Prioritizing Mental Health within HIV and Tuberculosis Services in PEPFAR.

Underprioritization of mental health is a global problem and threatens the decades-long progress of the US President's Emergency Plan for AIDS Relief (PEPFAR) program. In recent years, mental health has become globally recognized as a part of universal healthcare, making this an opportune moment for the global community to integrate mental health services into routine programming. PEPFAR is well positioned to lead by example. We conceptualized 5 key strategies that might help serve as a framework to support mental health programming as part of PEPFAR's current 5-year strategic plan. PEPFAR and the global community have an opportunity to identify mental health service gaps and interweave global mental health priorities with actions to end the HIV and TB epidemics by 2030.

Client Experiences in a Mobile-Phone Counseling Intervention for Enhancing Access to Prevention of Mother To-Child Transmission (PMTCT) Services in Kenya.

Background: The prevention of mother-to-child transmission (PMTCT) is considered one of the most successful HIV prevention strategies in detecting and reducing HIV acquisition in utero or at birth. It is anticipated that with the increasing growth of digital technologies mobile phones can be utilized to enhance PMTCT services by improving provider-client interactions, expanding access to counseling services, and assisting in counteracting social and structural barriers to uptake of PMTCT services. Understanding the subjective experiences of women accessing PMTCT services in different settings has the potential to inform the development and promotion of such methods. This paper explores the perspectives of HIV-positive pregnant women attending maternal and neonatal clinic services in Kisumu, Kenya. Methods: Data are reported from in-depth interviews with women, following a longitudinal study investigating the impact of a structured, counselor-delivered, mobile phone counseling intervention to promote retention in care and adherence to ARV prophylaxis/treatment, for HIV-positive pregnant women. Thematic content analysis was conducted. Results: Discussions indicated that mobile-phone counseling provided useful health-related information, enhanced agency, and assisted mothers access critical PMTCT services across the cascade of care. Similarly, mobile-phone counseling offered personalized one-to-one contact with trained health providers including facilitating discussion of personal issues that likely affect access to services. Findings also identified barriers to the uptake of services, including a lack of partner support, poor health, poverty, facility-related factors, and provider attitudes. Discussion: Overall, findings show that mobile-phone counseling is feasible, acceptable, and can enhance access to PMTCT services by overcoming some of the individual and facility-level barriers. Although mobile-phone counseling has not been routinized in most health facilities, future work is needed to assess whether mobile-phone counseling can be scaled-up to aid in the effective use of HIV and PMTCT services, as well as improving other related outcomes for mother and child dyad.

Cost-Effectiveness of Peer-Delivered HIV Self-Tests for MSM in Uganda.

Introduction: Distribution of HIV self-testing (HIVST) kits through MSM peer networks is a novel and effective strategy to increase HIV testing coverage in this high-risk population. No study has evaluated the cost or cost effectiveness of peer distribution of HIVST strategies among MSM in sub-Saharan Africa. Methods: From June to August 2018, we conducted a pilot study of secondary MSM peer HIVST kit distribution at The AIDS Support Organization at Entebbe and Masaka. We used an ingredients approach to estimate the cost of MSM peer HIVST kit distribution relative to standard-of-care (SOC) hotspot testing using programme expenditure data reported in US dollars. The provider perspective was used to estimate incremental cost-effective ratios per HIV infection averted using the difference in HIV annual transmission rates between MSM with HIV who knew their status and were not virologically suppressed and MSM with HIV who did not know their status. Results: We enrolled 297 participants of whom 150 received MSM peer HIVST kit distribution (intervention group) and 147 received TASO standard of care HIV testing (control group). Provider cost for the intervention was $2,276 compared with $1,827 for SOC during the 3-month study period. Overall, the intervention resulted in higher HIV positivity yield (4.9 vs. 1.4%) and averted more HIV infections per quarter (0.364 vs. 0.104) compared with SOC. The cost per person tested was higher for the intervention compared to SOC ($15.90 vs. $12.40). Importantly, the cost per new HIV diagnosis ($325 vs. $914) and cost per transmission averted ($6,253 vs. $ 17,567) were lower for the intervention approach relative to SOC. The incremental cost per HIV transmission averted by the self-testing program was $1,727. The incremental cost to providers per additional HIV-positive person identified by the intervention was $147.30. Conclusion: The intervention strategy was cost-effective, and identified more undiagnosed HIV infections than SOC hotspot testing at a cost-effectiveness threshold of US $2,129. Secondary distribution of HIVST kits through peers should further be evaluated with longer duration aimed at diagnosing 95% of all persons with HIV by 2030; the first UNAIDS 95-95-95 target.

Prevalence and characteristics of HIV drug resistance among antiretroviral treatment (ART) experienced adolescents and young adults living with HIV in Ndola, Zambia.

BACKGROUND: HIV drug resistance (HIVDR) poses a threat to the HIV epidemic control in Zambia especially in sub-populations such as the 15-24 years where there is poor virological suppression. Understanding the prevalence and patterns of HIVDR in this population (15-24 years) will contribute to defining effective antiretroviral therapy (ART) regimens, improving clinical decision making, and supporting behavioral change interventions needed to achieve HIV epidemic control. METHODS: A cross-sectional analysis of study enrollment data from the Project YES! Youth Engaging for Success randomized controlled trial was conducted. Participants were 15 to 24 years old, who knew their HIV status, and had been on ART for at least 6 months. All participants completed a survey and underwent viral load (VL) testing. Participants with viral failure (VL ≥1,000 copies/mL) underwent HIVDR testing which included analysis of mutations in the protease and reverse transcriptase genes. RESULTS: A total of 99 out of 273 analyzed participants receiving ART had VL failure, of whom 77 had successful HIVDR amplification and analysis. Out of the 77, 75% (58) had at least one drug resistant mutation, among which 83% (48/58) required a drug change. Among the 58 with HIVDR mutations, the prevalence of at least one HIVDR mutation to nucleoside reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs) and protease inhibitors (PIs) were 81%, 65.5% and 1.7%. The mutation M184V which confers resistance to NRTI drugs of lamivudine (3TC) and emtricitabine (FTC) was the most common (81%) among NRTI associated mutations followed by K65R (34.5%) which is associated with both tenofovir disoproxil fumarate (TDF) and tenofovir alafenamide fumarate (TAF) resistance. Thymidine analogue mutations (TAMs) which confer resistance primarily to zidovudine (AZT), stavudine (d4T) and other NRTIs were observed at 32.8%. Common TAMs were K70RTQNE (32.8%), K219QE (22.4%), D67N (17.2%) and T215IT (15.5%). The most common NNRTI associated mutation was the K103N (65.5%) which confers resistance to both efavirenz (EFV) and nevirapine (NVP). There was a relatively high occurrence of other NNRTI mutations V106A (36.2%), as well as Y188C (36.2%) and Y181C (36.2%) which confer resistance to etravirine. CONCLUSIONS: There is a high prevalence of HIVDR including TAMs despite majority of these patients (90.48%) being on AZT or d4T sparing first line ART among the youth. Emergence of these mutations including the NNRTI associated mutations (Y181C and Y188C) may compromise future second- and third-line regimens in the absence of routine HIVDR testing. HIVDR monitoring at start of ART or at first-line failure can better inform clinical decision making and ART programing.

Addressing Intimate Partner Violence and Power in Intimate Relationships in HIV Testing Services in Nairobi, Kenya.

Intimate partner violence (IPV) undermines women's uptake of HIV services and violates their human rights. In a two-arm randomized controlled trial we evaluated a short intervention that went a step beyond IPV screening to discuss violence and power with women receiving HIV testing services during antenatal care (ANC). The intervention included training and support for HIV counselors, a take-home card for clients, and an on-site IPV counselor. One third (35%) of women (N = 688) reported experiencing IPV in the past year; 6% were living with HIV. Among women experiencing IPV, program participants were more likely to disclose violence to their counselor than women receiving standard care (32% vs. 7%, p < 0.001). At second ANC visit, intervention group women were significantly more likely to report that talking with their counselor made a positive difference (aOR 2.9; 95% CI 1.8, 4.4; p < 0.001) and felt more confident in how they deserved to be treated (aOR 2.7; 95% CI 1.7, 4.4; p < 0.001). Exploratory analyses of intent to use ARVs to prevent mother-to-child transmission and actions to address violence were also encouraging.

Research Capacity Strengthening in Sub-Saharan Africa: Recognizing the Importance of Local Partnerships in Designing and Disseminating HIV Implementation Science to Reach the 90-90-90 Goals.

Capacity building in implementation science is integral to PEPFAR's mission and to meeting the 90-90-90 goals. The USAID funded Project SOAR sponsored a 4 day workshop for investigators and governmental and non-governmental partners from 12 African countries. The workshop was designed to address both findings from a pre-workshop online needs assessment as well as capacity challenges across the capacity building pyramid, from individual skills to institutional systems and resources. Activities were output-oriented and skill based. An online survey evaluated sessions and changes in perceptions of needs; a majority of respondents strongly agreed that after the workshop, they better understood their personal and institutional capacity strengthening needs. Participants 'strongly agreed' that workshop content was relevant to their jobs (90%) and that they left the workshop with a specific plan for conducting future research (65%). Workshop results suggest that skill-building should be done in conjunction with systems capacity building within the cultural context.

Cell Phone Counseling Improves Retention of Mothers With HIV Infection in Care and Infant HIV Testing in Kisumu, Kenya: A Randomized Controlled Study.

BACKGROUND: We evaluated the effectiveness of a cell phone counseling intervention to promote retention in care and HIV testing of infants among women with HIV accessing prevention of mother-to-child services in Kisumu, Kenya. METHODS: Between May 2013 and September 2015, we recruited 404 pregnant women with HIV who were between 14 and 36 weeks of gestation and randomly assigned them to the intervention (n=207) or control arm (n=197). Retention was assessed at delivery and at 6 and 14 weeks postpartum. We also measured uptake of infant HIV testing. The intervention comprised a fixed protocol of counselor-delivered phone calls to provide one-to-one need-based support. The number of calls made varied depending on when participants presented for antenatal care services; the maximum number was 42. The control group received routine care. We evaluated retention at 3 time points using the complementary log-log regression model taking into account factors associated with retention and loss to follow-up time. We calculated the incidence rate for HIV transmission among infants and used binary logistic regression to identify predictors of HIV infection among infants. RESULTS: Participants attended on average 63% of the required number of counseling calls during the study period. Retention was higher in the intervention arm than the control arm at delivery (95.2% vs. 77.7%, respectively); 6 weeks postpartum (93.9% vs. 72.9%, respectively); and 14 weeks postpartum (83.3% vs. 66.5%, respectively) (P<.001). The counseling intervention (hazard ratio [HR]=0.29; 95% confidence interval [CI]=0.12, 0.69) and positive health perceptions (HR=0.99; 95% CI=0.98, 1.00) were associated with lower hazards of being lost to follow-up. HIV testing of infants was higher in the intervention than control arm (93% vs. 68%, respectively; P<.001). In total, 9 of 308 (2.9%) infants tested positive for HIV infection (incidence rate=0.39 infections/100 infant-weeks). Medication Possession Ratio (MPR) >90%, used to assess adherence to ART, was associated with lower odds of a positive HIV test among infants (adjusted odds ratio=0.20; 95% CI=0.04, 0.99). Attendance at antenatal and postnatal care visits was higher among participants in the intervention arm than the control arm. CONCLUSIONS: The one-on-one tailored counseling delivered via cell phone was effective in retaining mothers with HIV infection in care and promoting uptake of infant HIV testing and antenatal and postnatal care services. Phone counseling offers a practical approach to reach and retain pregnant women with HIV infection and postpartum mothers in care, but greater emphasis on collection of medications and adherence is required.

Performance of Kalon herpes simplex virus 2 assay using dried blood spots among young women in Uganda.

The study evaluated the performance of the Kalon HSV-2 assay on dried blood spots (DBS) of various dilutions compared with plasma from young women aged 18-24 years in Uganda. We estimated the sensitivity and specificity of three DBS dilutions using plasma as the reference. All three evaluated DBS dilutions yielded low sensitivities and specificities with DBS 1:2 yielding the highest concurrence. Other HSV-2 assays should be examined with regard to their utility for testing DBS.

Adolescent HIV disclosure in Zambia: barriers, facilitators and outcomes.

INTRODUCTION: As adolescents living with HIV gain autonomy over their self-care and begin to engage in sexual relationships, their experiences of being informed about their HIV status and of telling others about their HIV status may affect their ability to cope with having the disease. METHODS: In 2010, we conducted a qualitative study among adolescents aged 10-19 living with HIV in Zambia, and with their parents and health care providers. Through interviews and focus group discussions, we explored the disclosure of HIV status to adolescents living with HIV; adolescents' disclosure of their status to others; and the impact of both forms of disclosure on adolescents. RESULTS: Our study identified three main barriers to disclosure of HIV status: local norms that deter parents from communicating with their children about sexuality; fear of HIV stigma; and an underlying presumption that adolescents would not understand the consequences of a HIV diagnosis on their lives and relationships. With regard to adolescents' disclosure of their HIV status to their sexual partners, our study identified fear of rejection as a common barrier. In rare cases, open family conversations about HIV helped adolescents come to terms with a HIV diagnosis. Findings indicated that disclosure had various outcomes at the individual and interpersonal levels. At the individual level, some adolescents described being anxious, depressed and blaming themselves after being told they had HIV. At the interpersonal level, disclosure created opportunities for adolescents to access adherence support and other forms of psychosocial support from family members and peers. At the same time, it occasionally strained adolescents' sexual relationships, although it did not always lead to rejection. CONCLUSIONS: There is a need for public health interventions that guide adolescents living with HIV, their parents and families through the disclosure process. Such interventions should help parents to assess and understand the evolving cognitive capacity and maturity of their adolescents in order to determine the appropriate time to inform them of their HIV-positive status. Such interventions should also mitigate the risk of HIV stigma, as well as local norms that may prevent discussions of sexuality within families. Adolescents who have been informed of their HIV status should be provided with on-going support to prevent disclosure from negatively affecting their psychological and sexual wellbeing. Further research is needed to explore the potential role of trusted family members in contributing to the disclosure process.

Effectiveness of a community-based positive prevention intervention for people living with HIV who are not receiving antiretroviral treatment: a prospective cohort study.

BACKGROUND: We report effectiveness of an HIV-prevention intervention delivered by community health workers (CHWs) in Mombasa, Kenya, to PLHIV who have not initiated or who have discontinued ART-an often difficult-to-reach population because they fall outside the ambit of health care and prevention services. METHODS: A 2-arm cohort study assessed a structured risk-reduction intervention involving at least 4 one-to-one counseling sessions and personalized support. The control group received standard prevention services. CHWs recruited treatment-naïve people living with HIV (PLHIV) or those who had previously taken antiretroviral drugs. Data were analyzed using a Propensity Score Matched (PSM)-sample to control for baseline differences between the groups. RESULTS: 634 PLHIV were recruited and followed for 6 months. Median age was 35 years, and 74.3% were female. Participants in the intervention group reported reduced risky sexual behaviors both at endline compared with baseline and compared with the control group. At endline, in the PSM analysis, participants in the intervention arm were less likely than participants in the control group to report unprotected sex with a spouse (Odds Ratio [OR] = 0.08, 95% confidence interval [CI] = 0.03-0.24), and they reported fewer unprotected sex acts (12.3% versus 46.0%, respectively; OR = 0.16, 95% CI = 0.09-0.29; P<0.001). Further, 92.4% of participants in the intervention group reported zero unsafe sex acts (with partners of negative or unknown HIV status) compared with 70.8% in the control group (P<0.001), and more participants in the intervention arm were receiving ART (34.3% versus 12.7%, respectively; P<0.001). CONCLUSION: CHWs effectively reached PLHIV who had never received or who had discontinued ART, and they delivered a risk-reduction intervention that led to declines in reported sexual risk behaviors, as well as to increases in ART uptake. A scaled-up intervention warrants consideration.

Stronger health systems for more effective HIV/AIDS prevention and care.

Of the 42 million living with HIV/AIDS world-wide some 90% live in developing countries. The international community acknowledges the devastating impact of HIV/AIDS on development and over the past few years resources to control HIV/AIDS have increased considerably. We argue that strengthening of health systems is a necessary prerequisite for improving the prevention of HIV infection and the care of HIV-infected persons. Sexual behaviour change requires a multidisciplinary approach, but health services play a crucial role in detection and treatment of other sexually transmitted infections; HIV counselling and testing; prevention of mother-to-child transmission of HIV; and care of HIV-infected patients. Increasing access to antiretroviral treatment especially poses formidable challenges to health authorities in developing countries. Additional resources for the prevention of HIV-infection and the care of HIV-infected persons may not have the desired impact if health systems in developing countries are not strengthened. Further, any activity in the area of HIV/AIDS prevention and care, carried out within health services, can have a positive ripple effect on other health care activities and vice versa. This interactive effect needs to be acknowledged and built on.