Cost-outcome analysis of HIV testing and counseling, linkage, and defaulter tracing services in Bukoba, Tanzania.

Effective services along the HIV continuum of care from HIV testing and counseling to linkage, and from linkage to antiretroviral therapy (ART) initiation and retention, are key to improved health outcomes of persons living with HIV. A comprehensive analysis of the costs and outcomes of cascade services is needed to help allocate and prioritize resources to achieve UNAIDS targets. We evaluated the costs and population-level impact of a community-wide, integrated scale-up of testing, linkage, and defaulter-tracing programs implemented in Bukoba Municipal Council, Tanzania. Costs per identified HIV-positive client for provider-initiated, and home- and venue-based testing and counseling were $92.64 United States dollars (USD), $256.33 USD, and $281.57 USD, respectively. Costs per patient linked to HIV care and ART were $47.69 USD and $74.12 USD, respectively, during all ART-eligibility periods combined. Costs per defaulter traced and returned to HIV care were $47.56 USD and $206.77 USD, respectively. The provider-initiated testing and counseling was the most cost-effective modality. Testing approaches targeted to populations groups and geographic location with high testing positivity rates may improve the overall efficiency of testing services. The expansion of ART eligibility criteria and high linkage rate also result in efficiency gains and economies of scale of linkage services.

Mask Use and Ventilation Improvements to Reduce COVID-19 Incidence in Elementary Schools - Georgia, November 16-December 11, 2020.

To meet the educational, physical, social, and emotional needs of children, many U.S. schools opened for in-person learning during fall 2020 by implementing strategies to prevent transmission of SARS-CoV-2, the virus that causes COVID-19 (1,2). To date, there have been no U.S. studies comparing COVID-19 incidence in schools that varied in implementing recommended prevention strategies, including mask requirements and ventilation improvements* (2). Using data from Georgia kindergarten through grade 5 (K-5) schools that opened for in-person learning during fall 2020, CDC and the Georgia Department of Public Health (GDPH) assessed the impact of school-level prevention strategies on incidence of COVID-19 among students and staff members before the availability of COVID-19 vaccines.† Among 169 K-5 schools that participated in a survey on prevention strategies and reported COVID-19 cases during November 16-December 11, 2020, COVID-19 incidence was 3.08 cases among students and staff members per 500 enrolled students.§ Adjusting for county-level incidence, COVID-19 incidence was 37% lower in schools that required teachers and staff members to use masks, and 39% lower in schools that improved ventilation, compared with schools that did not use these prevention strategies. Ventilation strategies associated with lower school incidence included methods to dilute airborne particles alone by opening windows, opening doors, or using fans (35% lower incidence), or in combination with methods to filter airborne particles with high-efficiency particulate absorbing (HEPA) filtration with or without purification with ultraviolet germicidal irradiation (UVGI) (48% lower incidence). Multiple strategies should be implemented to prevent transmission of SARS-CoV-2 in schools (2); mask requirements for teachers and staff members and improved ventilation are important strategies that elementary schools could implement as part of a multicomponent approach to provide safer, in-person learning environments. Universal and correct mask use is still recommended by CDC for adults and children in schools regardless of vaccination status (2).

COVID-19 Testing to Sustain In-Person Instruction and Extracurricular Activities in High Schools - Utah, November 2020-March 2021.

Cessation of kindergarten through grade 12 in-person instruction and extracurricular activities, which has often occurred during the COVID-19 pandemic, can have negative social, emotional, and educational consequences for children (1,2). Although preventive measures such as masking, physical distancing, hand hygiene, and improved ventilation are commonly used in schools to reduce transmission of SARS-CoV-2, the virus that causes COVID-19, and support in-person instruction (3-6), routine school-based COVID-19 testing has not been as widely implemented. In addition to these types of standard preventive measures, Utah health and school partners implemented two high school testing programs to sustain extracurricular activities and in-person instruction and help identify SARS-CoV-2 infections: 1) Test to Play,* in which testing every 14 days was mandated for participation in extracurricular activities; and 2) Test to Stay,† which involved school-wide testing to continue in-person instruction as an alternative to transitioning to remote instruction if a school crossed a defined outbreak threshold (3). During November 30, 2020-March 20, 2021, among 59,552 students tested through these programs, 1,886 (3.2%) received a positive result. Test to Play was implemented at 127 (66%) of Utah's 193 public high schools and facilitated completion of approximately 95% of scheduled high school extracurricular winter athletics competition events.§ Test to Stay was conducted at 13 high schools, saving an estimated 109,752 in-person instruction student-days.¶ School-based COVID-19 testing should be considered as part of a comprehensive prevention strategy to help identify SARS-CoV-2 infections in schools and sustain in-person instruction and extracurricular activities.

Prevalence of Voluntary Medical Male Circumcision for HIV Infection Prevention - Chókwè District, Mozambique, 2014-2019.

Male circumcision is an important preventive strategy that confers lifelong partial protection (approximately 60% reduced risk) against heterosexually acquired HIV infection among males (1). In Mozambique, the prevalence of male circumcision was 51% when the voluntary medical male circumcision (VMMC) program began in 2009. The Mozambique Ministry of Health set a goal of 80% circumcision prevalence among males aged 10-49 years by 2019 (2). CDC analyzed data from five cross-sectional surveys of the Chókwè Health and Demographic Surveillance System (CHDSS) to evaluate progress toward the goal and guide ongoing needs for VMMC in Mozambique. During 2014-2019, circumcision prevalence among males aged 15-59 years increased 42%, from 50.1% to 73.5% (adjusted prevalence ratio [aPR] = 1.42). By 2019, circumcision prevalence among males aged 15-24 years was 90.2%, exceeding the national goal (2). However, circumcision prevalence among males in older age groups remained below 80%; prevalence was 62.7%, 54.5%, and 55.7% among males aged 25-34, 35-44, and 45-59 years, respectively. A multifaceted strategy addressing concerns about the safety of the procedure, cultural norms, and competing priorities that lead to lack of time could help overcome barriers to circumcision among males aged ≥25 years.

Overcoming Barriers to HIV Care: Findings from a Peer-Delivered, Community-Based, Linkage Case Management Program (CommLink), Eswatini, 2015-2018.

To help persons living with HIV (PLHIV) in Eswatini initiate antiretroviral therapy (ART), the CommLink case-management program provided a comprehensive package of linkage services delivered by HIV-positive, peer counselors. Of 1250 PLHIV participants aged ≥ 15 years diagnosed in community settings, 75% reported one or more barriers to care (e.g., fearing stigmatization). Peer counselors helped resolve 1405 (65%) of 2166 identified barriers. During Test and Treat (October 2016-September 2018), the percentage of participants who initiated ART and returned for ≥ 1 antiretroviral refills was 92% overall (759/824); 99% (155/156) among participants without any identified barriers; 96% (544/564) among participants whose counselors helped resolve all or all but one barrier; and 58% (59/102) among participants who had ≥ 2 unresolved barriers to care. The success of CommLink is attributed, at least in part, to peer counselors who helped their clients avoid or at least temporarily resolve many well-known barriers to HIV care.

RESUMEN: Para ayudar a las personas que viven con el VIH (PVVIH) en Eswatini a iniciar la terapia antirretroviral (TARV), el programa de gestión de casos CommLink proporcionó un paquete integral de servicios de la vinculación prestados por consejeros pares VIH positivos. De los 1.250 participantes de las PVVIH de 15 años o más diagnosticados en entornos comunitarios, el 75% informó una o más barreras para la atención (por ejemplo, por temor a la estigmatización). Los consejeros pares ayudaron a resolver 1.405 (65%) de 2.166 barreras identificadas. Durante el período de prueba y tratamiento (octubre de 2016 - septiembre de 2018), el porcentaje de participantes que iniciaron TARV y recibieron ≥ 1 recargas antirretroviral fue del 92% en general (759/824); 99% (155/156) entre los participantes sin barreras identificadas; 96% (544/564) entre los participantes cuyos consejeros ayudaron a resolver todas o todas las barreras excepto una; y 58% (59/102) entre los participantes que tenían ≥ 2 barreras no resueltas para la atención. El éxito de CommLink se atribuye, al menos en parte, a los consejeros pares que ayudaron a sus clientes a evitar o al menos temporalmente resolver muchas barreras conocidas para la atención del VIH.

Threefold Increases in Population HIV Viral Load Suppression Among Men and Young Adults - Bukoba Municipal Council, Tanzania, 2014-2017.

Reducing HIV-related morbidity and mortality, and effectively eliminating HIV transmission risk, depends on use of antiretroviral therapy (ART) to achieve and maintain viral load suppression (VLS)* (1,2). By 2020, sub-Saharan African countries are working to achieve VLS among 90% of persons using ART and 73% of all persons living with HIV infection (1). In Tanzania, a country with 1.4 million persons with HIV infection, 49.6% of HIV-positive persons aged 15-49 years had achieved VLS in 2017, including only 21.5% of men and 44.6% of women aged 25-29 years (3). To identify interventions that might increase VLS in Tanzania, and reduce VLS-associated sex and age-group disparities, the Bukoba Combination Prevention Evaluation (BCPE) scaled up new HIV testing, linkage to care, and retention on ART interventions throughout Bukoba Municipal Council (Bukoba), Tanzania, during October 2014-March 2017 (4,5). Located on the western shore of Lake Victoria, Bukoba is a mixed urban and rural municipality of 150,000 persons and capital of Kagera Region. Of the 31 regions of Tanzania, Kagera has the fourth highest prevalence of HIV infection (6.8%) among residents aged 15-49 years (3). CDC analyzed data from BCPE preintervention and postintervention surveys and found that VLS prevalence among HIV-positive Bukoba residents aged 18-49 years increased approximately twofold overall (from 28.6% to 64.8%) and among women (33.3% to 67.8%) and approximately threefold among men (20.5% to 59.1%) and young adults aged 18-29 years (15.6% to 56.7%). During 2017, BCPE facility-based testing and linkage interventions were approved as new service delivery models by the Tanzania Ministry of Health, Community Development, Gender, Elderly and Children (4,5). After a successful rollout to 208 facilities in 11 regions in 2018, BCPE interventions are being scaled up in all regions of Tanzania in 2019 with support from the United States President's Emergency Plan for AIDS Relief (PEPFAR).†.

Peer-Delivered Linkage Case Management and Same-Day ART Initiation for Men and Young Persons with HIV Infection - Eswatini, 2015-2017.

To achieve epidemic control of human immunodeficiency virus (HIV) infection, sub-Saharan African countries are striving to diagnose 90% of HIV infections, initiate and retain 90% of HIV-diagnosed persons on antiretroviral therapy (ART), and achieve viral load suppression* for 90% of ART recipients (90-90-90) (1). In Eswatini (formerly Swaziland), the country with the world's highest estimated HIV prevalence (27.2%), achieving 90-90-90 depends upon improving access to early ART for men and young adults with HIV infection, two groups with low ART coverage (1-3). Although community-based strategies test many men and young adults with HIV infection in Eswatini, fewer than one third of all persons who test positive in community settings enroll in HIV care within 6 months of diagnosis after receiving standard referral services (4,5). To evaluate the effectiveness of peer-delivered linkage case management† in improving early ART initiation for persons with HIV infection diagnosed in community settings in Eswatini, CDC analyzed data on 651 participants in CommLink, a community-based, mobile HIV-testing, point-of-diagnosis HIV care, and peer-delivered linkage case management demonstration project, and found that after diagnosis, 635 (98%) enrolled in care within a median of 5 days (interquartile range [IQR] = 2-8 days), and 541 (83%) initiated ART within a median of 6 days (IQR = 2-14 days), including 402 (74%) on the day of their first clinic visit (same-day ART). After expanding ART eligibility to all persons with HIV infection on October 1, 2016, 96% of 225 CommLink clients initiated ART, including 87% at their first clinic visit. Compared with women and adult clients aged ≥30 years, similar high proportions of men and persons aged 15-29 years enrolled in HIV care and received same-day ART. To help achieve 90-90-90 by 2020, the United States President's Emergency Plan for AIDS Relief (PEPFAR) is supporting the national scale-up of CommLink in Eswatini and recommending peer-delivered linkage case management as a potential strategy for countries to achieve >90% early enrollment in care and ART initiation after diagnosis of HIV infection (6).

Low and Decreasing Prevalence and Rate of False Positive HIV Diagnosis - Chókwè District, Mozambique, 2014-2017.

In 2017, rapid human immunodeficiency virus (HIV) testing services enabled the HIV diagnosis and treatment of approximately 15.3 million persons with HIV infection in sub-Saharan Africa with life-saving antiretroviral therapy (ART) (1). Although suboptimal testing practices and misdiagnoses have been reported in sub-Saharan Africa and elsewhere, trends in population burden and rate of false positive HIV diagnosis (false diagnosis) have not been reported (2,3). Understanding the population prevalence and trends of false diagnosis is fundamental for guiding rapid HIV testing policies and practices. To help address this need, CDC analyzed data from 57,655 residents aged 15-59 years in the Chókwè Health and Demographic Surveillance System (CHDSS) in Mozambique to evaluate trends in the rate (the percentage of false diagnoses among retested persons reporting a prior HIV diagnosis) and population prevalence of false diagnosis. From 2014 to 2017, the observed rate of false diagnosis in CHDSS decreased from 0.66% to 0.00% (p<0.001), and the estimated population prevalence of false diagnosis decreased from 0.08% to 0.01% (p = 0.0016). Although the prevalence and rate of false diagnosis are low and have decreased significantly in CHDSS, observed false diagnoses underscore the importance of routine HIV retesting before ART initiation and implementation of comprehensive rapid HIV test quality management systems (2,4,5).

Trends in HIV prevalence and HIV testing among young MSM: five United States cities, 1994-2011.

We examined trends in cross-sectional HIV prevalence (a surrogate for incidence) and past 12 month testing behavior among young men who have sex with men (MSM). The Young Men's Survey and the National HIV Behavioral Surveillance System conducted interviews and HIV testing among MSM recruited by venue-based sampling during 1994-2011. Using data from five cities, we determined whether interview year was associated with HIV prevalence and recent testing for MSM ages 18-22 and 23-29 years, after adjusting for city, race/ethnicity, and education. Multivariable analysis demonstrated an overall increase in prevalence among MSM ages 23-29 years, driven by an increase in Baltimore. There was no change in HIV prevalence among MSM ages 18-22 years overall, although prevalence increased in Baltimore. HIV testing increased significantly for both age groups. Gains in HIV testing are encouraging, but increasing prevalence among young MSM in Baltimore suggests increasing incidence and the need for additional efforts for this population.

Behavior Skills Training with Zoological Staff to Increase Killer Whale Attending Behavior.

Attending is a requisite behavior for interactions between animals in zoological care and their care specialist (trainers). Head-dropping behavior (HDB) is incompatible with attending and was observed with two killer whales during whale-trainer interactions (WTI). Initial observations also noted inconsistencies in the trainers' application of shaping procedures during WTI. A three-part plan was developed to address trainers procedural fidelity, increase whale attending during WTI, and program for the behavioral generalization and maintenance of the whale-trainer dyads (dyad). First, behavior skills training (BST) was used to instruct trainers on discrete trial training (DTT). Second, the trainers' applied their acquired skill of DTT, targeting attending behavior, with their whale during WTI. Third, behavioral generalization was programed by switching the dyad pairs in an additional DTT generalization phase. The findings demonstrated a strong positive correlation between trainer DTT fidelity and whale attending. Finally, the results suggest that future assessments of behavioral management programs with zoological trainers and animals are warranted.

Comparison of demographic and behavioral characteristics of men who have sex with men by enrollment venue type in the National HIV Behavioral Surveillance System.

BACKGROUND: During 2003-2005, the National HIV Behavioral Surveillance System (NHBS) enrolled men who have sex with men (MSM) from 12 different venue types in 15 metropolitan areas in the United States. Our goal was to examine whether limiting NHBS enrollment venues to gay bars and dance clubs could increase efficiency without changing the overall results and conclusions. METHODS: We used logistic regression analysis to compare the demographic characteristics and reported HIV risk behaviors among MSM enrolled in gay bars and dance clubs with those enrolled in sex venues and those enrolled in other venues. RESULTS: Of the 11,471 eligible men included in the analysis, 6419 (56%) were enrolled at bars and clubs, 481 (4%) at sex venues, and 4571 (40%) at other venues. Compared with men enrolled at bars and clubs, men enrolled at sex venues were more likely to be older, of nonwhite race/ethnicity, bisexual, infrequent gay venue attendees, and to have 10 or more male sex partners in the past 12 months. Men enrolled at other venues were more likely to be older and less likely to use noninjecting drugs in the past 12 months. The absolute differences in these characteristics between men enrolled in bars and clubs and those enrolled in comparison venue categories were small in most instances. CONCLUSIONS: Although the differences in characteristics by venue category were not large in magnitude, there was evidence that restricting NHBS enrollment to bars and clubs would affect national estimates of behavioral risk factors among MSM.

Client characteristics and gender-specific correlates of testing HIV positive: a comparison of standalone center versus mobile outreach HIV testing and counseling in Botswana.

Using data from Botswana's largest HIV testing and counseling (HTC) provider, Tebelopele, we evaluate populations served and gender-specific correlates of testing HIV-positive among clients of two programs: standalone centers and outreach testing. Client records from January to June 2007 (n = 47,890) were evaluated by HTC program and gender. Bivariate and multivariate analyses were performed to identify demographic, testing, and risk-behavior variables associated with testing HIV-positive. Compared to outreach testing, standalone centers served proportionally more clients who were young, well-educated, unmarried, and HIV-infected; outreach testing reached an older, less-educated population. Age, educational attainment, marital status, couples testing, testing because of illness or discordant relationship, and nonuse of condoms (among young clients only) were consistently associated with testing HIV-positive, by HTC program and gender. Our evaluation suggests that Tebelopele standalone and outreach HTC programs serve different populations, and identifies strategies to reduce HIV infection risk and to improve uptake of HTC by HIV-infected, undiagnosed Batswana.

Evaluation of Community-Based, Mobile HIV-Care, Peer-Delivered Linkage Case Management in Manzini Region, Eswatini.

The success of antiretroviral therapy (ART) requires continuous engagement in care and optimal levels of adherence to achieve sustained HIV viral suppression. We evaluated HIV-care cascade costs and outcomes of a community-based, mobile HIV-care, peer-delivered linkage case-management program (CommLink) implemented in Manzini region, Eswatini. Abstraction teams visited referral facilities during July 2019-April 2020 to locate, match, and abstract the clinical data of CommLink clients diagnosed between March 2016 and March 2018. An ingredients-based costing approach was used to assess economic costs associated with CommLink. The estimated total CommLink costs were $2 million. Personnel costs were the dominant component, followed by travel, commodities and supplies, and training. Costs per client tested positive were $499. Costs per client initiated on ART within 7, 30, and 90 days of diagnosis were $2114, $1634, and $1480, respectively. Costs per client initiated and retained on ART 6, 12, and 18 months after diagnosis were $2343, $2378, and $2462, respectively. CommLink outcomes and costs can help inform community-based HIV testing, linkage, and retention programs in other settings to strengthen effectiveness and improve efficiency.

Antiretroviral therapy initiation and retention among clients who received peer-delivered linkage case management and standard linkage services, Eswatini, 2016-2020: retrospective comparative cohort study.

BACKGROUND: Persons living with HIV infection (PLHIV) who are diagnosed in community settings in sub-Saharan Africa are particularly vulnerable to barriers to care that prevent or delay many from obtaining antiretroviral therapy (ART). METHODS: We conducted a retrospective cohort study to assess if a package of peer-delivered linkage case management and treatment navigation services (CommLink) was more effective than peer-delivered counseling, referral, and telephone follow-up (standard linkage services, SLS) in initiating and retaining PLHIV on ART after diagnosis in community settings in Eswatini. HIV-test records of 773 CommLink and 769 SLS clients aged ≥ 15 years diagnosed between March 2016 and March 2018, matched by urban and rural settings of diagnosis, were selected for the study. CommLink counselors recorded resolved and unresolved barriers to care (e.g., perceived wellbeing, fear of partner response, stigmatization) during a median of 52 days (interquartile range: 35-69) of case management. RESULTS: Twice as many CommLink than SLS clients initiated ART by 90 days of diagnosis overall (88.4% vs. 37.9%, adjusted relative risk (aRR): 2.33, 95% confidence interval (CI): 1.97, 2.77) and during test and treat when all PLHIV were eligible for ART (96.2% vs. 37.1%, aRR: 2.59, 95% CI: 2.20, 3.04). By 18 months of diagnosis, 54% more CommLink than SLS clients were initiated and retained on ART (76.3% vs. 49.5%, aRR: 1.54, 95% CI: 1.33, 1.79). Peer counselors helped resolve 896 (65%) of 1372 identified barriers of CommLink clients. Compared with clients with ≥ 3 unresolved barriers to care, 42% (aRR: 1.42, 95% CI: 1.19, 1.68) more clients with 1-2 unresolved barriers, 44% (aRR: 1.44, 95% CI: 1.25, 1.66) more clients with all barriers resolved, and 54% (aRR: 1.54, 95% CI: 1.30, 1.81) more clients who had no identified barriers were initiated and retained on ART by 18 months of diagnosis. CONCLUSIONS: To improve early ART initiation and retention among PLHIV diagnosed in community settings, HIV prevention programs should consider providing a package of peer-delivered linkage case management and treatment navigation services. Clients with multiple unresolved barriers to care measured as part of that package should be triaged for differentiated linkage and retention services.

Reasons for not HIV testing, testing intentions, and potential use of an over-the-counter rapid HIV test in an internet sample of men who have sex with men who have never tested for HIV.

BACKGROUND: Correlates of main reasons for not HIV testing, HIV testing intentions, and potential use of an over-the-counter rapid HIV test (OTCRT) among men who have sex with men who have never tested for HIV (NTMSM) are unknown. METHODS: We evaluated these correlates among 946 NTMSM from 6 US cities who participated in an internet-based survey in 2007. FINDINGS: Main reasons for not testing were low perceived risk (32.2%), structural barriers (25.1%), and fear of testing positive (18.1%). Low perceived risk was associated with having fewer unprotected anal intercourse (UAI) partners and less frequent use of the internet for HIV information; structural barriers were associated with younger age and more UAI partners; fear of testing positive was associated with black and Hispanic race/ethnicity, more UAI partners, and more frequent use of the internet for HIV information. Strong testing intentions were held by 25.9% of all NTMSM and 14.8% of those who did not test because of low perceived risk. Among NTMSM who were somewhat unlikely, somewhat likely, and very likely to test for HIV, 47.4%, 76.5%, and 85.6% would likely use an OTCRT if it was available, respectively. CONCLUSIONS: Among NTMSM who use the internet, main reasons for not testing for HIV vary considerably by age, race/ethnicity, UAI, and use of the internet for HIV information. To facilitate HIV testing of NTMSM, programs should expand interventions and services tailored to address this variation. If approved, OTCRT might be used by many NTMSM who might not otherwise test for HIV.

HIV/AIDS complacency and HIV infection among young men who have sex with men, and the race-specific influence of underlying HAART beliefs.

BACKGROUND: Among men who have sex with men (MSM) in the United States, the influence of HIV/AIDS complacency and beliefs about the efficacy of highly active antiretroviral therapy (HAART) on HIV-infection risk is unknown. METHODS: We analyzed data from a 1998-2000 cross-sectional 6-city survey of 1575 MSM aged 23 to 29 years who had never tested for HIV or had last tested HIV-negative to assess these plausible influences overall and by race/ethnicity. FINDINGS: Measured as strong endorsement for reduced HIV/AIDS concern due to HAART, HIV/AIDS complacency was associated with reporting ≥10 male sex partners (odds ratio [OR], 2.94; 95% confidence interval [CI], 2.12-4.07), unprotected anal intercourse with an HIV-positive or HIV-unknown-status male partner (OR, 2.06; 95% CI, 1.51-2.81), and testing HIV-positive (adjusted OR [AOR], 2.35; 95% CI, 1.38-3.98). Strong endorsement of the belief that HAART mitigates HIV/AIDS severity was more prevalent among black (21.8%) and Hispanic (21.3%) than white (9.6%) MSM (P < 0.001), and was more strongly associated with testing HIV-positive among black (AOR, 4.65; 95% CI, 1.97-10.99) and Hispanic (AOR, 4.12; 95% CI, 1.58-10.70) than white (AOR, 1.62; 95% CI, 0.64-4.11) MSM. CONCLUSIONS: Young MSM who are complacent about HIV/AIDS because of HAART may be more likely to engage in risk behavior and acquire HIV. Programs that target HIV/AIDS complacency as a means to reduce HIV incidence among young MSM should consider that both the prevalence of strong HAART-efficacy beliefs and the effects of these beliefs on HIV-infection risk might differ considerably by race/ethnicity.

A plausible causal model of HAART-efficacy beliefs, HIV/AIDS complacency, and HIV-acquisition risk behavior among young men who have sex with men.

Despite considerable research, the causal relationship remains unclear between HIV/AIDS complacency, measured as reduced HIV/AIDS concern because of highly active antiretroviral therapy (HAART), and HIV risk behavior. Understanding the directionality and underpinnings of this relationship is critical for programs that target HIV/AIDS complacency as a means to reduce HIV incidence among men who have sex with men (MSM). This report uses structural equation modeling to evaluate a theory-based, HIV/AIDS complacency model on 1,593 MSM who participated in a venue-based, cross-sectional survey in six U.S. cities, 1998-2000. Demonstrating adequate fit and stability across geographic samples, the model explained 15.0% of the variance in HIV-acquisition behavior among young MSM. Analyses that evaluated alternative models and models stratified by perceived risk for HIV infection suggest that HIV/AIDS complacency increases acquisition behavior by mediating the effects of two underlying HAART-efficacy beliefs. New research is needed to assess model effects on current acquisition risk behavior, and thus help inform prevention programs designed to reduce HIV/AIDS complacency and HIV incidence among young MSM.

HIV testing and ART initiation among partners, family members, and high-risk associates of index clients participating in the CommLink linkage case management program, Eswatini, 2016-2018.

To help diagnose and initiate antiretroviral therapy (ART) for ≥95% of all persons living with HIV (PLHIV), the World Health Organization (WHO) recommends offering HIV testing to biological children, and sexual and needle-sharing partners of all PLHIV (index-client testing, ICT). Many index clients, however, do not identify or have contactable partners, and often substantially fewer than 95% of HIV-positive partners initiate ART soon after index testing. To help improve early HIV diagnosis and ART initiation in Eswatini (formerly Swaziland), we implemented a community-based HIV testing and peer-delivered, linkage case management program (CommLink) that provided ICT as part of a comprehensive package of WHO recommended linkage services. CommLink was implemented June 2015 -March 2017 (Phase I), and April 2017 -September 2018 (Phase II). In addition to biological children and partners, HIV testing was offered to adult family members (Phases I and II) and high-risk associates including friends and acquaintances (Phase II) of CommLink index clients. Compared with Phase I, in Phase II proportionally more CommLink clients disclosed their HIV-infection status to a partner or family member [94% (562/598) vs. 75% (486/652)], and had ≥1 partners, family members, or high-risk associates (contacts) tested through CommLink [41% (245/598) vs. 18% (117/652)]. Of 537 contacts tested, 253 (47%) were HIV-positive and not currently in HIV care, including 17% (17/100) of family members aged <15 years, 42% (78/187) of non-partner family members aged ≥15 years, 60% (73/121) of sexual partners, and 66% (85/129) of high-risk associates. Among 210 HIV-positive contacts aged ≥15 years who participated in CommLink, nearly all received recommended linkage services including treatment navigation (95%), weekly telephone follow-up (93%), and ≥3 counseling sessions (94%); peer counselors resolved 76% (306/404) of identified barriers to care (e.g., perceived wellness); and 200 (95%) initiated ART at a healthcare facility, of whom 196 (98%) received at least one antiretroviral refill before case-management services ended. To help countries achieve ≥90% ART coverage among all PLHIV, expanding ICT for adult family members and high-risk associates of index clients, and providing peer-delivered linkage case management for all identified PLHIV, should be considered.

Annual home-based HIV testing in the Chókwè Health Demographic Surveillance System, Mozambique, 2014 to 2019: serial population-based survey evaluation.

INTRODUCTION: WHO recommends implementing a mix of community and facility testing strategies to diagnose 95% of persons living with HIV (PLHIV). In Mozambique, a country with an estimated 506,000 undiagnosed PLHIV, use of home-based HIV testing services (HBHTS) to help achieve the 95% target has not been evaluated. METHODS: HBHTS was provided at 20,000 households in the Chókwè Health Demographic Surveillance System (CHDSS), Mozambique, in annual rounds (R) during 2014 to 2019. Trends in prevalence of HIV infection, prior HIV diagnosis among PLHIV (diagnostic coverage), and undiagnosed HIV infection were assessed with three population-based surveys conducted in R1 (04/2014 to 04/2015), R3 (03/2016 to 12/2016), and R5 (04/2018 to 03/2019) of residents aged 15 to 59 years. Counts of patients aged ≥15 years tested for HIV in CHDSS healthcare facilities were obtained from routine reports. RESULTS: During 2014 to 2019, counsellors conducted 92,512 home-based HIV tests and newly diagnosed 3711 residents aged 15 to 59 years. Prevalence of HIV infection was stable (R1, 25.1%; R3 23.6%; R5 22.9%; p-value, 0.19). After the first two rounds (44,825 home-based tests; 31,717 facility-based tests), diagnostic coverage increased from 73.8% (95% CI 70.3 to 77.2) in R1 to 93.0% (95% CI 91.3 to 94.7) in R3, and prevalence of undiagnosed HIV infection decreased from 6.6% (95% CI 5.6 to 7.5) in R1 to 1.7% (95% CI 1.2 to 2.1) in R3. After two more rounds (32,226 home-based tests; 46,003 facility-based tests), diagnostic coverage was 95.4% (95% CI 93.7 to 97.1) and prevalence of undiagnosed HIV infection was 1.1% (95% CI 0.7 to 1.5) in R5. Prevalence of having last tested at home was 12.7% (95% CI 11.3 to 14.0) in R1, 45.2% (95% CI 43.4 to 47.0) in R3, and 41.4% (95% CI 39.5 to 43.2) in R5, and prevalence of having last tested at a healthcare facility was 45.3% (95% CI 43.3 to 47.3) in R1, 40.1% (95% CI 38.4 to 41.8) in R3, and 45.2% (95% CI 43.3 to 47.0) in R5. CONCLUSIONS: HBHTS successfully augmented facility-based testing to achieve HIV diagnostic coverage in a high-burden community of Mozambique. HBHTS should be considered in sub-Saharan Africa communities striving to diagnose 95% of persons living with HIV.

High Coverage of Antiretroviral Treatment With Annual Home-Based HIV Testing, Follow-up Linkage Services, and Implementation of Test and Start: Findings From the Chókwè Health Demographic Surveillance System, Mozambique, 2014-2019.

BACKGROUND: Early antiretroviral therapy (ART) is necessary for HIV epidemic control and depends on early diagnosis and successful linkage to care. Since 2014, annual household-based HIV testing and counseling and linkage services have been provided through the Chókwè Health and Demographic Surveillance System for residents testing HIV positive in this high HIV-burden district. METHODS: District-wide Test and Start [T&S, ART for all people living with HIV (PLHIV)] began in August 2016, supported by systematic interventions to improve linkage to care and treatment. Annual rounds (R) of random household surveys were conducted to assess trends in population prevalence of ART use and viral load suppression (<1000 viral RNA copies/mL). RESULTS: Between R1 (April 2014-April 2015) and R5 (April 2018-Mar 2019), 46,090 (67.2%) of 68,620 residents aged 15-59 years were tested for HIV at home at least once, and 3711 were newly diagnosed with HIV and provided linkage services. Population prevalence of current ART use among PLHIV increased from 65.0% to 87.5% between R1 and R5. ART population prevalence was lowest among men aged 25-34 years (67.8%) and women aged 15-24 (78.0%), and highest among women aged 35-44 years (93.6%) and 45-59 years (93.7%) in R5. Viral load suppression prevalence increased among all PLHIV aged 15-59 years from 52.0% in R1 to 78.3% in R5. DISCUSSION: Between 2014 and 2019, Chókwè Health and Demographic Surveillance System residents surpassed the UNAIDS targets of ≥81% of PLHIV on ART and ≥73% virally suppressed. This achievement supports the combination of efforts from household-based HIV testing and counseling, support for linkage to care and treatment, and continued investments in T&S implementation.