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Journal ArticleDOI

HIV Treatment as Prevention: Optimising the Impact of Expanded HIV Treatment Programmes

TL;DR: In re-evaluating the allocation of ART in light of the new data about ART preventing transmission, the goal should be to create policies that maximise epidemiological and clinical benefit while still being feasible, affordable, acceptable, and equitable.
Abstract: Until now, decisions about how to allocate ART have largely been based on maximising the therapeutic benefit of ART for patients. Since the results of the HPTN 052 study showed efficacy of antiretroviral therapy (ART) in preventing HIV transmission, there has been increased interest in the benefits of ART not only as treatment, but also in prevention. Resources for expanding ART in the short term may be limited, so the question is how to generate the most prevention benefit from realistic potential increases in the availability of ART. Although not a formal systematic review, here we review different ways in which access to ART could be expanded by prioritising access to particular groups based on clinical or behavioural factors. For each group we consider (i) the clinical and epidemiological benefits, (ii) the potential feasibility, acceptability, and equity, and (iii) the affordability and cost-effectiveness of prioritising ART access for that group. In re-evaluating the allocation of ART in light of the new data about ART preventing transmission, the goal should be to create policies that maximise epidemiological and clinical benefit while still being feasible, affordable, acceptable, and equitable.

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Citations
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Journal ArticleDOI
29 Sep 2014-PLOS ONE
TL;DR: It is suggested that FSWs can achieve levels of ART uptake, retention, adherence, and treatment response comparable to that seen among women in the general population, but these data are from only a few research settings.
Abstract: Purpose We aimed to characterize the antiretroviral therapy (ART) cascade among female sex workers (FSWs) globally.

124 citations


Cites background from "HIV Treatment as Prevention: Optimi..."

  • ...To date, this is the first study to systematically review and quantify the ART cascade among FSWs globally, which builds on a limited review already undertaken by the authors [15]....

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  • ...transmitting HIV [15,17], it is crucial to understand the extent to which FSWs currently access ART, and continue ART with good adherence....

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  • ...Ensuring high levels of ART uptake, adherence and retention among FSWs, would provide not only individual benefits to HIV-infected FSWs, but could also help reduce HIV transmission at the population level [15,16]....

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Journal ArticleDOI
TL;DR: Sensitising health workers through specialised training, refining referral systems from sex-worker friendly clinics into the national system, and providing opportunities for SW to collectively organise for improved treatment and rights might help alleviate the barriers to treatment initiation and attention currently faced by SW.
Abstract: Although disproportionately affected by HIV, sex workers (SWs) remain neglected by efforts to expand access to antiretroviral treatment (ART). In Zimbabwe, despite the existence of well-attended services targeted to female SWs, fewer than half of women diagnosed with HIV took up referrals for assessment and ART initiation; just 14% attended more than one appointment. We conducted a qualitative study to explore the reasons for non-attendance and the high rate of attrition. Three focus group discussions (FGD) were conducted in Harare with HIV-positive SWs referred from the ‘Sisters with a Voice’ programme to a public HIV clinic for ART eligibility screening and enrolment. Focus groups explored SWs’ experiences and perceptions of seeking care, with a focus on how managing HIV interacted with challenges specific to being a sex worker. FGD transcripts were analyzed by identifying emerging and recurring themes that were specifically related to interactions with health services and how these affected decision-making around HIV treatment uptake and retention in care. SWs emphasised supply-side barriers, such as being demeaned and humiliated by health workers, reflecting broader social stigma surrounding their work. Sex workers were particularly sensitive to being identified and belittled within the health care environment. Demand-side barriers also featured, including competing time commitments and costs of transport and some treatment, reflecting SWs’ marginalised socio-economic position. Improving treatment access for SWs is critical for their own health, programme equity, and public health benefit. Programmes working to reduce SW attrition from HIV care need to proactively address the quality and environment of public services. Sensitising health workers through specialised training, refining referral systems from sex-worker friendly clinics into the national system, and providing opportunities for SW to collectively organise for improved treatment and rights might help alleviate the barriers to treatment initiation and attention currently faced by SW.

100 citations


Cites background from "HIV Treatment as Prevention: Optimi..."

  • ...At the same time, the “Universal Access” agenda has made equity a guiding principle for national programmes, leading to greater prioritisation of key populations, including sex workers [10,11]....

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Journal ArticleDOI
24 Apr 2013-AIDS
TL;DR: Migration and globalization has contributed to the spread of non-B subtypes contributing to 20–60% of new infections in Europe, Asia and America.
Abstract: In 30 years, the HIV-1/AIDS pandemic has evolved into an increasingly complex disease composed of multiple epidemics, each influenced by a complex array of biological, behavioural and cultural factors [1–4]. The concentrated subtype B epidemics in Western world settings have been largely restricted to MSM and IDU populations [3]. The generalized heterosexual (HET) epidemics in Africa and Asia have expanded and diversified to include nine major HIV-1 subtypes (A–D, F–H, J and K) and mosaic circulating recombinant forms (e.g. CRF01_AE and CRF02_AG) [1,5,6]. Migration and globalization has contributed to the spread of non-B subtypes contributing to 20–60% of new infections in Europe, Asia and America [1,2,7].

83 citations

Journal ArticleDOI
TL;DR: It is hoped that the principles described here will become a shared resource that facilitates constructive discussions about the policy implications that emerge from HIV epidemiology modelling results, and that promotes joint understanding about when modelling is useful as a tool in quantifying HIV epidemiological outcomes and improving prevention programming.
Abstract: Public health responses to HIV epidemics have long relied on epidemiological modelling analyses to help prospectively project and retrospectively estimate the impact, cost-effectiveness, affordability, and investment returns of interventions, and to help plan the design of evaluations. But translating model output into policy decisions and implementation on the ground is chal- lenged by the differences in background and expectations of modellers and decision-makers. As part of the PLoS Medicine Collection ''Investigating the Impact of Treat- ment on New HIV Infections''—which focuses on the contribution of modelling to current issues in HIV prevention—we present here principles of ''best practice'' for the construction, reporting, and interpretation of HIV epidemiological models for public health decision-making on all aspects of HIV. Aimed at both those who conduct modelling research and those who use modelling results, we hope that the principles described here will become a shared resource that facilitates constructive discussions about the policy implications that emerge from HIV epidemiology modelling results, and that promotes joint understanding between modellers and decision-makers about when modelling is useful as a tool in quantifying HIV epidemiological outcomes and improving prevention programming.

83 citations


Cites background from "HIV Treatment as Prevention: Optimi..."

  • ...[19], or prioritised for treatment as prevention [20])....

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Journal ArticleDOI
TL;DR: “treatment as prevention” for adult-to-adult transmission reduction includes expanded HIV testing, linkage to care, antiretroviral coverage, retention in care, adherence to therapy, and management of key co-morbidities such as depression and substance use.
Abstract: HIV research has identified approaches that can be combined to be more effective in transmission reduction than any 1 modality alone: delayed adolescent sexual debut, mutual monogamy or sexual partner reduction, correct and consistent condom use, pre-exposure prophylaxis with oral antiretroviral drugs or vaginal microbicides, voluntary medical male circumcision, antiretroviral therapy (ART) for prevention (including prevention of mother to child HIV transmission [PMTCT]), treatment of sexually transmitted infections, use of clean needles for all injections, blood screening prior to donation, a future HIV prime/boost vaccine, and the female condom. The extent to which evidence-based modalities can be combined to prevent substantial HIV transmission is largely unknown, but combination approaches that are truly implementable in field conditions are likely to be far more effective than single interventions alone. Analogous to PMTCT, “treatment as prevention” for adult-to-adult transmission reduction includes expanded HIV testing, linkage to care, antiretroviral coverage, retention in care, adherence to therapy, and management of key co-morbidities such as depression and substance use. With successful viral suppression, persons with HIV are far less infectious to others, as we see in the fields of sexually transmitted infection control and mycobacterial disease control (tuberculosis and leprosy). Combination approaches are complex, may involve high program costs, and require substantial global commitments. We present a rationale for such investments and cite an ongoing research agenda that seeks to determine how feasible and cost-effective a combination prevention approach would be in a variety of epidemic contexts, notably that in a sub-Saharan Africa.

78 citations

References
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Journal ArticleDOI
19 Jun 2003-BMJ
TL;DR: It is argued that a commonsense approach based on simple country by country analyses could improve the situation and help to prevent HIV infection.
Abstract: Despite worldwide efforts to prevent HIV infection, the number of people affected continues to rise. The authors of this article argue that a commonsense approach based on simple country by country analyses could improve the situation

136 citations

Journal Article
01 Jan 2003-AIDS
TL;DR: The increase in condom use and the decline in prevalence of HIV infection and other STD may well have resulted from the prevention campaign for female sex workers, and such campaigns should therefore be continued, strengthened, and expanded.
Abstract: Objective: To assess clinic- and community-based trends in demographic and behavioral characteristics and clinic-based trends in HIV infection and other sexually transmitted diseases (STD) in female sex workers in Abidjan, Cote d'lvoire. Design: Multiyear cross-sectional study of first-time attenders in Clinique de Confiance, a confidential STD clinic; biannual community-based behavioral surveys. Methods: From 1992 to 1998, female sex workers were invited to attend Clinique de Confiance, where they were counseled, interviewed, clinically examined during their first visit and tested for STD and HIV infection. Community-based surveys, conducted in 1991, 1993, 1995, and 1997, interviewed women regarding socio-demographic characteristics and HIV/STD-related knowledge, attitudes and behavior. Results: Among female sex workers in Abidjan, there was a trend toward shorter duration of sex work, higher prices, and more condom use. Among sex workers attending Clinique de Confiance for the first time, significant declines were found in the prevalence of HIV infection (from 89 to 32%), gonorrhoea (from 33 to 11%), genital ulcers (from 21 to 4%), and syphilis (from 21 to 2%). In a logistic regression model that controlled for socio-demographic and behavioral changes, the year of screening remained significantly associated with HIV infection. Conclusion: The increase in condom use and the decline in prevalence of HIV infection and other STD may well have resulted from the prevention campaign for female sex workers, and such campaigns should therefore be continued, strengthened, and expanded.

118 citations

Journal ArticleDOI
TL;DR: In this paper, the authors used an interval-censored survival model to assess whether factors, including type of HAART regimen, race, region of birth, and baseline immunological and virological status, were associated with the duration of time necessary to suppress viral load below undetectable levels before delivery of a newborn.
Abstract: Background. There have been no clinical trials in resource-rich regions that have addressed the question of which highly active antiretroviral therapy (HAART) regimens are more effective for optimal viral response in antiretroviral-naive, human immunodeficiency virus (HIV)-infected pregnant women.Methods. Data on 240 HIV-1-infected women starting HAART during pregnancy who were enrolled in the prospective European Collaborative Study from 1997 through 2004 were analyzed. An interval-censored survival model was used to assess whether factors, including type of HAART regimen, race, region of birth, and baseline immunological and virological status, were associated with the duration of time necessary to suppress viral load below undetectable levels before delivery of a newborn.Results. Protease inhibitor-based HAART was initiated in 156 women (65%), 125 (80%) of whom received nelfinavir, and a nevirapine-based regimen was initiated in the remaining 84 women (35%). Undetectable viral loads were achieved by 73% of the women by the time of delivery. Relative hazards of time to achieving viral suppression were 1.54 (95% confidence interval, 1.05-2.26) for nevirapine-based HAART versus PI-based regimens and 1.90 (95% confidence interval, 1.16-3.12) for western African versus non-African women. The median duration of time from HAART initiation to achievement of an undetectable viral load was estimated to be 1.4 times greater in women receiving PI-based HAART, compared with women receiving nevirapine-based HAART. Baseline HIV RNA load was also a significant predictor of the rapidity of achieving viral suppression by delivery, but baseline immune status was not.Conclusions. In this study, nevirapine-based HAART (compared with PI [mainly nelfinavir]-based HAART), western African origin, and lower baseline viral load were associated with shorter time to achieving viral suppression.

114 citations


"HIV Treatment as Prevention: Optimi..." refers background in this paper

  • ...Whether ART initiation during pregnancy would effectively override this risk elevation is questionable, given the lag time of up to five months between ART initiation and viral load suppression [39]....

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Journal ArticleDOI
TL;DR: To quantify attrition between women testing HIV‐positive in pregnancy‐related services and accessing long‐term HIV care and treatment services in low‐ or middle‐income countries and to explore the reasons underlying client drop‐out by synthesising current literature on this topic.
Abstract: Objectives To quantify attrition between women testing HIV-positive in pregnancy-related services and accessing long-term HIV care and treatment services in low- or middle-income countries and to explore the reasons underlying client drop-out by synthesising current literature on this topic. Methods A systematic search in Medline, EMBASE, Global Health and the International Bibliography of the Social Sciences of literature published 2000–2010. Only studies meeting pre-defined quality criteria were included. Results Of 2543 articles retrieved, 20 met the inclusion criteria. Sixteen (80%) drew on data from sub-Saharan Africa. The pathway between testing HIV-positive in pregnancy-related services and accessing long-term HIV-related services is complex, and attrition was usually high. There was a failure to initiate highly active antiretroviral therapy (HAART) among 38–88% of known-eligible women. Providing ‘family-focused care’, and integrating CD4 testing and HAART provision into prevention of mother-to-child HIV transmission services appear promising for increasing women’s uptake of HIV-related services. Individual-level factors that need to be addressed include financial constraints and fear of stigma. Conclusions Too few women negotiate the many steps between testing HIV-positive in pregnancy-related services and accessing HIV-related services for themselves. Recent efforts to stem patient drop-out, such as the MTCT-Plus Initiative, hold promise. Addressing barriers and enabling factors both within health facilities and at the levels of the individual woman, her family and society will be essential to improve the uptake of services. Objectif: Quantifier le decouragement chez les femmes testees VIH positives dans les services lies a la grossesse et l’acces aux services de soins et de traitement de longue duree du VIH dans les pays a revenus faibles ou intermediaires, explorer les raisons qui sous-tendent le desistement des patients en synthetisant la litterature actuelle sur ce sujet. Methodes: Recherche systematique dans Medline, EMBASE, Global Health et l’International Bibliography of Social Sciences, sur la litterature publiee entre 2000 et 2010. Seules les etudes repondant aux criteres de qualite predefinis ont ete incluses. Resultats: Sur 2.543 articles trouves, 20 repondaient aux criteres d’inclusion. 16 (80%) articles etaient appuyes sur des donnees provenant d’Afrique subsaharienne. La voie entre le resultat VIH-positif dans les services lies a la grossesse et l’acces aux services de traitements de longue duree du VIH est complexe et le decouragement etait generalement eleve. La therapie antiretrovirale hautement active (HAART) n’a pas ete initiee chez 38 a 88% des femmes eligibles connues. La fourniture «des soins axes sur la famille», l’integration de la mesure des CD4 et l’administration de l’HAART dans les services de prevention de la transmission mere-enfant du VIH (PTME) semblent prometteuses pour accroitre l’utilisation des services VIH par les femmes. Les facteurs qui devraient etre adresses a l’echelle individuelle comprennent les contraintes financieres et la crainte de la stigmatisation. Conclusions: Trop peu de femmes negocient les nombreuses etapes entre le resultat VIH-positif dans les services lies a la grossesse et l’acces aux services VIH pour elles-memes. Les recents efforts visant a endiguer le decouragement des patientes, comme l’initiative PTME-Plus, sont prometteurs. Surmonter les obstacles et permettre des facteurs favorables a la fois au sein des etablissements de sante et a l’echelle individuelle de la femme, de sa famille et de la societe est essentiel pour ameliorer l’utilisation des services. Objetivo: Cuantificar el abandono entre mujeres que dieron positivo en una prueba de VIH en servicios prenatales y el acceso a los cuidados y el tratamiento para el VIH de larga duracion en paises con ingresos bajos y medios, y mediante la sintesis de la literatura actual sobre este tema explorar las razones por las cuales los clientes abandonan. Metodos: Busqueda sistematica en Medline, EMBASE, Global Health y la Bibliografia Internacional de Ciencias Sociales de la literatura publicada entre el 2000 y 2010. Solo se incluyeron estudios que cumplian criterios de calidad predefinidos. Resultados: De 2,543 articulos encontrados, 20 cumplian los criterios de inclusion. 16 (80%) eran datos sobre Africa subSahariana. El camino entre dar positivo para VIH en servicios prenatales y acceder a servicios de larga duracion para el VIH es complejo y el abandono es usualmente alto. Habia un fallo a la hora de iniciar el tratamiento antirretroviral de gran actividad (TARGA) en 38-88% de las mujeres que se sabia eran elegibles. La provision de ‘cuidados en el hogar’ e integracion de la prueba de CD4 asi como la entrega del TARGA dentro de los servicios de prevencion de la transmision vertical (PTV) parecen aumentar la aceptacion, por parte de las mujeres, de los servicios relacionados con el VIH. Los factores individuales que deben ser atendidos incluyen las restricciones financieras y el miedo a la estigmatizacion. Conclusiones: Muy pocas mujeres consiguen superar los multiples pasos que hay entre el dar positivo en una prueba realizada en un centro prenatal y el acceder a los servicios para VIH por si solas. Los esfuerzos recientes para erradicar el abandono de los pacientes, tales como la iniciativa MTCT-Plus, mantienen la esperanza. En la mejora de la aceptacion y toma de servicios para VIH sera esencial remover las barreras y promover los factores, tanto dentro de los centros sanitarios como a nivel individual de la mujer, de su familia y sociedad.

112 citations


"HIV Treatment as Prevention: Optimi..." refers background in this paper

  • ...found that 38%–88% of known ART-eligible women in sub-Saharan countries fail to initiate treatment [49]....

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Journal ArticleDOI
13 Nov 2011-AIDS
TL;DR: Nearly one in five treatment-eligible HIV-infected individuals in Soweto refused to initiate ART after VCT, putting them at higher risk for early mortality and highlighting the urgent need for research to inform interventions targeting ART refusers.
Abstract: OBJECTIVE: To determine rates and predictors of treatment refusal in newly identified HIV-infected individuals in Soweto South Africa. DESIGN: It is designed as a cross-sectional study. METHODS: We analyzed data from adult clients (>18 years) presenting for voluntary counseling and testing (VCT) at the Zazi Testing Center Perinatal HIV Research Unit to determine rates of antiretroviral therapy (ART) refusal among treatment-eligible HIV-infected individuals (CD4(+) cell count < 200 cells/mul or WHO stage 4). Multiple logistic regression models were used to investigate factors associated with refusal. RESULTS: From December 2008 to December 2009 7287 adult clients were HIV tested after counseling. Two thousand five hundred and sixty-two (35%) were HIV-infected of whom 743 (29%) were eligible for immediate ART. One hundred and forty-eight (20%) refused referral to initiate ART most of whom (92%) continued to refuse after 2 months of counseling. The leading reason for ART refusal was given as feeling healthy (37%) despite clients having a median CD4(+) cell count of 110 cells/mul and triple the rate of active tuberculosis as seen in nonrefusers. In adjusted models single clients [adjusted odds ratio (AOR) 1.80 95% confidence interval (CI) 1.06-3.06] and those with active tuberculosis (AOR 3.50 95% CI 1.55-6.61) were more likely to refuse ART. CONCLUSION: Nearly one in five treatment-eligible HIV-infected individuals in Soweto refused to initiate ART after VCT putting them at higher risk for early mortality. Feeling healthy was given as the most common reason to refuse ART despite a suppressed CD4(+) count and comorbidities such as tuberculosis. These findings highlight the urgent need for research to inform interventions targeting ART refusers.

111 citations


"HIV Treatment as Prevention: Optimi..." refers background in this paper

  • ...Moreover, HIV-infected individuals who are feeling healthy may decline the option to initiate treatment [22], a challenge likely to be exacerbated under earlier treatment eligibility at high CD4 counts....

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