Progress in Reversing the HIV Epidemic through Intensified Access to Antiretroviral Therapy: Results from a Nationally Representative Population-Based Survey in Kenya, 2012

Background

In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) called for 90% of persons living with HIV (PLHIV) to know their status, 90% of these to be on antiretroviral therapy (ART), and 90% of these to be virally suppressed by 2020 (90-90-90). It is not clear whether planned ART scale-up in countries whose eligibility criteria for ART initiation are based on recommendations from the 2013 World Health Organization treatment guidelines will be sufficient to meet UNAIDS' new global targets.

Materials and Methods

Using data from a nationally representative population-based household survey of persons in Kenya we compared coverage and unmet need associated with HIV diagnosis, ART, and viral suppression among PLHIV aged 15–64 years in 2012 based on criteria outlined in the 2014 national ART guidelines and UNAIDS’ 90-90-90 goals. Estimates were weighted to account for sampling probability and nonresponse.

Results

Eight in ten PLHIV aged 15–64 years needed ART based on treatment eligibility. Need for treatment based on the national treatment policy was 97.4% of treatment need based on UNAIDS’ 90-90-90 goals, requiring an excess of 24,000 PLHIV to access treatment beyond those eligible for ART to achieve UNAIDS’ 90-90-90 treatment target. The gap in treatment coverage was high, ranging from 43.1% nationally to 52.3% in Nyanza among treatment-eligible PLHIV and 44.6% nationally to 52.4% in Nyanza among all PLHIV.

Conclusion

Maintaining the current pace of ART scale-up in Kenya will result in thousands of PLHIV unreached, many with high viral load and at-risk of transmitting infection to others. Careful strategies for reaching 90-90-90 will be instrumental in determining whether intensified access to treatment can be achieved to reach all who require ART.

Below:  Baseline estimates of coverage of 90-90-90 targets in Kenya, Kenya AIDS Indicator Survey, 2012–2013

Below:  Baseline estimates of coverage of 90-90-90 targets in Nyanza region, Kenya AIDS Indicator Survey, 2012–2013

Below:  Baseline estimates of coverage of diagnosis, treatment, and viral suppression among persons eligible for ART in Kenya based on the 2014 national treatment guidelines, Kenya AIDS Indicator Survey, 2012–2013

Below:  Baseline estimates of coverage of diagnosis, treatment, and viral suppression among persons eligible for ART in Nyanza region based on the 2014 national treatment guidelines, Kenya AIDS Indicator Survey, 2012–2013

Full article at:   http://goo.gl/OU0RzP

By:  Andrea A. Kim,1,* Irene Mukui,2 Lucy N’gan’ga,1 Abraham Katana,1 Dan Koros,1 Joyce Wamicwe,2 Kevin M. De Cock,1and KAIS Study Group¶

¹US Centers for Disease Control and Prevention, Division of Global HIV and Tuberculosis, Nairobi, Kenya

²Ministry of Health, National AIDS and STI Control Programme, Nairobi, Kenya

British Columbia Centre for Excellence in HIV/AIDS, CANADA

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Which New Health Technologies Do We Need to Achieve an End to HIV/AIDS?

In the last 15 years, antiretroviral therapy (ART) has been the most globally impactful life-saving development of medical research. Antiretrovirals (ARVs) are used with great success for both the treatment and prevention of HIV infection. Despite these remarkable advances, this epidemic grows relentlessly worldwide. Over 2.1 million new infections occur each year, two-thirds in women and 240,000 in children. The widespread elimination of HIV will require the development of new, more potent prevention tools. Such efforts are imperative on a global scale. However, it must also be recognised that true containment of the epidemic requires the development and widespread implementation of a scientific advancement that has eluded us to date—a highly effective vaccine. Striving for such medical advances is what is required to achieve the end of AIDS…

Even with all the biomedical and behavioural tools available today, HIV continues to be a formidable pathogen, altering the health economics and public health strategies of most countries worldwide. Of the 35 million HIV-infected individuals worldwide in 2014, more than half did not know their HIV status, and over a third were not receiving ARVs [1] despite the availability of affordable point-of-care diagnostics and treatments. Adoption of “universal test and treat” approaches, extension of medical male circumcision programs, universal access to basic harm reduction services for people who inject drugs, and more widespread use of PrEP in targeted populations can do much to “bend the curve” and initiate a process to slow the rate of new HIV infections (Table 4). Such efforts are imperative on a global scale. However, it must also be recognised that true containment of the epidemic requires the development and widespread implementation of a scientific advance that has eluded us to date—a highly effective vaccine. There are potential synergies that will accrue from an integrated approach involving treatment, microbicides, and HIV vaccines (Fig 2). Various mathematical models agree that treatment roll-out on its own will decrease HIV incidence over time. However, when a 30% preventative HIV vaccine was introduced to a model with expanding treatment access in southern Africa, incidence was predicted to be 67% lower over time compared to a scenario with no vaccine introduction [35].

Below: Medical interventions required to end the epidemic of HIV

Below:  The spectrum of biomedical innovation required to end AIDS

Full article at:   http://goo.gl/SmCmO6

By:  Glenda E. Gray,1,2,* Fatima Laher,2 Tanya Doherty,1,3,4 Salim Abdool Karim,5,6 Scott Hammer,7 John Mascola,8 Chris Beyrer,9,10 and Larry Corey11

¹South African Medical Research Council, Cape Town, South Africa

²Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

³School of Public Health, University of Western Cape, Bellville, South Africa

⁴School of Public Health, University of the Witwatersrand, Johannesburg, South Africa

⁵Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa

⁶Mailman School of Public Health, Columbia University, New York City, New York, United States of America

⁷Columbia University Medical Center, New York City, New York, United States of America

⁸Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health. Bethesda, Maryland, United States of America

⁹Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America

¹⁰The International AIDS Society, Geneva, Switzerland

¹¹HIV Vaccine Trials Network, Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington

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Social & Clinical Attributes of Patients Who Restart Antiretroviral Therapy in Central & Copperbelt Provinces, Zambia

Background

About 30 % of the patients initiated on antiretroviral therapy in Zambia default treatment. Some of these patients later restart treatment; however, the characteristics of these patients have not been well described and documented. The aim of this study was to describe and document the socio-demographic and clinical characteristics of patients who default and restart antiretroviral therapy, and to determine the socio-demographic characteristics associated with CD4 count response at 6 and 24 months of restarting antiretroviral therapy.

Methods

A longitudinal retrospective analysis was performed on data from 535 adult patients restarting antiretroviral therapy in 2009 and 2010 at five antiretroviral therapy centres in Copperbelt and Central provinces of Zambia. To determine the association between the socio-demographic characteristics and CD4 cell count, quantile regression models were used.

Results

Older age above 45 years was associated with a significantly lower CD4 cell response by 38.1 cells/mm³ compared to the younger age (15–29 years). Patients in formal employment and self-employment gained significantly higher CD4 cells than those unemployed. In addition, baseline CD4 count, type of treatment, WHO staging, total duration on treatment and duration lost to follow-up were found to be strong predictors of CD4 cell count at 6 and 24 months after restarting antiretroviral therapy treatment.

Conclusion

Age and occupation were the only socio-demographic characteristics predicting CD4 count in the patients at 6 months after restarting antiretroviral therapy after adjusting for other confounding clinical variables.  

Below:  Boxplots of Interquartile range of CD4 count at restarting ART, 6 and 24 months after restaring ART

Full article at:  http://goo.gl/8P145h

By:  Chama Mulubwa, Oliver Mweemba, Patrick Katayamoyo, and Hikabasa Halwindi

Department of Public Health, School of Medicine, University of Zambia, PO Box 50110, Lusaka, Zambia

FHI 360, Plot 2374, Farmers Village, ZNFU Complex, Lusaka, Zambia

BMC Public Health. 2016; 16: 289.

Published online 2016 Mar 29. doi:  10.1186/s12889-016-2922-3

Department of Public Health, School of Medicine, University of Zambia, PO Box 50110, Lusaka, Zambia

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What to Expect at the HIV Doctor - Video

Via:    http://goo.gl/OcvTEY

CD4 Counts at Entry to HIV Care in Mexico for Patients under the “Universal Antiretroviral Treatment Program for the Uninsured Population,” 2007–2014

In Mexico, public health services have provided universal access to antiretroviral therapy (ART) since 2004. For individuals receiving HIV care in public healthcare facilities, the data are limited regarding CD4 T-lymphocyte counts (CD4e) at the time of entry into care. Relevant population-based estimates of CD4e are needed to inform strategies to maximize the impact of Mexico’s national ART program, and may be applicable to other countries implementing universal HIV treatment programs. 

For this study, we retrospectively analyzed the CD4e of persons living with HIV and receiving care at state public health facilities from 2007 to 2014, comparing CD4e by demographic characteristics and the marginalization index of the state where treatment was provided, and assessing trends in CD4e over time. 

Our sample included 66,947 individuals who entered into HIV care between 2007 and 2014, of whom 79% were male. During the study period, the male-to-female ratio increased from 3.0 to 4.3, reflecting the country's HIV epidemic; the median age at entry decreased from 34 years to 32 years. 

Overall, 48.6% of individuals entered care with a CD4≤200 cells/μl, ranging from 42.2% in states with a very low marginalization index to 52.8% in states with a high marginalization index, and from 38.9% among individuals aged 18–29 to 56.5% among those older than 50. 

The adjusted geometric mean (95% confidence interval) CD4e increased among males from 135 (131,142) cells/μl in 2007 to 148 (143,155) cells/μl in 2014 (p-value<0.0001); no change was observed among women, with a geometric mean of 178 (171,186) and 171 (165,183) in 2007 and 2014, respectively. 

There have been important gains in access to HIV care and treatment; however, late entry into care remains an important barrier in achieving optimal outcomes of ART in Mexico. The geographic, socioeconomic, and demographic differences observed reflect important inequities in timely access to HIV prevention, care, and treatment services, and highlight the need to develop contextual and culturally appropriate prevention and HIV testing strategies and linkage programs.

Below:  CD4e counts at health care program entry decline after 2011

Full article at:   http://goo.gl/PYlXy0

By:  

Alfonso C. Hernández-Romieu, Carlos del Rio 
Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America

Alfonso C. Hernández-Romieu, Carlos del Rio 

Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States of America

Carlos del Rio 

Center for AIDS Research, Emory University, Atlanta, GA, United States of America

Juan Eugenio Hernández-Ávila, Hugo Lopez-Gatell, Mauricio Hernández-Ávila 

National Institute of Public Health (INSP), Cuernavaca, Mexico

José Antonio Izazola-Licea 

National Center for Prevention and Control of HIV/AIDS (CENSIDA), Mexico City, Mexico

José Antonio Izazola-Licea, Patricia Uribe Zúñiga 

Joint United Nations Programme on HIV/AIDS (UNAIDS), Evaluation and Economics Division, Geneva, Switzerland

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Low Frequency Drug Resistance in HIV-infected Ugandans on Antiretroviral Treatment is Associated with Regimen Failure

BACKGROUND:

Most patients failing antiretroviral treatment in Uganda will continue to fail their treatment regimen even if a dominant drug resistant HIV-1 genotype is not detected. In a recent retrospective study we observed that approximately 30% of HIV-infected individuals in the Joint Clinical Research Centre (Kampala, Uganda) experienced virologic failure with a susceptible HIV-1 genotype based on standard Sanger sequencing. Selection of minority drug resistant HIV-1 variants (not detectable by Sanger sequencing) under antiretroviral therapy pressure can lead to a shift in the viral quasispecies distribution, becoming dominant members of the virus population and eventually causing treatment failure.

METHODS AND FINDINGS:

Here we used a novel HIV-1 genotyping assay based on deep sequencing (DEEPGEN) to quantify low-level drug-resistant HIV-1 variants in thirty-three patients failing a first-line antiretroviral treatment regimen in the absence of drug resistant mutations, as screened by standard population-based Sanger sequencing. Using this sensitive assay we observed that 64% (21/33) of these individuals had low-frequency (or minority) drug resistant variants in the intrapatient HIV-1 population, which correlated with treatment failure. Moreover, the presence of these minority HIV-1 variants was associated with higher intrapatient HIV-1 diversity, suggesting a dynamic selection or fading of drug resistance HIV-1 variants from the viral quasispecies in the presence or absence of drug pressure, respectively.

CONCLUSIONS:

This study has identified low-frequency HIV drug resistance mutations by deep sequencing in Uganda patients failing antiretroviral treatment but lacking dominant drug resistance mutations as determined by Sanger sequencing methods. We showed that these low-abundance drug resistant viruses could have significant consequences on clinical outcomes, especially if treatment is not modified based on a susceptible HIV-1 genotype based on Sanger sequencing. Therefore, we propose to base clinical decisions using more sensitive methods to detect minority HIV-1 variants.

Purchase full article at:   http://goo.gl/v4h4F4

By:  Kyeyune F1, Gibson RM2, Nankya I3, Venner C2, Metha S4, Akao J4, Ndashimye E5, Kityo CM4, Salata RA6, Mugyenyi P4, Arts EJ7, Quiñones-Mateu ME8.

• 1Center for AIDS Research Uganda Laboratories, Joint Clinical Research Centre, Kampala, Uganda Department of Molecular Biology and Microbiology.
• 2Department of Microbiology and Immunology, University of Western Ontario, London, Ontario, Canada.
• 3Center for AIDS Research Uganda Laboratories, Joint Clinical Research Centre, Kampala, Uganda Department of Medicine, and Department of Pathology, Case Western Reserve University, Cleveland, Ohio, USA.
• 4Center for AIDS Research Uganda Laboratories, Joint Clinical Research Centre, Kampala, Uganda TREAT, Joint Clinical Research Centre, Kampala, Uganda.
• 5Center for AIDS Research Uganda Laboratories, Joint Clinical Research Centre, Kampala, Uganda.
• 6Department of Medicine, and Department of Pathology, Case Western Reserve University, Cleveland, Ohio, USA.
• 7Center for AIDS Research Uganda Laboratories, Joint Clinical Research Centre, Kampala, Uganda Department of Microbiology and Immunology, University of Western Ontario, London, Ontario, Canada Department of Medicine, and Department of Pathology, Case Western Reserve University, Cleveland, Ohio, USA earts@uwo.ca.
• 8Center for AIDS Research Uganda Laboratories, Joint Clinical Research Centre, Kampala, Uganda Department of Medicine, and Department of Pathology, Case Western Reserve University, Cleveland, Ohio, USA Department of Medicine, and Department of Pathology, Case Western Reserve University, Cleveland, Ohio, USA University Hospital Translational Laboratory, University Hospitals Case Medical Center, Cleveland, Ohio, USA meq@case.edu. 

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Client Satisfaction: Correlates & Implications for Improving HIV/AIDS Treatment & Care Services in Southern Ethiopia

INTRODUCTION:

Satisfaction with services is a qualitative but important measure of the fit between clients and care providers and is also a measure of the outcome of treatment. This study investigated the level and correlates of client satisfaction with HIV care.

METHODS:

A cross-sectional questionnaire-based study was conducted on 485 people using HIV/AIDS treatment and care services in six health facilities in Wolaita Zone of Ethiopia from November 2014 to March 2015.

RESULTS:

A total of 222 (45.8%) and 263 (54.2%) of the participants attended care at the health centers and hospital, respectively; 192 (39.6%) visited traditional medical practitioners. Seventy-five (15.5%) of the participants suffered probable mild to major mental depression. In total, 342 (70.7%) said that the quality of care was good and 224 (46.4%) were satisfied with the services. In multivariate analysis, probable mental depression, health system responsiveness, perceived quality of care and type of health facility were independently associated with satisfaction with HIV care (p<0.05).

CONCLUSIONS:

Healthcare systems need to improve the responsiveness and quality of HIV care, and integrate a mental health care component to achieve higher client satisfaction. Further studies on the types of health facilities (between health centers and hospitals) in relation to satisfaction with services are recommended.

Purchase full article at:   http://goo.gl/0EOazq

By:  Yakob B¹, Purity Ncama B².

¹School of Nursing & Public Health, Howard College, University of KwaZulu-Natal, Durban, South Africa Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa berekbot@yahoo.com.

²School of Nursing & Public Health, Howard College, University of KwaZulu-Natal, Durban, South Africa.

Int Health. 2016 Mar 23. pii: ihw008.

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Mental Health among Men Who Have Sex with Men in Cambodia: Implications for Integration of Mental Health Services within HIV Programs

BACKGROUND:

Poor mental health contributes to poor HIV prevention, treatment and care outcomes. This paper documents factors associated with psychological distress among men who have sex with men (MSM) in Cambodia and discusses potential ways in which routine mental health management could be integrated into HIV services.

METHODS:

A cross-sectional study was conducted in 2014 among 394 MSM randomly selected from two provinces using a two-stage cluster sampling method. A structured questionnaire was used to assess psychological distress, sexual behaviors, substance use, adverse childhood experiences and family dysfunction. Multivariate logistic regression analysis was performed to explore factors associated with levels of psychological distress.

RESULTS:

In total, 10.7 % of the respondents reported having suicidal thoughts and 6.6 % reported having attempted to commit suicide in the past three months, while 38.8 % had a higher level of psychological distress, which indicates poor mental health. Higher levels of psychological distress were independently associated with older age, alcohol use, illicit drug use, poor self-reported quality of life, and reduced condom use at last sex. MSM with higher levels of psychological distress were significantly more likely to report that a family member said hurtful things to them, a parent or guardian had been physically abused, and a family member had been mentally ill when they were growing up.

CONCLUSIONS:

In order to mitigate psychological distress among MSM in Cambodia, integration of mental health interventions within HIV programmes should be strengthened. To achieve optimal impact, these interventions should also address alcohol and other substance use, and low condom use among distressed MSM. In addition, training of clinical and non-clinical HIV service providers to screen for mental health symptoms, and subsequent provision of peer-based outreach and social support for MSM identified with psychological distress is required.

Comparisons of sexual behaviors and HIV/STI testing among MSM with a lower and higher level of psychological distress

Sexual behaviors in the past 3 months	Total	Total GHQ-12 score
	(n = 394)	≤3 (n = 241)	>3 (n = 153)	p-value*
Mean number of sex partners	3.9 ± 5.4	3.8 ± 5.7	4.0 ± 5.0	0.68
Used a condom in the last sex	313 (82.8)	202 (87.4)	211 (75.5)	0.003
Had sex with girlfriends	118 (29.9)	79 (32.7)	39 (15.4)	0.03
Mean number of girlfriends you had sex with	1.7 ± 1.1	1.7 ± 1.0	1.9 ± 1.2	0.26
Used a condom in last sex with girlfriends	97 (82.2)	68 (86.1)	29 (74.4)	0.12
Had sex with boyfriends	206 (86.9)	126 (85.7)	80 (88.9)	0.48
Mean number of boyfriends you had sex with	2.4 ± 3.8	2.3 ± 3.5	2.6 ± 4.3	0.53
Used a condom in last sex with boyfriends	192 (92.8)	117 (92.9)	75 (92.6)	0.94
Had anal sex with boyfriends	196 (94.2)	116 (91.3)	80 (98.8)	0.03
Used condom in last anal sex with boyfriend	187 (92.1)	114 (94.2)	73 (89.0)	0.18
Sold sex to men	67 (17.0)	42 (17.4)	25 916.3)	0.78
Used condom when selling sex last time	63 (94.0)	40 (95.2)	23 (92.0)	0.59
Tested for HIV in the past 6 months	252 (64.0)	160 (66.4)	92 (60.1)	0.21
Been diagnosed with an STI	28 (7.1)	16 (6.6)	12 (7.9)	0.63

GHQ general health questionnaire, MSM men who have sex with men, STI sexually transmitted infection

Values are number (%) for categorical variables and mean ± SD for continuous variables

*Chi-square test or Fisher’s exact test was used as appropriate for categorical variables and Student’s t-test was used for continuous variables

Full article at:   http://goo.gl/nJqgnZ

By:  Yi S1, Tuot S1, Chhoun P2, Pal K2, Choub SC2, Mburu G3,4.

• 1Research Department, KHANA, Phnom Penh, Cambodia.
• 2Programs Department, KHANA, Phnom Penh, Cambodia.
• 3Program Impact Unit, International HIV/AIDS Alliance, Brighton, UK. gmburu@aidsalliance.org.
• 4Department of Health Research, Lancaster University, Lancaster, UK. gmburu@aidsalliance.org. 

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