Implementation of a Test, Treat, and Prevent HIV program among men who have sex with men and transgender women in Thailand, 2015-2016.

INTRODUCTION: Antiretroviral therapy reduces the risk of serious illness among people living with HIV and can prevent HIV transmission. We implemented a Test, Treat, and Prevent HIV Program among men who have sex with men (MSM) and transgender women at five hospitals in four provinces of Thailand to increase HIV testing, help those who test positive start antiretroviral therapy, and increase access to pre-exposure prophylaxis (PrEP). METHODS: We implemented rapid HIV testing and trained staff on immediate antiretroviral initiation at the five hospitals and offered PrEP at two hospitals. We recruited MSM and transgender women who walked-in to clinics and used a peer-driven intervention to expand recruitment. We used logistic regression to determine factors associated with prevalent HIV infection and the decision to start antiretroviral therapy and PrEP. RESULTS: During 2015 and 2016, 1880 people enrolled. Participants recruited by peers were younger (p<0.0001), less likely to be HIV-infected (p<0.0001), and those infected had higher CD4 counts (p = 0.04) than participants who walked-in to the clinics. Overall, 16% were HIV-positive: 18% of MSM and 9% of transgender women; 86% started antiretroviral therapy and 46% of eligible participants started PrEP. A higher proportion of participants at hospitals with one-stop HIV services started antiretroviral therapy than other hospitals. Participants who started PrEP were more likely to report sex with an HIV-infected partner (p = 0.002), receptive anal intercourse (p = 0.02), and receiving PrEP information from a hospital (p<0.0001). CONCLUSIONS: We implemented a Test, Treat, and Prevent HIV Program offering rapid HIV testing and immediate access to antiretroviral therapy and PrEP. Peer-driven recruitment reached people at high risk of HIV and people early in HIV illness, providing an opportunity to promote HIV prevention services including PrEP and early antiretroviral therapy. Sites with one-stop HIV services had a higher uptake of antiretroviral therapy and PrEP.

Monitoring HIV Drug Resistance: Early Warning Indicators to Assess Performance of Thailand's Antiretroviral Treatment Program.

OBJECTIVE: To describe trends in Thailand's antiretroviral treatment (ART) program performance assessed by HIV drug resistance early warning indicators (EWIs), as recommended by WHO, between 2009 and 2013. MATERIAL AND METHOD: Seven EWIs were monitored, viral load (VL) testing coverage, VL suppression, retention in ART, lost to follow-up (LTFU), antiretrovirals (ARVs) dispensing practices, on-time pill pick-up, and pharmacy stock-outs. Data from ART adult patients in National Health Security Office Scheme were analyzed except for pharmacy stock-outs, which were reported from hospitals. Aggregated averages were calculated for each EWI. Chi-square for trend was applied to measure significant changes. RESULTS: By September 2013, 174,284 adults were receiving ART at 929 hospitals. Over time, improvement in VL testing coverage (53.8% in 2009 to 79.8% in 2013) was observed. VL suppression and on-time pill pick up rates were well above 90%. Rates of retention in ART declined from 84.0 to 82.9%, whereas LTFU rates increased from 8.3 to 9.2% (p<0.001). Prescriptions with inappropriate ARVs decreased from 0.32 to 0.10% (p<0.001). Of reporting hospitals, 96.1%, 96.3%, and 96.2% observed no ARVs stock-out between 2011 and 2013. CONCLUSION: EWI is a useful tool to monitor ART program performance and to identify area where improvement is needed.

Knowledge, attitudes, and practices related to treatment and prevention of cholera, Haiti, 2010.

In response to the recent cholera outbreak, a public health response targeted high-risk communities, including resource-poor communities in Port-au-Prince, Haiti. A survey covering knowledge and practices indicated that hygiene messages were received and induced behavior change, specifically related to water treatment practices. Self-reported household water treatment increased from 30.3% to 73.9%.

Considerations for oral cholera vaccine use during outbreak after earthquake in Haiti, 2010-2011.

Oral cholera vaccines (OCVs) have been recommended in cholera-endemic settings and preemptively during outbreaks and complex emergencies. However, experience and guidelines for reactive use after an outbreak has started are limited. In 2010, after over a century without epidemic cholera, an outbreak was reported in Haiti after an earthquake. As intensive nonvaccine cholera control measures were initiated, the feasibility of OCV use was considered. We reviewed OCV characteristics and recommendations for their use and assessed global vaccine availability and capacity to implement a vaccination campaign. Real-time modeling was conducted to estimate vaccine impact. Ultimately, cholera vaccination was not implemented because of limited vaccine availability, complex logistical and operational challenges of a multidose regimen, and obstacles to conducting a campaign in a setting with population displacement and civil unrest. Use of OCVs is an option for cholera control; guidelines for their appropriate use in epidemic and emergency settings are urgently needed.

Risk factors early in the 2010 cholera epidemic, Haiti.

During the early weeks of the cholera outbreak that began in Haiti in October 2010, we conducted a case-control study to identify risk factors. Drinking treated water was strongly protective against illness. Our results highlight the effectiveness of safe water in cholera control.

Rapid assessment of cholera-related deaths, Artibonite Department, Haiti, 2010.

We evaluated a high (6%) cholera case-fatality rate in Haiti. Of 39 community decedents, only 23% consumed oral rehydration salts at home, and 59% did not seek care, whereas 54% of 48 health facility decedents died after overnight admission. Early in the cholera epidemic, care was inadequate or nonexistent.

Epidemic cholera in a crowded urban environment, Port-au-Prince, Haiti.

We conducted a case-control study to investigate factors associated with epidemic cholera. Water treatment and handwashing may have been protective, highlighting the need for personal hygiene for cholera prevention in contaminated urban environments. We also found a diverse diet, a possible proxy for improved nutrition, was protective against cholera.

Prevalence of transmitted HIV drug resistance in Botswana: lessons learned from the HIVDR-Threshold Survey conducted among women presenting for routine antenatal care as part of the 2007 national sentinel survey.

The emergence and spread of transmitted drug resistance (TDR) poses a major threat to the success of the rapidly expanding antiretroviral treatment (ART) programs in resource-limited countries. The World Health Organization recommends the use of the HIV Drug Resistance Threshold Survey (HIVDR-TS) as an affordable means to monitor the presence of TDR in these settings. We report our experiences and results of the 2007 HIVDR-TS in Botswana, a country with one of the longest-existing national public ART programs in Africa. The HIVDR-TS and HIV-1 incidence testing were performed in the two largest national sites as part of the 2007 antenatal Botswana Sentinel Survey. The HIVDR-TS showed no significant drug resistance mutations (TDR less than 5%) in one site. TDR prevalence, however, could not be ascertained at the second site due to low sample size. The agreement between HIVDR-TS eligibility criteria and laboratory-based methodologies (i.e., BED-CEIA and LS-EIA) in identifying recently HIV-1 infected adults was poor. Five years following the establishment of Botswana's public ART program, the prevalence of TDR remains low. The HIVDR-TS methodology has limitations for low-density populations as in Botswana, where the majority of antenatal sites are too small to recruit sufficient numbers of patients. In addition, the eligibility criteria (age <25 years and parity (first pregnancy)) of the HIVDR-TS performed poorly in identifying recent HIV-1 infections in Botswana. An alternative sampling strategy should be considered for the surveillance of HIVDR in Botswana and similar geographic settings.

Perceptions of door-to-door HIV counselling and testing in Botswana.

Prevalence of HIV infection in Botswana is among the highest in the world, at 23.9% of 15 - 49-year-olds. Most HIV testing is conducted in voluntary counselling and testing centres or medical settings. Improved access to testing is urgently needed. This qualitative study assessed and documented community perceptions about the concept of door-to-door HIV counselling and rapid testing in two of the highest-prevalence districts of Botswana. Community members associated many positive benefits with home-based, door-to-door HIV testing, including convenience, confidentiality, capacity to increase the number of people tested, and opportunities to increase knowledge of HIV transmission, prevention and care through provision of correct information to households. Community members also saw the intervention as increasing opportunities to engage and influence family members and to role model positive behaviours. Participants also perceived social risks and dangers associated with home-based testing including the potential for conflict, coercion, stigma, and psychological distress within households. Community members emphasised the need for individual and community preparation, including procedures to protect confidentiality, provisions for psychological and social support, and links to appropriate services for HIV-positive persons.

Validation of AIDS-related mortality in Botswana.

BACKGROUND: Mortality data are used to conduct disease surveillance, describe health status and inform planning processes for health service provision and resource allocation. In many countries, HIV- and AIDS-related deaths are believed to be under-reported in government statistics. METHODS: To estimate the extent of under-reporting of HIV- and AIDS-related deaths in Botswana, we conducted a retrospective study of a sample of deaths reported in the government vital registration database from eight hospitals, where more than 40% of deaths in the country in 2005 occurred. We used the consensus of three physicians conducting independent reviews of medical records as the gold standard comparison. We examined the sensitivity, specificity and other validity statistics. RESULTS: Of the 5276 deaths registered in the eight hospitals, 29% were HIV- and AIDS-related. The percentage of HIV- and AIDS-related deaths confirmed by physician consensus (positive predictive value) was 95.4%; however, the percentage of non-HIV- and non-AIDS-related deaths confirmed (negative predictive value) was only 69.1%. The sensitivity and specificity of the vital registration system was 55.7% and 97.3%, respectively. After correcting for misclassification, the percentage of HIV- and AIDS--related deaths was estimated to be in the range of 48.8% to 54.4%, depending on the definition. CONCLUSION: Improvements in hospitals and within government offices are necessary to strengthen the vital registration system. These should include such strategies as training physicians and coders in accurate reporting and recording of death statistics, implementing continuous quality assurance methods, and working with the government to underscore the importance of using mortality statistics in future evidence-based planning.

Entertainment-education radio serial drama and outcomes related to HIV testing in Botswana.

Makgabaneng is an entertainment-education radio serial drama written and produced in Botswana to promote prevention of HIV. This effort is part of the national response to HIV/AIDS. Broadcast of the serial drama began in August 2001, and two new 15-minute episodes air each week. We examined associations between exposure to Makgabaneng and outcomes related to HIV testing, including stigmatizing attitudes, intention to be tested, talking with a partner about testing, and testing for HIV, among 555 sexually active respondents. The four measures of exposure to Makgabaneng were frequency of listening, duration of listening, talking about the program, and attentiveness to and identification with relevant characters. Data were collected approximately 18 months after the drama began airing. We found positive associations between exposure to the program and intermediate outcomes, including lower level of stigmatizing attitudes, stronger intention to have HIV testing, and talking to a partner about testing. Although associations were identified with all four measures of exposure, increased duration of listening was associated with more positive outcomes than the other measures. This finding suggests that longer term exposure to entertainment-education programming may be important for behavior change.

Early diagnosis of human immunodeficiency virus in infants using polymerase chain reaction on dried blood spots in Botswana's national program for prevention of mother-to-child transmission.

BACKGROUND: Botswana has high antenatal human immunodeficiency virus (HIV) prevalence (33.4%). The public health system provides free services for prevention of mother to child transmission of HIV (PMTCT) and antiretroviral therapy, which can reduce vertical HIV transmission from 35% to <5%. Infant HIV diagnosis is challenging in resource-limited settings, and HIV prevalence among HIV-exposed infants in Botswana is unknown. Dried blood spot (DBS) polymerase chain reaction (PCR) provides a feasible method to assess PMTCT programs and identify HIV-infected children. METHODS: We trained staff in 15 clinics and a hospital to obtain DBS on HIV-exposed infants age 6 weeks to 17 months receiving routine care. Samples were sent to the national HIV reference laboratory. Roche Amplicor 1.5 DNA PCR testing was performed. RESULTS: Between June-December 2005, 1931 HIV-exposed infants age 6 weeks to 17 months were tested for HIV, of whom 136 (7.0%) were HIV infected. Among infants

"A bull cannot be contained in a single kraal": concurrent sexual partnerships in Botswana.

To inform efforts to curb HIV in Botswana, we describe sexual concurrency and related norms and behaviors among a sample of 807 Batswana age 15-49 years who participated in a 2003 population-based survey. Of 546 sexually active respondents, 23% reported ever having a concurrent sexual partnership with any of the last three partners from the last 12 months. Multivariate analysis found that men and youth (age <25 years), and non-religious people were more likely than their respective counterparts to report concurrency. Respondents reporting concurrency were more likely than those not, to have norms that support multiple partnerships and report low self-efficacy to be faithful to one partner. However, a majority of both groups reported believing that fidelity is important and that they would be looked down upon by family and friends if discovered to have multiple partnerships. The findings suggest that concurrency in Botswana is not uncommon, and yet may not be generally acceptable.

Faithfulness to partners: a means to prevent HIV infection, a source of HIV infection risks, or both? A qualitative study of women's experiences in Abidjan, Côte d'Ivoire.

A cross-sectional study was carried out at a programme to prevent mother-to-child transmission of HIV (MTCT) at a public antenatal clinic in Abidjan, Côte d'Ivoire. The objectives were to obtain information from women concerning their reactions to HIV test results received through the programme, their experiences with faithfulness to partners as a means of primary HIV prevention for themselves and their infants, their relationships with partners, their own and their partners' experiences with HIV testing, and their knowledge of their partners' HIV serostatus. The participants were a purposive sample of 87 women who had received HIV-1-positive test results and 30 women who had received HIV-1-negative test results through the clinic's programme. Eighty-five per cent of the HIV-positive women were surprised by their test result; 52% of those who tested HIV-negative anticipated that result. Nearly two-thirds of those who were surprised to be HIV-positive and a similar proportion of those who expected to be HIV-negative explained their reactions by referring to faithfulness to their partners. Only five of the 117 women interviewed expressed a belief that their partners were faithful to them; and only two, and none of those who received an HIV-positive test result, reported using condoms with partners. No more than one-fourth of either the HIV-positive or the HIV-negative groups of women had been previously tested for HIV; less than one-fourth of the women in each group reported having partners who had been tested for HIV, or knew their partners' serostatus. Relationship characteristics of some HIV-positive women may have increased their vulnerability to HIV infection. Although being faithful to partners can be effective for the primary prevention of HIV infection, the manner in which it was practiced by many of the women in our study may have further increased their risk of infection. Organisations that choose to fund HIV prevention programmes that promote faithfulness to partners, and the programmes that stress faithfulness, must ensure that women are informed about the conditions that can influence the effectiveness of faithfulness as a protective action. However, women need more than information. Prevention programmes, whether concerned primarily with prevention of MTCT or with HIV prevention more broadly, must promote and elicit cooperation from women's sexual partners to support women's efforts to be tested for HIV, to be tested for HIV themselves, to disclose their test results, to reciprocate women's faithfulness and, if HIV serodiscordant or unwilling to be faithful, to use condoms. These steps may increase the likelihood that women will be able to protect themselves and their infants from HIV infection by being faithful to their partners.

Botswana's Tebelopele voluntary HIV counseling and testing network: use and client risk factors for HIV infection, 2000-2004.

BACKGROUND: : HIV services, including voluntary counseling and testing (VCT) and antiretroviral (ARV) therapy, expanded rapidly in Botswana from 2000 through 2004. METHODS: : Client data from Botswana's Tebelopele VCT network were analyzed to describe clients, factors associated with HIV infection, and trends in VCT use. RESULTS: : Tebelopele provided free, anonymous, same-day HIV tests for 117,234 clients from 2000 through 2004. Before ARV therapy was available, 8.3% of clients sought a test because of illness, and 26.3% were HIV-positive. After ARV therapy became available, 20.1% of clients sought a test because of illness, and 38.8% were HIV-positive. Most VCT clients (82.7%) were unmarried; 89.8% reported no or 1 sexual partner in the last 3 months; and 50.2% of unmarried clients reported always using condoms in the last 3 months. In multivariate analysis, higher educational level, marriage, and always using condoms were associated with a lower risk of HIV. Having only 1 recent sexual partner was associated with less condom use and a higher risk of being HIV-positive for men. CONCLUSIONS: : VCT has been well accepted in Botswana. Analysis of this data set supports efforts to promote 100% condom use and to emphasize that partner reduction must be combined with condom use and HIV testing to protect against HIV.

Prevention of mother-to-child transmission and voluntary counseling and testing programme data: what is their utility for HIV surveillance?

OBJECTIVE: Antenatal clinic (ANC)-based surveillance through unlinked anonymous testing (UAT) for HIV without informed consent provides solid long-term trend data in resource-constrained countries with generalized epidemics. The rapid expansion of the prevention of mother-to-child transmission (PMTCT) and voluntary counseling and testing (VCT) programmes prompts the question regarding their utility for HIV surveillance and their potential to replace UAT-based ANC surveillance. METHODS: Four presentations on the use of PMTCT or VCT data for HIV surveillance were presented at a recent international conference. The main findings are presented in this paper, and the operational and epidemiological aspects of using PMTCT or VCT data for surveillance are considered. RESULTS: VCT data in Uganda confirm the falling trend in HIV prevalence observed in ANC surveillance. Thailand, a country with nationwide PMTCT coverage and a very high acceptance of HIV testing, has replaced UAT data in favor of PMTCT data for surveillance. Studies from Botswana and Kenya showed that PMTCT-based HIV prevalences was similar, but the quality and availability of the PMTCT data varied. CONCLUSION: The strength of UAT lies in the absence of selection bias and the availability of individual data. Conversely, the quantity of VCT and PMTCT programme testing data often exceed those in UAT, but may be subject to bias due to self-selection or test refusal. When using VCT or PMTCT data for surveillance, investigators must consider these caveats, as well as their varying data quality, accessibility, and availability of individual records.

Changes in HIV RNA viral load, CD4+ T-cell counts, and levels of immune activation markers associated with anti-tuberculosis therapy and cotrimoxazole prophylaxis among HIV-infected tuberculosis patients in Abidjan, Cote d'Ivoire.

We analyzed changes in plasma human immunodeficiency virus (HIV)-1 viral load, CD4+ T-cell count, and markers of immune activation markers at start of treatment of tuberculosis and 12 months after among 44 HIV-1-infected patients with newly diagnosed, sputum-smear positive for Mycobacterium tuberculosis pulmonary infection. All patients received a standard regimen of 6 months of rifampicin and isoniazid with first 2 months of pyrazinamid with or without cotrimoxazole. Compared with values at start of treatment, median viral load increased by a median of 0.64 log10 copies/ml after 12 months of follow-up (P=0.0002). Median CD4+ T-cell counts were 393 cells/L at start of treatment and 370 cells/L after 12 months of follow-up (P=0.61). Levels of serum activation markers decreased significantly at 12 months of follow-up of the patients for both patients on standard and cotrimoxazole treatment. Levels of viral load, CD4+ T-cell counts, and markers of immune activation were not different for patients on standard treatment of tuberculosis compared with those on standard and cotrimoxazole treatment. Levels of serum activation markers decreased significantly at 12 months of follow-up of the patients for both patients on standard and cotrimoxazole treatment. Because viral load is a predictor of disease progression, its persistent elevated levels in blood of HIV-infected patients co-infected with tuberculosis, who successfully complete TB treatment, may account for the high mortality observed in this population.

Women's reasons for not participating in follow up visits before starting short course antiretroviral prophylaxis for prevention of mother to child transmission of HIV: qualitative interview study.

OBJECTIVE: To find out why pregnant women who receive HIV-1 positive test results and are offered short course antiretroviral prophylaxis to prevent transmission of HIV from mother to child do not participate in necessary follow up visits before starting prophylaxis. DESIGN: Qualitative interview study. SETTING: A programme aiming to prevent transmission of HIV from mother to child at a public antenatal clinic in Abidjan, Côte d'Ivoire. PARTICIPANTS: Purposive sample of 27 women who had received HIV-1 positive test results and were invited to return for monthly follow up visits before starting prophylaxis with zidovudine at 36 weeks' gestation, but who had either refused or discontinued the visits. None of the women started prophylaxis. RESULTS: Most of the women explained their non-participation in follow up visits by referring to negative experiences that they had had while interacting with programme staff or to their views about the programme. Additional reasons concerned their disbelief of HIV positive test results and personal factors. CONCLUSIONS: Difficulties experienced by women during their contacts with staff working on the prevention programme and negative views that they have about the programme can contribute to their non-participation in prophylaxis. Training and supervision of programme staff may increase the likelihood of positive interactions between staff and clients, thereby facilitating women's participation in preventing transmission of HIV from mother to child. Outreach and mobilisation in communities that are served by prevention programmes may complement these measures at programme level by contributing to increased social support for women's efforts to prevent transmission of HIV from mother to child.

Differences in HIV-2 plasma viral load and immune activation in HIV-1 and HIV-2 dually infected persons and those infected with HIV-2 only in Abidjan, Côte D'Ivoire.

OBJECTIVE: To determine whether blood plasma levels of HIV-2 RNA viral loads and immune activation markers differ between persons infected with HIV-2 only and those dually infected with HIV-1 and HIV-2. METHODS: Between September 1996 and February 2000, we collected, analyzed and compared levels of HIV-2 RNA in plasma and immune activation markers among 52 persons infected with HIV-2 alone and 75 with confirmed dual infection. We also compared viral load and immune activation in patients who were infected with HIV-1 only and those who were dually infected. RESULTS: When we conducted a CD4 T-cell count-stratified multivariate analysis of HIV-2 viral load, controlling for difference in CD4 T-cell counts, age and sex: at < 200 x 10 CD4 T cells/l, HIV-2 viral load was 2.0 log10 copies/ml lower in dually infected patients than in HIV-2 only patients (P < 0.0001). At CD4 T-cell counts between 200 x 10 and 500 x 10/l, HIV-2 viral load was 0.3 log10 copies/ml lower in dually infected patients (P = 0.45). However, at CD4 T-cells counts > 500 x 10/l, HIV-2 viral load was 0.9 log10 copies/ml higher in dually infected patients (P < 0.0001). Dually infected persons with undetectable HIV-2 viral loads had significantly higher median levels of CD8 T cells expressing CD38 (P < 0.001) and HLA-DR (P = 0.01) than HIV-2 only infected patients. CONCLUSION: These results suggest that in dual infection, the level of HIV-2 replication depends on the immune status of the patients, with HIV-1 out-replicating HIV-2 as disease progress.

HIV-1 viral load and other risk factors for mother-to-child transmission of HIV-1 in a breast-feeding population in Cote d'Ivoire.

Short-course antiretroviral regimens have been evaluated to reduce mother-to-child transmission of HIV in resource-limited settings. This report from Abidjan, Cote d'Ivoire, examines the risk factors for HIV transmission by 1 and 24 months among breast-feeding women. Eligible HIV-1-seropositive pregnant women enrolled in this randomized double-blind clinical trial were randomly assigned to receive either oral zidovudine (ZDV) (n = 126) prophylaxis or placebo (n = 124). Maternal prophylaxis began at 36 weeks of gestation (300 mg ZDV twice daily antepartum and 300 mg every 3 hours intrapartum); there was no neonatal prophylaxis component. The cumulative risk of transmission in the treatment group was 11.9% and 22.1% by 1 and 24 months, respectively. In adjusted analyses, viral load at enrollment was the strongest predictor of transmission (per log increment: odds ratio [OR] = 4.8, 95% confidence interval [CI]: 2.5-9.5 at 1 month; OR = 5.7; 95% CI: 3.1-10.8 at 24 months). Overall, ZDV prophylaxis was not significantly protective for infection at 1 or 24 months. Comparing ZDV with placebo following dichotomization of viral load (<50,000 vs. > or =50,000 copies/mL) at enrollment, however, there was a significant effect of ZDV seen only among those women with a low viral load at enrollment. The substantial risk of transmission despite ZDV prophylaxis, particularly among those with higher viral loads, underscores the need to find more effective regimens appropriate for use in resource-limited settings.