Equity and HIV/AIDS

Who are the male partners of adolescent girls and young women in Swaziland? Analysis of survey data from community venues across 19 DREAMS districts
Reynolds Z; Gottert A; Luben E; et al: PLOS One, doi: https://doi.org/10.1371/journal.pone.0203208, 2017

Adolescent girls and young women (AGYW, ages 15–24) are at high risk of HIV in Swaziland and understanding more about their male sexual partners can inform HIV prevention efforts for both. Using the PLACE methodology across all 19 DREAMS implementation districts, 843 men ages 20–34 were surveyed between December 2016-February 2017. Surveys were conducted at 182 venues identified by community informants as places where AGYW and men meet/socialize. In multivariate analyses, men who reported three or more AGYW partners in the last year were more likely to be HIV-positive. Men were also less likely to disclose their HIV status to adolescent versus older partners and partners more than 5 years younger than themselves. Results also revealed relatively high unemployment and mobility, substantial financial responsibilities, and periodic homelessness. Most men identified through community venues reported relationships with AGYW, and these relationships demonstrated substantial HIV risk. Challenging life circumstances suggest structural factors may underlie some risk behaviours. Engaging men in HIV prevention and targeted health services is argued to be critical, and informant-identified community venues are suggested to be promising intervention sites to reach high-risk male partners of AGYW.

Associations between health systems capacity and mother-to-child HIV prevention program outcomes in Zambia
Price J; Chi B; Phiri W: PLOS ONE 13(9), doi: https://doi.org/10.1371/journal.pone.0202889, 2018

In this study, the authors investigated the association between health system capacity and use of prevention of mother-to-child HIV transmission (PMTCT) services in Zambia. They analyzed data from two studies conducted in rural and semi-urban Lusaka Province in 2014–2015. Among 29 facilities, the median overall facility score was 72. Median domain scores were: patient satisfaction 75; human resources 85; finance 50; governance 82; service capacity 77; service provision 60. The programmatic outcome was measured from 804 HIV-infected mothers. Median community-level antiretroviral use at 12 months was 81%. Patient satisfaction was the only domain score significantly associated with 12-month maternal antiretroviral use. When the authors excluded the human resources and finance domains, a positive association between composite 4-domain facility score and 12-month maternal antiretroviral use in peri-urban but not rural facilities was found. In these Zambian health facilities, patient satisfaction was positively associated with maternal antiretroviral 12 months postpartum. The association between overall health system capacity and maternal antiretroviral drug use was stronger in peri-urban versus rural facilities.

High rates of smoking in people with HIV in sub-Saharan Africa
Carter M: Aidsmap, September 2018

This research analysed data from the Demographic and Health Surveys (DHS) and AIDS Indicator Surveys (AIS) from 25 sub-Saharan African countries to determine prevalence of cigarette smoking and use of smokeless tobacco according to HIV status. Cross-sectional data were collected between 2005 and 2015 from adults aged between 15 and 59 years. As well as HIV status, data were also collected on gender, marital/relationship status, level of education, income, area of residence (rural/urban) and employment status. These factors were taken into account in statistical analyses of the association between HIV status and tobacco use. Turning to HIV, the prevalence of smoking was higher among HIV-positive than HIV-negative individuals (10.6% vs 8.1%). Analysis by gender showed that 25.9% of HIV-positive men and 1.2% of HIV-positive women smoked, significantly higher than the 16.1% and 0.7% prevalence seen in HIV-negative men and women, respectively. Country-level analyses showed considerable variability in tobacco use between individual countries. The prevalence of smoking ranged from 2.4% in Ghana to 19.9% in Lesotho. Over half of countries (14 of 25) showed a higher smoking prevalence among people with HIV. The difference was significant in five countries: Gambia, Niger, Swaziland, Zambia and Zimbabwe. But in Ethiopia and Namibia, HIV-positive participants were less likely to smoke than HIV-negative ones. The investigators acknowledge a number of limitations, including the cross-sectional design of their study, failure to collect data on frequency and intensity of tobacco use and a lack of data on use of antiretroviral therapy.

HIV self-testing perceptions, delivery strategies, and post-test experiences among pregnant women and their male partners in Central Uganda
Matovu J; Kisa R; Buregyeya E; et al: Global Health Action 11(1503784) 1-12, 2018

This was a qualitative study was conducted in Central Uganda between February and March 2017 through 32 in-depth interviews to document women and men’s perceptions about HIV self-testing (HIVST) strategies used by women in delivering the kits to their male partners, male partners’ reactions to receiving kits from their female partners, and positive and negative social outcomes post-test. Women were initially anxious about their male partners’ reaction if they brought HIVST kits home, but the majority eventually managed to deliver the kits to them successfully. Women who had some level of apprehension used a variety of strategies to deliver the kits including placing the kits in locations that would arouse male partners’ inquisitiveness or waited for ‘opportune’ moments when their husbands were likely to be more receptive. A few women lied about the purpose of the test kit while one woman stealthily took a mucosal swab from the husband. Most men initially doubted the ability of oral HIVST kits to test for HIV, but this did not stop them from using them. Both men and women perceived HIVST as an opportunity to learn about each other’s HIV status. No serious adverse events were reported post-test. The author’s findings lend further credence to the feasibility of female-delivered HIVST to improve male partner HIV testing in sub-Saharan Africa. They suggest that women need support in challenging relationships to minimize potential for deception and coercion.

Southern Africa HIV and AIDS Regional Exchange (SHARE) Research Digest, April—May 2018
Southern Africa HIV and AIDS Regional Exchange (SHARE), 2018

This digest offers article abstracts from peer-reviewed literature related to HIV and AIDS in Southern Africa and is designed to keep readers in touch with the rapidly expanding evidence base pertaining to HIV in the region. For example in this issue there are 72 abstracts published April through May 2018 that feature articles from Botswana (4), Lesotho (2), Malawi (7), Mozambique (5), South Africa (43), Swaziland (2), Tanzania (4), Zambia (2) and Zimbabwe (9). Articles include a mixed methods study on access to HIV care and treatment for migrants between Lesotho and South Africa; findings from a cross-sectional study on HIV status disclosure among postpartum women with varied intimate partner violence experiences in Zambia; and lessons learned from the ZENITH trial in Zimbabwe on the role of community health workers in improving HIV treatment outcomes in children. The articles are catered to advocates, health care providers, implementers, lay health workers, policy makers and researchers.

The impact of intimate partner violence on women's contraceptive use: Evidence from the Rakai Community Cohort Study in Rakai, Uganda
Maxwell L; Brahmbhatt H: Ndyanabo A; et al: Social Science & Medicine, (209) 25-32, 2018

A systematic review of longitudinal studies suggests that intimate partner violence is associated with reduced contraceptive use. The authors used seven waves of data from the Rakai Community Cohort Study in Rakai, Uganda to estimate the effect of prior year intimate partner violence at one visit on women's current contraceptive use at the following visit. The analysis included 7923 women interviewed between 2001 and 2013. Women who experienced any form of prior year intimate partner violence were 20% less likely to use condoms at last sex than women who had not. The authors did not find evidence that intimate partner violence affects current use of modern contraception, however, current use of a partner-dependent method was 27% lower among women who reported any form of prior-year intimate partner violence compared to women who had not. Women who experienced prior-year intimate partner violence were less likely to use condoms and other forms of contraception that required negotiation with their male partners and more likely to use contraception that they could hide from their male partners. Longitudinal studies in Rakai and elsewhere have found that women who experience intimate partner violence have a higher rate of HIV than women who do not. The finding in this paper that women who experience IPV are less likely to use condoms may help explain the relation between intimate partner violence and HIV.

HIV infection in patients with sexually transmitted infections in Zimbabwe – Results from the Zimbabwe STI etiology study
Kilmarx P; Gonese E; Lewis D; et al.: PLoS One, doi: https://doi.org/10.1371/journal.pone.0198683, 2018

HIV and other sexually transmitted infections (STI) frequently co-occur. The authors conducted HIV diagnostic testing in an assessment of the etiologies of major STI syndromes in Zimbabwe. A total of 600 patients were enrolled at six geographically diverse, high-volume STI clinics in Zimbabwe in 2014–15: 200 men with urethral discharge, 200 women with vaginal discharge, and 100 men and 100 women each with genital ulcer disease (GUD). Patients completed a questionnaire, underwent a genital examination, and had specimens taken for etiologic testing. Patients were offered, but not required to accept, HIV testing using a standard HIV algorithm in which two rapid tests defined a positive result. A total of 489 participants accepted HIV testing; 201 tested HIV-1-positive, including 16 of 134 participants who reported an HIV-negative status at study enrollment, and 58 of 206 participants who reported their HIV status as unknown. Of 147 who self-reported being HIV-positive at study enrollment, 21 tested HIV negative. HIV infection prevalence was higher in women than in men, and was 28.5% in men with urethral discharge, 40.5% in women with vaginal discharge, 45.2% in men with GUD, and 59.8% in women with GUD. The high prevalence of HIV infection in STI clinic patients in Zimbabwe is argued by the authors to underscore the importance of providing HIV testing and referral for indicated prevention and treatment services for this population. The discrepancy between positive self-reported and negative study HIV test results highlights the need for operator training, strict attention to laboratory quality assurance, and clear communication with patients about their HIV infection status.

How antiretrovirals have cut the HIV/AIDS burden on SA's economy
Mahlakoana T: Business live, May 2018

Lost earnings attributable to HIV and AIDS as a result of either death or inability to work have declined significantly globally as countries scale up antiretroviral therapy. In 2005 HIV and AIDS were believed to have resulted in about $17bn in lost income, but the figure is projected to fall to $7.2bn in 2020. A study released by the International Labour Organisation shows that the number of employees living with the virus and unable to work has fallen "dramatically" since 2005. South Africa has the biggest HIV epidemic in the world with more than 7-million people living with the virus in 2016 and a stubbornly high rate of new infections. The country also has the largest antiretroviral treatment programme, which has increased life expectancy from 61 years in 2010 to 67 in 2015. The Employee Assistance Professionals Association’s Dr Dennis Cronson said there had been a great improvement in the effect of the virus on workers, especially in South Africa. "Hundreds of thousands of people are on ARVs and corporate managed programmes, and it’s a major success story …. the impact on productivity and other factors have improved," Cronson said.

Prevention of mother-to-child transmission of HIV: a cross-sectional study in Malawi
van Lettow M; Landes M; van Oosterhout J; et al: Bulletin World Health Organisation96(4) 256–265, 2018

This paper provided an estimated use and outcomes of the Malawian programme for the prevention of mother-to-child transmission of human immunodeficiency virus. In a cross-sectional analysis of 33 744 mother–infant pairs, the authors estimated the weighted proportions of mothers who had received antenatal human immunodeficiency virus testing and/or maternal antiretroviral therapy and infants who had received nevirapine prophylaxis and/or human immunodeficiency virus testing. The authors calculated the ratios of mother-to-child transmission at 4–26 weeks postpartum for subgroups that had missed none or at least one of these four steps. The estimated uptake of antenatal testing was 97.8%; while maternal antiretroviral therapy was 96.3%; infant prophylaxis was 92.3%; and infant human immunodeficiency virus testing was 53.2%. Estimated ratios of mother-to-child transmission were 4.7% overall and 7.7% for the pairs that had missed maternal antiretroviral therapy, 10.7% for missing both maternal antiretroviral therapy and infant prophylaxis and 11.4% for missing maternal antiretroviral therapy, infant prophylaxis and infant testing. Women younger than 19 years were more likely to have missed human immunodeficiency virus testing and infant prophylaxis than older women. Women who had never started maternal antiretroviral therapy were more likely to have missed infant prophylaxis and infant testing than women who had. Most women used the Malawian programme for the prevention of mother-to-child transmission. The risk of mother-to-child transmission increased if any of the main steps in the programme were missed.

The role of community health workers in improving HIV treatment outcomes in children: lessons learned from the ZENITH trial in Zimbabwe
Busza J; Dauya E; Bandason T; et al: Health Policy and Planning 33(3) 328–334, 2018

For the Zimbabwe study for Enhancing Testing and Improving Treatment of HIV in Children (ZENITH) randomized controlled trial, the authors based their intervention on an existing evidence-based framework for successful community health worker (CHW) programmes. To assess CHWs’ experiences delivering the intervention, they conducted longitudinal, qualitative semi-structured interviews with all 19 CHWs at three times during implementation. The study explored community health workers’ perceptions of how the intervention’s structure and management affected their performance, and considers implications for the programme’s future scale-up and adoption in other settings. Community health workers expressed strong motivation, commitment and job satisfaction. Intensive supervision and mentoring emerged as critical to ensuring community health workers long-term satisfaction. Provision of job aids, standardized manuals and refresher training were also important, as were formalized links between clinics and community health workers. Concerns raised by community health workers included poor remuneration, their reluctance to stop providing support to individual families following the requisite number of home visits, and disappointment at the lack of programme sustainability following completion of the trial. Furthermore, intensive supervision and integration with clinical services may be difficult to replicate outside a trial setting. This study shows that existing criteria for designing successful community health workers programmes are useful for maximizing effectiveness, but challenges remain for ensuring long-term sustainability of ‘task shifting’ strategies.