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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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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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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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
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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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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TL;DR: Uptake of PMTCT services in resource-limited settings can be improved by utilizing innovative alternatives to mitigate the effects of human resource shortage such as by providing technical assistance and mentorship beyond regular training courses.
Abstract: Background
As in other resource limited settings, the Ministry of Health in Zambia is challenged to make affordable and acceptable PMTCT interventions accessible and available. With a 14.3% HIV prevalence, the MOH estimates over one million people are HIV positive in Zambia. Approximately 500,000 children are born annually in Zambia and 40,000 acquire the infection vertically each year if no intervention is offered. This study sought to review uptake of prevention of mother-to-child (PMTCT) services in a resource-limited setting following the introduction of context-specific interventions.
82 citations
TL;DR: The number of MSM who sell sex in and around Mombasa, Kenya, is estimated to be 739, a sizeable population who urgently need to be targeted by HIV prevention strategies.
Abstract: Background: Men who have sex with men (MSM) are highly vulnerable to HIV infection, but this population can be particularly difficult to reach in sub-Saharan Africa. We aimed to estimate the number of MSM who sell sex in and around Mombasa, Kenya, in order to plan HIV prevention research. Methods: We identified 77 potential MSM contact locations, including public streets and parks, brothels, bars and nightclubs, in and around Mombasa and trained 37 MSM peer leader enumerators to extend a recruitment leaflet to MSM who were identified as ‘on the market’, that is, a man who admitted to selling sex to men. We captured men on two consecutive Saturdays, 1 week apart. A record was kept of when, where and by whom the invitation was extended and received, and of refusals. The total estimate of MSM who sell sex was derived from capture–recapture calculation. Results: Capture 1 included 284 men (following removal of 15 duplicates); 89 men refused to participate. Capture 2 included 484 men (following removal of 35 duplicates); 75 men refused to participate. Of the 484 men in capture 2, 186 were recaptures from capture 1, resulting in a total estimate of 739 (95% confidence interval, 690–798) MSM who sell sex in the study area. Conclusions: We estimated that 739 MSM sell sex in and around Mombasa. Of these, 484 were contacted through trained peer enumerators in a single day. MSM who sell sex in and around Mombasa represent a sizeable population who urgently need to be targeted by HIV prevention strategies.
81 citations
"HIV Treatment as Prevention: Optimi..." refers background in this paper
...Men Who Have Sex with Men and People Who Inject Drugs The arguments for expanded access to other key populations, including MSM and PWID, are similar to those for expanded access to FSWs....
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...Several studies in Africa have been able to recruit MSM [114,115], and it has been estimated that, in total, transmission among MSM could account for 6% of new infections in Kenya and up to 21% in some concentrated epidemics [115], a range that is broadly supported by the Joint United Nations Programme on HIV/AIDS review of modes of transmission ([116]; K....
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...Several studies in Africa have been able to recruit MSM [114,115], and it has been estimated that, in total, transmission among MSM could account for 6% of new infections in Kenya and up to 21% in some concentrated epidemics [115], a range that is broadly supported by the Joint United Nations Programme on HIV/AIDS review of modes of transmission ([116]; K. K. Case, P. D. Ghys, E. Gouws, J. W. PLoS Medicine | www.plosmedicine.org 7 July 2012 | Volume 9 | Issue 7 | e1001258 Eaton, P. Cuchi, et al., unpublished data]....
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...Behavioural risk groups that have been proposed for early treatment include HIVserodiscordant couples, female sex workers (FSWs), men who have sex with men (MSM), and people who inject drugs (PWID)....
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...Also, for the epidemics in Africa, there is little information about the population sizes of MSM and PWID, and their behaviours and contribution to the epidemic, which makes it hard to formulate firm recommendations about the benefits of prioritising access to these groups....
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TL;DR: In this article, the authors describe the scale-up and coverage of large-scale HIV-prevention services provided to female sex workers (FSWs) and high-risk men who have sex with men (HR-MSM) during the first 5 years of the Avahan program in India.
Abstract: Objective Documenting the implementation of a public health programme as per its design is critical to interpretation of results from survey-led outcome and impact evaluation activities, the authors describe the scale-up and coverage of large-scale HIV-prevention services provided to female sex workers (FSWs) and high-risk men who have sex with men (HR-MSM) during the first 5 years of the Avahan programme in India. Methods Implementing NGO partner-generated denominator estimates from 70 districts were used to estimate the programme9s intended coverage. Routine programme-monitoring data until December 2008 were used to describe the service and commodity availability, service utilisation to generate internal estimates of coverage. Coverage was validated in few districts using data from a cross-sectional survey. Results In December 2008, the estimated denominators for intended services were about 217 000 FSWs and 80 000 HR-MSM. By January 2007, 79% of eventual total clinics and 75% drop-in centres were established, and 83% of eventual peer educators were active. By month 48, sufficient condoms to cover all estimated FSW commercial sex acts were distributed free. By month 60, 75% of the estimated denominator intended to be covered was met monthly. 86% of FSWs and 67% of HR-MSM ever contacted had used sexually transmitted infections services at least once. Cross-sectional survey generated coverage results suggest that programme-monitoring data provide a proxy to coverage of services. Conclusion Avahan9s monitoring data show that Avahan achieved infrastructure scale by year 3 and high contact coverage through peers and with commodities by year 5 of implementation as per the design.
80 citations
TL;DR: There is a need to extend the programs in order to enhance access and adherence of IDUs to HAART and consider the treatment of drug addiction as an integral part of the treatment for HIV infection.
Abstract: Differences in the uptake and time to initiation of highly active antiretroviral therapy (HAART), the virological response to HAART, and survival from AIDS by transmission category were analyzed. A multicenter hospital-based cohort of HIV-infected patients attending 10 hospitals in Spain from January 1997 to December 2003 was used. Cross-checks with the National AIDS Registry were performed. Cox proportional hazard models were used to assess the impact of transmission category on time to HAART initiation, viral suppression (defined by first HIV-1 RNA viral load measurement <500 copies/ml after HAART), and survival from AIDS. Of 4643 patients, 73% were men and 56% were injecting drug users (IDUs). A statistically significant interaction was found between transmission category and previous non-HAART antiretroviral treatment (ART) (p < 0.05). Among ART naive patients, IDUs had a 33% lower risk of initiating HAART compared to men who have sex with men (MSM) [HR 0.67 (95% CI 0.57-0.79)]. No differences by transmission categories were seen among patients with prior non-HAART ART. IDUs had poorer viral load (VL) suppression than MSM [HR 0.86 (95% CI 0.74-0.99)] adjusting by baseline VL, AIDS diagnosis, and prior ART. Mortality from AIDS was two and a half times higher in IDUs than MSM [HR 2.51 (95% CI 1.03-6.1)]. Among patients who access the hospital network, IDUs have a lower uptake of HAART, have worse virological suppression, and have higher mortality after AIDS diagnosis. There is a need to extend the programs in order to enhance access and adherence of IDUs to HAART and consider the treatment of drug addiction as an integral part of the treatment for HIV infection.
74 citations
"HIV Treatment as Prevention: Optimi..." refers background in this paper
...This is likely to translate into smaller reductions in infectivity, and greater morbidity or mortality [93,107,108], and indicates that there would be a particular need for retention efforts and adherence counselling for this prioritisa-...
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TL;DR: Evaluating the needs of women engaged in survival sex work and assessing utilization and acceptance of HAART highlights the potential to reach this highly marginalized group and provides valuable baseline information on a population that has remained largely outside consistent HIV care.
Abstract: Many HIV-infected women are not realizing the benefits of highly active antiretroviral therapy (HAART) despite significant advancements in treatment. Women in Vancouver’s Downtown Eastside (DTES) are highly marginalized and struggle with multiple morbidities, unstable housing, addiction, survival sex, and elevated risk of sexual and drug-related harms, including HIV infection. Although recent studies have identified the heightened risk of HIV infection among women engaged in sex work and injection drug use, the uptake of HIV care among this population has received little attention. The objectives of this study are to evaluate the needs of women engaged in survival sex work and to assess utilization and acceptance of HAART. During November 2003, a baseline needs assessment was conducted among 159 women through a low-threshold drop-in centre servicing street-level sex workers in Vancouver. Cross-sectional data were used to describe the sociodemographic characteristics, drug use patterns, HIV/hepatitis C virus (HCV) testing and status, and attitudes towards HAART. High rates of cocaine injection, heroin injection, and smokeable crack cocaine use reflect the vulnerable and chaotic nature of this population. Although preliminary findings suggest an overall high uptake of health and social services, there was limited attention to HIV care with only 9% of the women on HAART. Self-reported barriers to accessing treatment were largely attributed to misinformation and misconceptions about treatment. Given the acceptability of accessing HAART through community interventions and women specific services, this study highlights the potential to reach this highly marginalized group and provides valuable baseline information on a population that has remained largely outside consistent HIV care.
73 citations