Despite significant progress on the proportion of individuals who know their HIV status in 2020, Côte d'Ivoire (76%), Senegal (78%), and Mali (48%) remain far below, and key populations (KP) ...including female sex workers (FSW), men who have sex with men (MSM), and people who use drugs (PWUD) are the most vulnerable groups with a HIV prevalence at 5-30%. HIV self-testing (HIVST), a process where a person collects his/her own specimen, performs a test, and interprets the result, was introduced in 2019 as a new testing modality through the ATLAS project coordinated by the international partner organisation Solthis (IPO). We estimate the costs of implementing HIVST through 23 civil society organisations (CSO)-led models for KP in Côte d'Ivoire (
= 7), Senegal (
= 11), and Mali (
= 5). We modelled costs for programme transition (2021) and early scale-up (2022-2023). Between July 2019 and September 2020, a total of 51,028, 14,472, and 34,353 HIVST kits were distributed in Côte d'Ivoire, Senegal, and Mali, respectively. Across countries, 64-80% of HIVST kits were distributed to FSW, 20-31% to MSM, and 5-8% to PWUD. Average costs per HIVST kit distributed were $15 for FSW (Côte d'Ivoire: $13, Senegal: $17, Mali: $16), $23 for MSM (Côte d'Ivoire: $15, Senegal: $27, Mali: $28), and $80 for PWUD (Côte d'Ivoire: $16, Senegal: $144), driven by personnel costs (47-78% of total costs), and HIVST kits costs (2-20%). Average costs at scale-up were $11 for FSW (Côte d'Ivoire: $9, Senegal: $13, Mali: $10), $16 for MSM (Côte d'Ivoire: $9, Senegal: $23, Mali: $17), and $32 for PWUD (Côte d'Ivoire: $14, Senegal: $50). Cost reductions were mainly explained by the spreading of IPO costs over higher HIVST distribution volumes and progressive IPO withdrawal at scale-up. In all countries, CSO-led HIVST kit provision to KP showed relatively high costs during the study period related to the progressive integration of the programme to CSO activities and contextual challenges (COVID-19 pandemic, country safety concerns). In transition to scale-up and integration of the HIVST programme into CSO activities, this model shows large potential for substantial economies of scale. Further research will assess the overall cost-effectiveness of this model.
The clinical presentation of dengue ranges from self-limited mild illness to severe forms, including death. African ancestry is often described as protective against dengue severity. However, in the ...Latin American context, African ancestry has been associated with increased mortality. This "severity paradox" has been hypothesized as resulting from confounding or heterogeneity by socioeconomic status (SES). However, few systematic analyses have been conducted to investigate the presence and nature of the disparity paradox.
We fit Bayesian hierarchical spatiotemporal models using individual-level surveillance data from Cali, Colombia (2012-2017), to assess the overall morbidity and severity burden of notified dengue. We fitted overall and ethnic-specific models to assess the presence of heterogeneity by SES across and within ethnic groups (Afro-Colombian vs. Non-Afro-Colombians), conducting sensitivity analyses to account for potential underreporting.
Our study included 65,402 dengue cases and 13,732 (21%) hospitalizations. Overall notified dengue incidence rates did not vary across ethnic groups. Severity risk was higher among Afro-Colombians (RR=1.16; 95% Credible Interval 95%CrI: 1.08-1.24) but after accounting for underreporting by ethnicity this association was nearly null (RR=1.02; 95% CrI: 0.97-1.07). Subsidized health insurance and low-SES were associated with increased overall dengue rates and severity.
The paradoxical increased severity among Afro-Colombians can be attributed to differential health-seeking behaviors and reporting among Afro-Colombians. Such differential reporting can be understood as a type of intersectionality between SES, insurance scheme, and ethnicity that requires a quantitative assessment in future studies.
Due to the discreet and private nature of HIV self-testing (HIVST), it is particularly challenging to monitor and assess the impacts of this testing strategy. To overcome this challenge, we conducted ...a study in Côte d'Ivoire to characterize the profile of end users of HIVST kits distributed through the ATLAS project (AutoTest VIH, Libre d'Accéder à la connaissance de son Statut). Feasibility was assessed using a pilot phone-based survey.
The ATLAS project aims to distribute 221300 HIVST kits in Côte d'Ivoire from 2019 to 2021 through both primary (e.g., direct distribution to primary users) and secondary distribution (e.g., for partner testing). The pilot survey used a passive recruitment strategy-whereby participants voluntarily called a toll-free survey phone number-to enrol participants. The survey was promoted through a sticker on the HIVST instruction leaflet and hotline invitations and informal promotion by HIVST kit-dispensing agents. Importantly, participation was not financially incentivized, even though surveys focussed on key populations usually use incentives in this context.
After a 7-month period in which 25,000 HIVST kits were distributed, only 42 questionnaires were completed. Nevertheless, the survey collected data from users receiving HIVST kits via both primary and secondary distribution (69% and 31%, respectively).
This paper provides guidance on how to improve the design of future surveys of this type. It discusses the need to financial incentivize participation, to reorganize the questionnaire, the importance of better informing and training stakeholders involved in the distribution of HIVST, and the use of flyers to increase the enrolment of users reached through secondary distribution.
Context:
The rate of HIV status disclosure to partners is low in Mali, a West African country with a national HIV prevalence of 1.2%. HIV self-testing (HIVST) could increase testing coverage among ...partners of people living with HIV (PLHIV). The
AutoTest-VIH, Libre d'accéder à la connaissance de son Statut
(ATLAS) program was launched in West Africa with the objective of distributing nearly half a million HIV self-tests from 2019 to 2021 in Côte d'Ivoire, Mali, and Senegal. The ATLAS program integrates several research activities. This article presents the preliminary results of the qualitative study of the ATLAS program in Mali. This study aims to improve our understanding of the practices, limitations and issues related to the distribution of HIV self-tests to PLHIV so that they can offer the tests to their sexual partners.
Methods:
This qualitative study was conducted in 2019 in an HIV care clinic in Bamako. It consisted of (i) individual interviews with eight health professionals involved in the distribution of HIV self-tests; (ii) 591 observations of medical consultations, including social service consultations, with PLHIV; (iii) seven observations of peer educator-led PLHIV group discussions. The interviews with health professionals and the observations notes have been subject to content analysis.
Results:
HIVST was discussed in only 9% of the observed consultations (51/591). When HIVST was discussed, the discussion was almost always initiated by the health professional rather than PLHIV. HIVST was discussed infrequently because, in most of the consultations, it was not appropriate to propose partner HIVST (e.g., when PLHIV were widowed, did not have partners, or had delegated someone to renew their prescriptions). Some PLHIV had not disclosed their HIV status to their partners. Dispensing HIV self-tests was time-consuming, and medical consultations were very short. Three main barriers to HIVST distribution when HIV status had not been disclosed to partners were identified: (1) almost all health professionals avoided offering HIVST to PLHIV when they thought or knew that the PLHIV had not disclosed their HIV status to partners; (2) PLHIV were reluctant to offer HIVST to their partners if they had not disclosed their HIV-positive status to them; (3) there was limited use of strategies to support the disclosure of HIV status.
Conclusion:
It is essential to strengthen strategies to support the disclosure of HIV+ status. It is necessary to develop a specific approach for the provision of HIV self-tests for the partners of PLHIV by rethinking the involvement of stakeholders. This approach should provide them with training tailored to the issues related to the (non)disclosure of HIV status and gender inequalities, and improving counseling for PLHIV.
In Canada, hepatitis C virus (HCV) transmission primarily occurs among people who inject drugs (PWID) and people with experience in the prison system bare a disproportionate disease burden. These ...overlapping groups of individuals have been identified as priority populations for HCV micro-elimination in Canada, which is currently not on track to achieve its elimination targets. Considering the missed opportunities to intervene in provincial prisons, this study aims to estimate the population-level impact of prison-based interventions and post-release risk reduction strategies on HCV transmission among PWID in Montréal, a Canadian city with high HCV burden.
A dynamic HCV transmission model among PWID was developed and calibrated to community and prison bio-behavioural surveys in Montréal. Then, the relative impact of prison-based testing and treatment or post-release linkage to care (both 90% testing and 75% treatment coverage), alone or in combination with strategies that reduce the heightened post-release transmission risk by 50%, was estimated from 2018 to 2030, and compared to counterfactual scenarios.
Prison-based test-and-treat strategies could lead to the greatest declines in incidence (48%; 95%CrI: 38–57%) over 2018–2030 and prevent the most new first chronic infections (22%; 95%CrI: 16−28%) among people never exposed to HCV. Prison testing and post-release linkage to care lead to a slightly lower decrease in incidence and prevented fraction of new chronic infections. Combining test-and-treat with risk reduction measures could further its epidemiological impact, preventing 35% (95%CrI: 29−40%) of new first chronic infections. When implemented concomitantly with community-based treatment scale-up, prison-based interventions had synergistic effects, averting a higher fraction of new first chronic infections.
Offering HCV testing and treatment in provincial prisons, where incarcerations are frequent and sentences short, could change the course of the HCV epidemic in Montréal. Prison-based interventions with potential integration of post-release risk reduction measures should be considered as an integral part of HCV micro-elimination strategies in this setting.
OBJECTIVE:The use of routinely collected data from prevention of mother-to-child transmission programs (ANC-RT) has been proposed to monitor HIV epidemic trends. This poses several challenges for ...surveillance, one of them being that women may opt-out of testing and/or test stock-outs may result in inconsistent service availability. In this study, we sought to empirically quantify the relationship between imperfect HIV testing coverage and HIV prevalence among pregnant women from ANC-RT data.
DESIGN:We used reports from the ANC Register of all antenatal care (ANC) sites in Malawi (2011–2018), including 49 244 monthly observations, from 764 facilities, totaling 4 375 777 women.
METHODS:Binomial logistic regression models with facility-level fixed effects and marginal standardization were used to assess the effect of testing coverage on HIV prevalence.
RESULTS:Testing coverage increased from 78 to 98% over 2011–2018. We estimated that, had testing coverage been perfect, prevalence would have been 0.4% point lower (95% CI 0.3–0.5%) than the 7.9% observed prevalence, a relative overestimation of 6%. Bias in HIV prevalence was the highest in 2012, when testing coverage was lowest (72%), resulting in a relative overestimation of HIV prevalence of 15% (95% CI 12–17%). Overall, adjustments for imperfect testing coverage led to a subtler decline in HIV prevalence over 2011--2018.
CONCLUSION:Malawi achieved high coverage of routine HIV testing in recent years. Nevertheless, imperfect testing coverage can lead to overestimation of HIV prevalence among pregnant women when coverage is suboptimal. ANC-RT data should be carefully evaluated for changes in testing coverage and completeness when used to monitor epidemic trends.
Soil-transmitted helminth (STH) infections are a leading cause of disability and disease burden in school-age children of worm-endemic regions. Their effect on school absenteeism, however, remains ...unclear. The World Health Organization currently recommends delivering mass deworming and health hygiene education through school-based programs, in an effort to control STH-related morbidity. In this cluster-RCT, the impact of a health hygiene education intervention on absenteeism was measured. From April to June 2010, all Grade 5 students at 18 schools in a worm-endemic region of the Peruvian Amazon were dewormed. Immediately following deworming, nine schools were randomly assigned to the intervention arm of the trial using a matched-pair design. The Grade 5 students attending intervention schools (N = 517) received four months of health hygiene education aimed at increasing knowledge of STH prevention. Grade 5 students from the other nine schools (N = 571) served as controls. Absenteeism was measured daily through teachers' attendance logs. After four months of follow-up, overall absenteeism rates at intervention and control schools were not statistically significantly different. However, post-trial non-randomized analyses have shown that students with moderate-to-heavy Ascaris infections and light hookworm infections four months after deworming had, respectively, missed 2.4% (95% CI: 0.1%, 4.7%) and 4.6% (95% CI: 1.9%, 7.4%) more schooldays during the follow-up period than their uninfected counterparts. These results provide empirical evidence of a direct effect of STH infections on absenteeism in school-age children.
PURPOSE OF REVIEWA relatively neglected topic to date has been the occurrence of concentrated epidemics within generalized epidemic settings and the potential role of targeted interventions in such ...settings. We review recent studies in high-risk groups as well as findings relating to geographical heterogeneity and the potential for targeting ‘high-transmission zones’ in the 10 countries with highest HIV prevalence.
RECENT FINDINGSOur review of recent studies confirmed earlier findings that, even in the context of generalized epidemics, MSM have a substantially higher prevalence than the general population. Estimates of prevalence of HIV among people who inject drugs (PWID) in sub-Saharan African countries are rarely available and, when they are, often outdated. We identified recent studies of sex workers in Kenya and Uganda. In all three cases – MSM, PWID, and sex workers – HIV prevalence estimates are mostly based on convenience. Moreover, good estimates of the total size of these populations are not available. Our review of recent studies of high-risk populations defined on the basis of geography showed high levels of both new and existing infections in Kenya (slums), South Africa (peri-urban communities), and Uganda (fishing villages).
SUMMARYRecent empirical findings combined with evidence from phylogenetic studies and supported by mathematical models provide a clear rationale for testing the feasibility, acceptability, and effectiveness of targeted HIV prevention approaches in hyperendemic populations to supplement measures aimed at the general population.
Monitoring knowledge of HIV status among people living with HIV is essential for an effective national HIV response. This study estimates progress and gaps in reaching the UNAIDS 2020 target of 90% ...knowledge of status, and the efficiency of HIV testing services in sub-Saharan Africa, where two thirds of all people living with HIV reside.
For this modelling study, we used data from 183 population-based surveys (including more than 2·7 million participants) and national HIV testing programme reports (315 country-years) from 40 countries in sub-Saharan Africa as inputs into a mathematical model to examine trends in knowledge of status among people living with HIV, median time from HIV infection to diagnosis, HIV testing positivity, and proportion of new diagnoses among all positive tests, adjusting for retesting. We included data from 2000 to 2019, and projected results to 2020.
Across sub-Saharan Africa, knowledge of status steadily increased from 5·7% (95% credible interval CrI 4·6–7·0) in 2000 to 84% (82–86) in 2020. 12 countries and one region, southern Africa, reached the 90% target. In 2020, knowledge of status was lower among men (79%, 95% CrI 76–81) than women (87%, 85–89) across sub-Saharan Africa. People living with HIV aged 15–24 years were the least likely to know their status (65%, 62–69), but the largest gap in terms of absolute numbers was among men aged 35–49 years, with 701 000 (95% CrI 611 000–788 000) remaining undiagnosed. As knowledge of status increased from 2000 to 2020, the median time to diagnosis decreased from 9·6 years (9·1–10) to 2·6 years (1·8–3·5), HIV testing positivity declined from 9·0% (7·7–10) to 2·8% (2·1–3·9), and the proportion of first-time diagnoses among all positive tests dropped from 89% (77–96) to 42% (30–55).
On the path towards the next UNAIDS target of 95% diagnostic coverage by 2025, and in a context of declining positivity and yield of first-time diagnoses, disparities in knowledge of status must be addressed. Increasing knowledge of status and treatment coverage among older men could be crucial to reducing HIV incidence among women in sub-Saharan Africa, and by extension, reducing mother-to-child transmission.
Steinberg Fund for Interdisciplinary Global Health Research (McGill University); Canadian Institutes of Health Research; Bill & Melinda Gates Foundation; Fonds the recherche du Québec—Santé; UNAIDS; UK Medical Research Council; MRC Centre for Global Infectious Disease Analysis; UK Foreign, Commonwealth & Development Office.
Key populations, including sex workers, are at high risk of HIV acquisition and transmission. Men who pay for sex can contribute to HIV transmission through sexual relationships with both sex workers ...and their other partners. To characterize the population of men who pay for sex in sub-Saharan Africa (SSA), we analyzed population size, HIV prevalence, and use of HIV prevention and treatment. We performed random-effects meta-analyses of population-based surveys conducted in SSA from 2000 to 2020 with information on paid sex by men. We extracted population size, lifetime number of sexual partners, condom use, HIV prevalence, HIV testing, antiretroviral (ARV) use, and viral load suppression (VLS) among sexually active men. We pooled by regions and time periods, and assessed time trends using meta-regressions. We included 87 surveys, totaling over 368,000 male respondents (15-54 years old), from 35 countries representing 95% of men in SSA. Eight percent (95% CI 6%-10%; number of surveys N.sub.s = 87) of sexually active men reported ever paying for sex. Condom use at last paid sex increased over time and was 68% (95% CI 64%-71%; N.sub.s = 61) in surveys conducted from 2010 onwards. Men who paid for sex had higher HIV prevalence (prevalence ratio PR = 1.50; 95% CI 1.31-1.72; N.sub.s = 52) and were more likely to have ever tested for HIV (PR = 1.14; 95% CI 1.06-1.24; N.sub.s = 81) than men who had not paid for sex. Men living with HIV who paid for sex had similar levels of lifetime HIV testing (PR = 0.96; 95% CI 0.88-1.05; N.sub.s = 18), ARV use (PR = 1.01; 95% CI 0.86-1.18; N.sub.s = 8), and VLS (PR = 1.00; 95% CI 0.86-1.17; N.sub.s = 9) as those living with HIV who did not pay for sex. Study limitations include a reliance on self-report of sensitive behaviors and the small number of surveys with information on ARV use and VLS. Paying for sex is prevalent, and men who ever paid for sex were 50% more likely to be living with HIV compared to other men in these 35 countries. Further prevention efforts are needed for this vulnerable population, including improved access to HIV testing and condom use initiatives. Men who pay for sex should be recognized as a priority population for HIV prevention.
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