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: Serosurveillance indicators of HIV in the population at large continue to indicate the relatively slow extension beyond those at highest risk of HIV, and immediate intensive preventions in high-risk groups may decelerate expansion to the broader population.
Abstract: The aim was to describe epidemiologic patterns and trends in HIV infection in Vietnam from 1996 through 1999 and to summarize the national response to the epidemic. The authors reviewed nationwide HIV case reports and analyzed annual seroprevalence among different sentinel populations in 21 provinces using the Chi-squared test for linear trend to assess trends in HIV prevalence. HIV prevention efforts were also reviewed. Through 1999 17046 HIV infections including 2947 AIDS cases and 1523 deaths had been reported in Vietnam. The cumulative incidence rate for the country was 22.5 per 100000 population. Injection drug users (IDUs) represented 89% of all those for whom risk was reported before 1997 and 88% in the period 1997-99. In 1999 HIV prevalence rates among IDUs ranged by province from 0% to 89.4%. Significantly increasing HIV trends among IDUs (p < 0.05) were found in 14 of the 21 sentinel provinces during 1996-99. HIV prevalence among commercial sex workers (CSWs) ranged from 0% to 13.2% increased significantly in 6 of 21 provinces. In 1999 prevalence among pregnant women blood donors and military recruits were 0.12% 0.20% and 0.61% respectively. Major prevention activities include mass information; peer education and outreach among groups at increased risk; availability of low-cost syringes and condoms through pharmacies; needle exchange pilot projects; widely available treatment for sexually transmitted diseases; antibody screening of blood for transfusion; and free medical treatment at government hospitals. The HIV epidemic continues to evolve rapidly intensifying among IDUs and increasing among CSWs. Serosurveillance indicators of HIV in the population at large continue to indicate the relatively slow extension beyond those at highest risk. Immediate intensive preventions in high-risk groups may decelerate expansion to the broader population. (authors)
64 citations
TL;DR: The results highlight targeted interventions can be cost-effective at all stages of HIV epidemics and suggests PPT could improve the cost-effectiveness of targeted STI interventions.
Abstract: Objective: The objective of this study was to estimate the costeffectiveness of syndromic management, with and without periodic presumptive treatment (PPT), in averting sexually transmitted infections (STIs) and HIV in female sex workers (FSWs) participating in a hotel-based intervention in Johannesburg. Study Design: Financial and economic providers’ costs were estimated. A mathematical model, fitted to epidemiologic data, projected the HIV and STIs averted by the intervention. Cost per HIV infection and DALY averted were estimated for different general population HIV prevalences. Results: Projections suggest 53 HIV infections were averted (July 2000 –June 2001) and a 3.1% decrease in the FSW HIV incidence. Costeffectiveness was $78 per DALY averted. Incremental cost of PPT was $31 per disability-adjusted life year (DALY) averted. Initiating the intervention at 15% general HIV prevalence would have improved costeffectiveness by 35%. Expanding PPT coverage to mass-treat all FSWs (instead of <17%) and their clients could increase impact 14-fold. Conclusion: The results highlight targeted interventions can be cost-effective at all stages of HIV epidemics and suggests PPT could improve the cost-effectiveness of targeted STI interventions.
62 citations
TL;DR: A high proportion of extended high viremics – individuals maintaining high plasma HIV-1 RNA load after acute infection – have been identified during primary HIV- 1 subtype C infection and likely contribute disproportionately to HIV-2 incidence.
Abstract: OBJECTIVE The present study addressed two questions: what fraction of individuals maintain a sustained high HIV-1 RNA load after the acute HIV-1C infection peak and how long is a high HIV-1 RNA load maintained after acute HIV-1C infection in this subpopulation? DESIGN/METHODS Plasma HIV-1 RNA dynamics were studied in 77 participants with primary HIV-1C infection from African cohorts in Gaborone, Botswana, and Durban, South Africa. HIV-infected individuals who maintained mean viral load of at least 100,000 (5.0 log(10)) copies/ml after 100 days postseroconversion (p/s) were termed extended high viremics. Individuals were followed longitudinally for a median [interquartile range (IQR)] of 573 (226-986) days p/s. RESULTS The proportion of extended high viremics was 34% [95% confidence interval (CI) 23-44%] during the period 100-300 days p/s and 19% (95% CI 9-29%) over the period of 200-400 days p/s. The median (IQR) duration of HIV-1 RNA load at least 100,000 copies/ml among extended high viremics was 271 (188-340) days p/s. For the subset with average viral load at least 100,000 copies/ml during 200-400 days p/s, the median (IQR) duration was 318 (282-459) days. The extended high viremics had a significantly shorter time to CD4 cell decline to 350 cells/μl (median: 88 vs. 691 days p/s for those not designated as extended high viremics; P < 0.0001, Gehan-Wilcoxon test). CONCLUSION A high proportion of extended high viremics - individuals maintaining high plasma HIV-1 RNA load after acute infection - have been identified during primary HIV-1 subtype C infection. These extended high viremics likely contribute disproportionately to HIV-1 incidence.
61 citations
"HIV Treatment as Prevention: Optimi..." refers background in this paper
...Another testing-related problem is that within-patient variability in CD4 cell count can be very high [19], such that the CD4 count from a single test could be an unreliable indicator of transmission risk and clinical need [20,21]....
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TL;DR: In southern India, HIV transmission could be driven by FSWs and their clients, and prevention programmes should also consider strategies to prevent transmission from clients to their noncommercial partners.
Abstract: BACKGROUND: In south India, general population HIV prevalence estimates range from 0.5 to 3%. To focus HIV prevention efforts, it is important to understand whether HIV transmission is driven by commercial sex. METHODS: A dynamic HIV/sexually transmitted infection transmission model was parameterized using data from Belgaum and Mysore in south India. Fits to sexually transmitted infection/HIV data from female sex workers (FSWs) and their clients for each district were obtained. Model HIV/herpes simplex virus-2 (HSV-2) prevalence projections for the general population were cross-validated against empirical estimates not used to fit model. The model estimated the proportion of incident HIV/HSV-2 infections due to HIV/HSV-2 transmission between FSWs/clients, their noncommercial partners and other low-risk partnerships. The relative impact of a generic intervention targeting different partnerships was explored. RESULTS: The model's general population HIV/HSV-2 prevalence projections agreed well with empirical estimates. Recent increases in condom use resulted in decreasing HIV epidemics in both settings. For men, most incident HIV/HSV-2 infections (>90%) directly result from commercial sex, whereas for women most are due to bridging infections from clients of FSWs (80-90%) with the remainder mainly due to commercial sex. Less than 1.5% of incident infections are due to low-risk partnerships. Intervention impact is maximized through targeting commercial sex but substantial impact could also be achieved through targeting noncommercial partners of clients. DISCUSSION: In southern India, HIV transmission could be driven by FSWs and their clients. While efforts to reduce HIV transmission due to commercial sex must continue, prevention programmes should also consider strategies to prevent transmission from clients to their noncommercial partners.
59 citations
"HIV Treatment as Prevention: Optimi..." refers background in this paper
...Previous modelling [81,82,87,88] and epidemiological analyses [89,90] suggest that prioritising interventions for FSWs and their clients in these settings can substantially reduce HIV transmission...
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TL;DR: In the setting of ongoing risk reduction education and provision of free condoms, initiation of ART was not associated with increased sexual risk behavior in this cohort of Kenyan FSWs.
Abstract: OBJECTIVE: The objective of this study was to test the hypothesis that sexual risk behavior would increase following initiation of antiretroviral therapy (ART) in Kenyan female sex workers (FSWs). DESIGN: Prospective cohort study. SETTING: FSW cohort in Mombasa Kenya 1993-2008. SUBJECTS: Eight hundred and ninety-eight women contributed HIV-1-seropositive follow-up visits of whom 129 initiated ART. INTERVENTION: Beginning in March 2004 ART was provided to women qualifying for treatment according to Kenyan National Guidelines. Participants received sexual risk reduction education and free condoms at every visit. MAIN OUTCOME MEASURES: Main outcome measures included unprotected intercourse abstinence 100% condom use number of sexual partners and frequency of sex. Outcomes were evaluated at monthly follow-up visits using a 1-week recall interval. RESULTS: Compared with non-ART-exposed follow-up visits following ART initiation were not associated with an increase in unprotected sex [adjusted odds ratio (AOR) 0.86 95% confidence interval (CI) 0.62-1.19 P = 0.4]. There was a nonsignificant decrease in abstinence (AOR 0.81 95% CI 0.65-1.01 P = 0.07) which was offset by a substantial increase in 100% condom use (AOR 1.54 95% CI 1.07-2.20 P = 0.02). Numbers of sex partners and frequency of sex were similar before versus after starting ART. A trend for decreased sexually transmitted infections following ART initiation provides additional support for the validity of the self-reported behavioral outcomes (AOR 0.67 95% CI 0.44-1.02 P = 0.06). CONCLUSION: In the setting of ongoing risk reduction education and provision of free condoms initiation of ART was not associated with increased sexual risk behavior in this cohort of Kenyan FSWs.
54 citations
"HIV Treatment as Prevention: Optimi..." refers background in this paper
..., potential increases in risk behaviours following ART expansion) [94,98,99]....
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