on treatment in 2017 [2]. The World Health Organisation (WHO) 2013 treatment guidelines for starting HIV-positive people on antiretroviral therapy (ART) were CD4< = 500 cells/µl and for pregnant women to commence ART regardless of CD4 cell count [3]. In 2015 the WHO guidelines changed to starting every HIV-positive person on ART regardless of CD4 cell count[4] (the so-called “test and treat” approach) although some countries have not yet implemented these recommendations.
With only half the population of HIV-positive individuals on treatment, containing the spread of HIV remains a challenge with only small declines in incidence[5]. However, more evidence is becoming available on the benefits of undetectable viral load and early ART initiation on mortality and morbidity[6–8] and on lowering the risk of transmission[9–13], bringing hope on how further spreading of the disease can be contained through a “test and treat” approach.
However, adopting the new WHO guidelines may have challenges such as costs associated with more people on ART, infrastructure, human resources and how to monitor everyone started on ART to ensure that they adhere to medication[4]. This makes it difficult for countries to transition if they do not know what to expect if they move to test and treat.
To plan properly for transitioning to the new WHO guidelines, countries need to know the number, proportion, age and sex distribution of the additional HIV-positive individuals that will need to start ART. Most studies on the impact of change in ART guidelines on eligibility have been based on mathematical modeling [14, 15] which can easily over or underestimate results depending on the model assumptions. Other studies however, have used population data, for example in Kenya, a study that estimated the impact of change in treatment guidelines using nationally representative Kenya AIDS indicator survey data fell short of measuring the differential impact of the new WHO guidelines on age and sex[16]. Our aim therefore, was to measure the impact of a “test and treat” policy on eligibility, stratified by sex and age, using population data from three countries (Kenya, Malawi and South Africa) at different stages of implementing previous WHO guidelines.
Latest WHO guidelines recommend starting HIV-positive individuals on antiretroviral therapy treatment (ART) regardless of CD4 count. We assessed additional impact of adopting new WHO guidelines.
Methods
We used data of individuals aged 15–59 years from three HIV population surveys conducted in 2012 (Kenya) and 2013 (Malawi and South Africa). Individuals were interviewed at home followed by rapid HIV and CD4 testing if tested HIV-positive. HIV-positive individuals were classified as “eligible for ART” if (i) had ever been initiated on ART or (ii) were not yet on ART but met the criteria for starting ART based on country’s guidelines at the time of the survey (Kenya–CD4< = 350 cells/µl and WHO Stage 3 or 4 disease, Malawi as for Kenya plus lifelong ART for all pregnant and breastfeeding women, South Africa as for Kenya plus ART for pregnant and breastfeeding women until cessation of breastfeeding).
Findings
Of 18,991 individuals who tested, 4,113 (21.7%) were HIV-positive. Using country’s ART eligibility guidelines at the time of the survey, the proportion of HIV-infected individuals eligible for ART was 60.0% (95% CI: 57.2–62.7) (Kenya), 73.4% (70.8–75.8) (South Africa) and 80.1% (77.3–82.6) (Malawi). Applying WHO 2013 guidelines (eligibility at CD4< = 500 and Option B+ for pregnant and breastfeeding women), the proportions eligible were 82.0% (79.8–84.1) (Kenya), 83.7% (81.5–85.6) (South Africa) and 87.6% (85.0–89.8) (Malawi). Adopting “test and treat” would mean a further 18.0% HIV-positive individuals (Kenya), 16.3% (South Africa) and 12.4% (Malawi) would become eligible. In all countries, about 20% of adolescents (aged 15–19 years), became eligible for ART moving from WHO 2013 to “test and treat” while no differences by sex were observed.
Conclusion
Countries that have already implemented 2013 WHO recommendations, the burden of implementing “test and treat” would be small. Youth friendly programmes to help adolescents access and adhere to treatment will be needed.
Go to:
Introduction
HIV remains one of the biggest contributors to mortality and morbidity in the world with most deaths occurring in the Sub-Saharan Africa (SSA)[1]. Despite freely available treatment for HIV/AIDS over the past decade, only (66.0%) of people living with HIV in eastern and southern part of SSA were on treatment in 2017 [2]. The World Health Organisation (WHO) 2013 treatment guidelines for starting HIV-positive people on antiretroviral therapy (ART) were CD4< = 500 cells/µl and for pregnant women to commence ART regardless of CD4 cell count [3]. In 2015 the WHO guidelines changed to starting every HIV-positive person on ART regardless of CD4 cell count[4] (the so-called “test and treat” approach) although some countries have not yet implemented these recommendations.
With only half the population of HIV-positive individuals on treatment, containing the spread of HIV remains a challenge with only small declines in incidence[5]. However, more evidence is becoming available on the benefits of undetectable viral load and early ART initiation on mortality and morbidity[6–8] and on lowering the risk of transmission[9–13], bringing hope on how further spreading of the disease can be contained through a “test and treat” approach.
However, adopting the new WHO guidelines may have challenges such as costs associated with more people on ART, infrastructure, human resources and how to monitor everyone started on ART to ensure that they adhere to medication[4]. This makes it difficult for countries to transition if they do not know what to expect if they move to test and treat.
To plan properly for transitioning to the new WHO guidelines, countries need to know the number, proportion, age and sex distribution of the additional HIV-positive individuals that will need to start ART. Most studies on the impact of change in ART guidelines on eligibility have been based on mathematical modeling [14, 15] which can easily over or underestimate results depending on the model assumptions. Other studies however, have used population data, for example in Kenya, a study that estimated the impact of change in treatment guidelines using nationally representative Kenya AIDS indicator survey data fell short of measuring the differential impact of the new WHO guidelines on age and sex[16]. Our aim therefore, was to measure the impact of a “test and treat” policy on eligibility, stratified by sex and age, using population data from three countries (Kenya, Malawi and South Africa) at different stages of implementing previous WHO guidelines.
Journal Article > ResearchFull Text
PLOS One. 2021 April 22; Volume 16 (Issue 4); DOI:10.1371/journal.pone.0248410
Conan N, Paye CP, Ortuno R, Chijuwa A, Chiwandira B, et al.
PLOS One. 2021 April 22; Volume 16 (Issue 4); DOI:10.1371/journal.pone.0248410
Journal Article > ResearchFull Text
J Int AIDS Soc. 2020 September 24; Volume 23 (Issue 9); DOI:10.1002/jia2.25613
Conan N, Coulborn R M, Simons E, Mapfumo A, Apollo T, et al.
J Int AIDS Soc. 2020 September 24; Volume 23 (Issue 9); DOI:10.1002/jia2.25613
Introduction: Gutu, a rural district in Zimbabwe, has been implementing comprehensive HIV care with the support of Médecins Sans Frontières (MSF) since 2011, decentralizing testing and treatment services to all rural healthcare facilities. We evaluated HIV prevalence, incidence and the cascade of care, in Gutu District five years after MSF began its activities.
Methods: A cross-sectional study was implemented between September and December 2016. Using multistage cluster sampling, individuals aged ≥15 years living in the selected households were eligible. Individuals who agreed to participate were interviewed and tested for HIV at home. All participants who tested HIV-positive had their HIV-RNA viral load (VL) measured, regardless of their antiretroviral therapy (ART) status, and those not on ART with HIV-RNA VL ≥ 1000 copies/mL had Limiting-Antigen-Avidity EIA Assay for cross-sectional estimation of population-level HIV incidence.
Results: Among 5439 eligible adults ≥15 years old, 89.0% of adults were included in the study and accepted an HIV test. The overall prevalence was 13.6% (95%: Confidence Interval (CI): 12.6 to 14.5). Overall HIV-positive status awareness was 87.4% (95% CI: 84.7 to 89.8), linkage to care 85.5% (95% CI: 82.5 to 88.0) and participants in care 83.8% (95% CI: 80.7 to 86.4). ART coverage among HIV-positive participants was 83.0% (95% CI: 80.0 to 85.7). Overall, 71.6% (95% CI 68.0 to 75.0) of HIV-infected participants had a HIV-RNA VL < 1000 copies/mL. Women achieved higher outcomes than men in the five stages of the cascade of care. Viral Load Suppression (VLS) among participants on ART was 83.2% (95% CI: 79.7 to 86.2) and was not statistically different between women and men (p = 0.98). The overall HIV incidence was estimated at 0.35% (95% CI 0.00 to 0.70) equivalent to 35 new cases/10,000 person-years.
Conclusions: Our study provides population-level evidence that achievement of HIV cascade of care coverage overall and among women is feasible in a context with broad access to services and implementation of a decentralized model of care. However, the VLS was relatively low even among participants on ART. Quality care remains the most critical gap in the cascade of care to further reduce mortality and HIV transmission.
Methods: A cross-sectional study was implemented between September and December 2016. Using multistage cluster sampling, individuals aged ≥15 years living in the selected households were eligible. Individuals who agreed to participate were interviewed and tested for HIV at home. All participants who tested HIV-positive had their HIV-RNA viral load (VL) measured, regardless of their antiretroviral therapy (ART) status, and those not on ART with HIV-RNA VL ≥ 1000 copies/mL had Limiting-Antigen-Avidity EIA Assay for cross-sectional estimation of population-level HIV incidence.
Results: Among 5439 eligible adults ≥15 years old, 89.0% of adults were included in the study and accepted an HIV test. The overall prevalence was 13.6% (95%: Confidence Interval (CI): 12.6 to 14.5). Overall HIV-positive status awareness was 87.4% (95% CI: 84.7 to 89.8), linkage to care 85.5% (95% CI: 82.5 to 88.0) and participants in care 83.8% (95% CI: 80.7 to 86.4). ART coverage among HIV-positive participants was 83.0% (95% CI: 80.0 to 85.7). Overall, 71.6% (95% CI 68.0 to 75.0) of HIV-infected participants had a HIV-RNA VL < 1000 copies/mL. Women achieved higher outcomes than men in the five stages of the cascade of care. Viral Load Suppression (VLS) among participants on ART was 83.2% (95% CI: 79.7 to 86.2) and was not statistically different between women and men (p = 0.98). The overall HIV incidence was estimated at 0.35% (95% CI 0.00 to 0.70) equivalent to 35 new cases/10,000 person-years.
Conclusions: Our study provides population-level evidence that achievement of HIV cascade of care coverage overall and among women is feasible in a context with broad access to services and implementation of a decentralized model of care. However, the VLS was relatively low even among participants on ART. Quality care remains the most critical gap in the cascade of care to further reduce mortality and HIV transmission.
Journal Article > ResearchFull Text
PLOS One. 2022 March 24; Volume 17 (Issue 3); e0265488.; DOI:10.1371/journal.pone.0265488
Conan N, Simons E, Chihana ML, Ohler L, FordKamara E, et al.
PLOS One. 2022 March 24; Volume 17 (Issue 3); e0265488.; DOI:10.1371/journal.pone.0265488
INTRODUCTION
High coverage of antiretroviral therapy (ART) in people living with HIV (PLHIV) increases viral suppression at population level and may reduce incidence. Médecins sans Frontières, in collaboration with the South African Department of Health, has been working in Eshowe/Mbongolwane (KwaZulu Natal) since 2011 to increase access to quality HIV services. Five years after an initial survey, we conducted a second survey to measure progress in HIV diagnosis and viral suppression and to identify remaining gaps.
METHODS
A cross-sectional, population-based, stratified two-stage cluster survey was implemented in 2018, using the same design as in 2013. Consenting participants aged 15-59 years were interviewed and tested for HIV at home. Those HIV-positive were tested for HIV viral load (viral suppression defined as <1000 copies/mL).
RESULTS
Overall, 3,278 individuals were included. The proportion of HIV-positive participants virally suppressed was 83.8% in 2018 compared to 57.1% in 2013 (p<0.001), with increases in all subpopulations. The largest gap remained in men aged 15-29 years, among whom viral suppression was 51.5%. Nevertheless, of the total unsuppressed participants, 60.3% were women, and 57.4% were individuals aged 30-59 years. Between 2013 and 2018, HIV-positive status awareness progressed from 75.2% to 89.9% and ART coverage among those aware from 70.4% to 93.8%, respectively. Among those on ART, 94.5% were virally suppressed in 2018.
CONCLUSIONS
Viral suppression improved significantly from 2013 to 2018, in all age and gender groups of PLHIV. However, almost half of HIV-positive young men remained unsuppressed, while the majority of virally unsuppressed PLHIV were women and older adults. To continue lowering HIV transmission, specific strategies are needed to increase viral suppression in those groups.
High coverage of antiretroviral therapy (ART) in people living with HIV (PLHIV) increases viral suppression at population level and may reduce incidence. Médecins sans Frontières, in collaboration with the South African Department of Health, has been working in Eshowe/Mbongolwane (KwaZulu Natal) since 2011 to increase access to quality HIV services. Five years after an initial survey, we conducted a second survey to measure progress in HIV diagnosis and viral suppression and to identify remaining gaps.
METHODS
A cross-sectional, population-based, stratified two-stage cluster survey was implemented in 2018, using the same design as in 2013. Consenting participants aged 15-59 years were interviewed and tested for HIV at home. Those HIV-positive were tested for HIV viral load (viral suppression defined as <1000 copies/mL).
RESULTS
Overall, 3,278 individuals were included. The proportion of HIV-positive participants virally suppressed was 83.8% in 2018 compared to 57.1% in 2013 (p<0.001), with increases in all subpopulations. The largest gap remained in men aged 15-29 years, among whom viral suppression was 51.5%. Nevertheless, of the total unsuppressed participants, 60.3% were women, and 57.4% were individuals aged 30-59 years. Between 2013 and 2018, HIV-positive status awareness progressed from 75.2% to 89.9% and ART coverage among those aware from 70.4% to 93.8%, respectively. Among those on ART, 94.5% were virally suppressed in 2018.
CONCLUSIONS
Viral suppression improved significantly from 2013 to 2018, in all age and gender groups of PLHIV. However, almost half of HIV-positive young men remained unsuppressed, while the majority of virally unsuppressed PLHIV were women and older adults. To continue lowering HIV transmission, specific strategies are needed to increase viral suppression in those groups.
Journal Article > ResearchFull Text
Glob Health Action. 2019 January 1; Volume 12 (Issue 1); 1679472.; DOI:10.1080/16549716.2019.1679472
Chihana ML, Huerga H, van Cutsem G, Ellman T, Goemaere E, et al.
Glob Health Action. 2019 January 1; Volume 12 (Issue 1); 1679472.; DOI:10.1080/16549716.2019.1679472
BACKGROUND
Despite substantial progress in antiretroviral therapy (ART) scale up, some people living with HIV (PLHIV) continue to present with advanced HIV disease, contributing to ongoing HIV-related morbidity and mortality.
OBJECTIVE
We aimed to quantify population-level estimates of advanced HIV from three high HIV prevalence settings in Sub-Saharan Africa.
METHODS
Three cross-sectional surveys were conducted in (Ndhiwa (Kenya): September–November 2012), (Chiradzulu (Malawi): February–May 2013) and (Eshowe (South Africa): July–October 2013). Eligible individuals 15–59 years old who consented were interviewed at home followed by rapid HIV test and CD4 count test if tested HIV-positive. Advanced HIV was defined as CD4 < 200 cells/µl. We used logistic regression to identify patient characteristics associated with advanced HIV.
RESULTS
Among 18,991 (39.2% male) individuals, 4113 (21.7%) tested HIV-positive; 385/3957 (9.7% (95% Confidence Interval [CI]: 8.8–10.7)) had advanced HIV, ranging from 7.8% (95%CI 6.4–9.5) Chiradzulu (Malawi) to 11.8% (95%CI 9.8–14.2) Ndhiwa (Kenya). The proportion of PLHIV with advanced disease was higher among men 15.3% (95% CI 13.2–17.5) than women 7.5% (95%CI 6.6–8.6) p < 0.001. Overall, 62.7% of all individuals with advanced HIV were aware of their HIV status and 40.3% were currently on ART. Overall, 65.6% of individuals not on ART had not previously been diagnosed with HIV, while only 29.6% of those on ART had been on ART for =6 months. Individuals with advanced HIV disease were more likely to be men (adjusted Odds Ratio [aOR]; 2.1 (95%CI 1.7–2.6), and more likely not to be on ART (aOR; 1.7 (95%CI 1.3–2.1).
CONCLUSIONS
In our study, about 1 in 10 PLHIV had advanced HIV with nearly 40% of them unaware of their HIV status. However, a substantial proportion of patients with advanced HIV were established on ART. Our findings suggest the need for a dual focus on alternative testing strategies to identify PLHIV earlier as well as improving ART retention.
Despite substantial progress in antiretroviral therapy (ART) scale up, some people living with HIV (PLHIV) continue to present with advanced HIV disease, contributing to ongoing HIV-related morbidity and mortality.
OBJECTIVE
We aimed to quantify population-level estimates of advanced HIV from three high HIV prevalence settings in Sub-Saharan Africa.
METHODS
Three cross-sectional surveys were conducted in (Ndhiwa (Kenya): September–November 2012), (Chiradzulu (Malawi): February–May 2013) and (Eshowe (South Africa): July–October 2013). Eligible individuals 15–59 years old who consented were interviewed at home followed by rapid HIV test and CD4 count test if tested HIV-positive. Advanced HIV was defined as CD4 < 200 cells/µl. We used logistic regression to identify patient characteristics associated with advanced HIV.
RESULTS
Among 18,991 (39.2% male) individuals, 4113 (21.7%) tested HIV-positive; 385/3957 (9.7% (95% Confidence Interval [CI]: 8.8–10.7)) had advanced HIV, ranging from 7.8% (95%CI 6.4–9.5) Chiradzulu (Malawi) to 11.8% (95%CI 9.8–14.2) Ndhiwa (Kenya). The proportion of PLHIV with advanced disease was higher among men 15.3% (95% CI 13.2–17.5) than women 7.5% (95%CI 6.6–8.6) p < 0.001. Overall, 62.7% of all individuals with advanced HIV were aware of their HIV status and 40.3% were currently on ART. Overall, 65.6% of individuals not on ART had not previously been diagnosed with HIV, while only 29.6% of those on ART had been on ART for =6 months. Individuals with advanced HIV disease were more likely to be men (adjusted Odds Ratio [aOR]; 2.1 (95%CI 1.7–2.6), and more likely not to be on ART (aOR; 1.7 (95%CI 1.3–2.1).
CONCLUSIONS
In our study, about 1 in 10 PLHIV had advanced HIV with nearly 40% of them unaware of their HIV status. However, a substantial proportion of patients with advanced HIV were established on ART. Our findings suggest the need for a dual focus on alternative testing strategies to identify PLHIV earlier as well as improving ART retention.
Journal Article > ResearchFull Text
S Afr Med J. 2021 August 2; Volume 111 (Issue 8); 768-776.; DOI:10.7196/SAMJ.2021.v111i8.15489
Chihana ML, Conan N, Ellman T, Poulet E, Garone DB, et al.
S Afr Med J. 2021 August 2; Volume 111 (Issue 8); 768-776.; DOI:10.7196/SAMJ.2021.v111i8.15489
BACKGROUND
HIV-serodiscordant couples are at high risk of HIV transmission. In sub-Saharan Africa, HIV-serodiscordant couples contribute ~30% of all new infections in the region.
OBJECTIVES
To quantify the prevalence of HIV-serodiscordant couples and evaluate steps of the HIV cascade of care among people living with HIV in serodiscordant relationships in four high-prevalence settings in sub-Saharan Africa.
METHODS
Four HIV prevalence surveys were conducted: in Ndhiwa (Kenya) in 2012, in Chiradzulu (Malawi) in 2013, and in Gutu (Zimbabwe) and Nsanje (Malawi) in 2016. Eligible individuals aged 15 - 59 years were asked to participate in voluntary rapid HIV testing. Viral load and CD4 counts were measured on those who tested HIV-positive. A couple was defined as a man and a woman who reported being married or cohabiting and were living together in the same household.
RESULTS
Among 4 385 couples, the prevalence of HIV serodiscordancy was 10.9% (95% confidence interval (CI) 10.2 - 11.5) overall, ranging from 6.7% (95% CI 5.6 - 7.9) in Nsanje to 15.8% (95% CI 14.5 - 17.3) in Ndhiwa. Men were the HIV-positive partner in 62.7% of the serodiscordant couples in Ndhiwa, in 60.4% in Gutu, in 48.8% in Chiradzulu and in 50.9% in Nsanje. Status awareness among HIV-positive partners in serodiscordant couples ranged from 45.4% in Ndhiwa to 70.7% in Gutu. Viral load suppression (VLS) ranged from 33.9% in Ndhiwa to 68.5% in Nsanje. VLS was similar by sex in three settings, Ndhiwa (37.8% (men) v. 27.8% (women); p=0.16), Nsanje (60.7% v. 76.9%; p=0.21) and Gutu (48.2% v. 55.6%; p=0.63), and dissimilar by sex in Chiradzulu (44.4% v. 62.7%; p=0.03).
CONCLUSIONS
Low HIV status awareness and poor VLS among HIV-positive partners are major gaps in preventing transmission among serodiscordant couples. Intensifying programmes that target couples to test for HIV and timely antiretroviral therapy initiation could increase VLS and reduce HIV transmission.
HIV-serodiscordant couples are at high risk of HIV transmission. In sub-Saharan Africa, HIV-serodiscordant couples contribute ~30% of all new infections in the region.
OBJECTIVES
To quantify the prevalence of HIV-serodiscordant couples and evaluate steps of the HIV cascade of care among people living with HIV in serodiscordant relationships in four high-prevalence settings in sub-Saharan Africa.
METHODS
Four HIV prevalence surveys were conducted: in Ndhiwa (Kenya) in 2012, in Chiradzulu (Malawi) in 2013, and in Gutu (Zimbabwe) and Nsanje (Malawi) in 2016. Eligible individuals aged 15 - 59 years were asked to participate in voluntary rapid HIV testing. Viral load and CD4 counts were measured on those who tested HIV-positive. A couple was defined as a man and a woman who reported being married or cohabiting and were living together in the same household.
RESULTS
Among 4 385 couples, the prevalence of HIV serodiscordancy was 10.9% (95% confidence interval (CI) 10.2 - 11.5) overall, ranging from 6.7% (95% CI 5.6 - 7.9) in Nsanje to 15.8% (95% CI 14.5 - 17.3) in Ndhiwa. Men were the HIV-positive partner in 62.7% of the serodiscordant couples in Ndhiwa, in 60.4% in Gutu, in 48.8% in Chiradzulu and in 50.9% in Nsanje. Status awareness among HIV-positive partners in serodiscordant couples ranged from 45.4% in Ndhiwa to 70.7% in Gutu. Viral load suppression (VLS) ranged from 33.9% in Ndhiwa to 68.5% in Nsanje. VLS was similar by sex in three settings, Ndhiwa (37.8% (men) v. 27.8% (women); p=0.16), Nsanje (60.7% v. 76.9%; p=0.21) and Gutu (48.2% v. 55.6%; p=0.63), and dissimilar by sex in Chiradzulu (44.4% v. 62.7%; p=0.03).
CONCLUSIONS
Low HIV status awareness and poor VLS among HIV-positive partners are major gaps in preventing transmission among serodiscordant couples. Intensifying programmes that target couples to test for HIV and timely antiretroviral therapy initiation could increase VLS and reduce HIV transmission.