Cumulative exposure to depressive symptoms and all-cause mortality among adults with HIV in Kenya, Nigeria, Tanzania, and Uganda.

OBJECTIVE: We estimated the effects of cumulative exposure to depressive symptoms on risk of all-cause mortality among people with HIV (PWH) in four African countries. DESIGN: An analysis of prospective cohort data. METHODS: The African Cohort Study (AFRICOS) is a prospective cohort of people receiving care at twelve clinics in Kenya, Nigeria, Tanzania, and Uganda. Every 6 months from January 2013 to May 2020, participants underwent laboratory monitoring, structured surveys, and assessment of depressive symptom severity using the Center for Epidemiologic Studies Depression Scale (CES-D). All-cause mortality was the outcome of interest. The predictor of interest was a time-updated measure of the percentage of days lived with depression (PDD). Marginal structural Cox proportional hazards regression models were used, adjusting for potential confounders including time-varying alcohol use, drug use, and viral load. RESULTS: Among 2520 enrolled participants, 1479 (59%) were women and the median age was 38 (interquartile range [IQR]: 32-46). At enrollment, 1438 (57%) were virally suppressed (<200 copies/ml) and 457 (18%) had CES-D at least 16, indicating possible depression. Across 9093 observed person-years, the median PDD was 0.7% (IQR: 0-5.9%) with 0.8 deaths per 100 person-years. Leading causes of death included cancer (18% of deaths) and accidents (14%). Models suggested that each 25% absolute increase in PDD was associated with a 69% increase in the risk of all-cause mortality (hazard ratio: 1.69; 95% confidence interval: 1.18-2.43). CONCLUSION: Cumulative exposure to depressive symptoms was substantially associated with the risk of mortality in this cohort of PWH in Africa.

High-risk human papillomavirus genotype distribution among women living with and at risk for HIV in Africa.

OBJECTIVE: Cervical cancer is a common preventable cancer among African women living with HIV (WLWH). Molecular diagnostics for high-risk human papillomavirus (HR-HPV) genotypes are standard components of cervical cancer screening in resource-rich countries but not in resource-limited settings. We evaluated HR-HPV genotypes among women with and without HIV in four African countries to inform cervical cancer preventive strategies. METHODS: The African Cohort Study (AFRICOS) enrolled participants with and without HIV at 12 clinics in Tanzania, Kenya, Uganda, and Nigeria. Cervical cytobrush specimens from women were genotyped for 14 HR-HPV types using the multiplex Seegene Anyplex real-time PCR assay. Robust Poisson regression was used to estimate relative risks (RRs) and 95% confidence intervals (CIs) for factors associated with HR-HPV in WLWH. RESULTS: From January 2015 to March 2020, 868 WLWH and 134 women living without HIV (WLWoH) were tested for HR-HPV with prevalence of 50.9 and 38.1%, respectively ( P  = 0.007). Among WLWH, 844 (97.4%) were antiretroviral therapy (ART)-experienced and 772 (89.7%) virally suppressed 1000 copies/ml or less. The most frequent HR-HPV types among WLWH were HPV-16 (13.5%), HPV-52 (9.5%), and HPV-35 (9.3%). HR-HPV infection was more common among Tanzanian WLWH (adjusted RR: 1.23, 95% CI 1.05-1.44, P  = 0.012). Also, WLWH with CD4 + T cells of less than 200 cell/µl had 1.51-fold increased risk of having HR-HPV (95% CI 1.23-1.86, P  < 0.001). CONCLUSION: HR-HPV was common in WLWH in four African countries, particularly among women with low CD4 + cell count. Scale up of HPV vaccines and development of vaccines with broader activity against less common HR-HPV types may improve cervical cancer prevention in Africa.

Predictors of All-Cause Mortality Among People With Human Immunodeficiency Virus (HIV) in a Prospective Cohort Study in East Africa and Nigeria.

BACKGROUND: Introduction of antiretroviral therapy (ART) has been associated with a decline in human immunodeficiency virus (HIV)-related mortality, although HIV remains a leading cause of death in sub-Saharan Africa. We describe all-cause mortality and its predictors in people living with HIV (PLWH) in the African Cohort Study (AFRICOS). METHODS: AFRICOS enrolls participants with or without HIV at 12 sites in Kenya, Uganda, Tanzania, and Nigeria. Evaluations every 6 months include sociobehavioral questionnaires, medical history, physical examination, and laboratory tests. Mortality data are collected from medical records and survivor interviews. Multivariable Cox proportional hazards models were used to calculate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for factors associated with mortality. RESULTS: From 2013 through 2020, 2724 PLWH completed at least 1 follow-up visit or experienced death. Of these 58.4% were females, 25.8% were aged ≥ 50 years, and 98.3% were ART-experienced. We observed 11.42 deaths per 1000 person-years (95% CI: 9.53-13.68) with causes ascertained in 54% of participants. Deaths were caused by malignancy (28.1%), infections (29.7%), and other non-HIV related conditions. Predictors of mortality included CD4 ≤ 350 cells/µL (aHR 2.01 [95% CI: 1.31-3.08]), a log10copies/mL increase of viral load (aHR 1.36 [95% CI: 1.22-1.51]), recent fever (aHR 1.85[95% CI: 1.22-2.81]), body mass index < 18.5 kg/m2 (aHR 2.20 [95% CI: 1.44-3.38]), clinical depression (aHR 2.42 [95% CI: 1.40-4.18]), World Health Organization (WHO) stage III (aHR 2.18 [95% CI: 1.31-3.61]), a g/dL increase in hemoglobin (aHR 0.79 [95% CI: .72-.85]), and every year on ART (aHR 0.67 [95% CI: .56-.81]). CONCLUSIONS: The mortality rate was low in this cohort of mostly virally suppressed PLWH. Patterns of deaths and identified predictors suggest multiple targets for interventions to reduce mortality.

Transient Reductions in Human Immunodeficiency Virus (HIV) Clinic Attendance and Food Security During the Coronavirus Disease 2019 (COVID-19) Pandemic for People Living With HIV in 4 African Countries.

The coronavirus disease 2019 (COVID-19) pandemic and associated public health responses have disrupted daily living activities with economic and health consequences globally. We observed transient decreases in human immunodeficiency virus (HIV) clinic visit adherence and food security among persons living with HIV early in the pandemic, and an increase in viral suppression later in the pandemic.

For Human Papillomavirus Self-Sampling, Stated Willingness Does Not Correspond With Subsequent Uptake by Rural Malawian Women.

BACKGROUND: Human papilloma virus (HPV), the causative agent for cervical cancer, can be tested for using self-collected vaginal samples. Self-collection is promising for HPV screening in hard-to-reach populations. To assess the relationship between willingness to self-collect and subsequent uptake of self-collection, we conducted a longitudinal study of reproductive-age women in rural Malawi. METHODS: At baseline, we asked women if they would be willing to self-collect a vaginal sample for HPV testing. At follow-up (12-18 months later), we offered the same women the opportunity to self-collect a sample for HPV testing. We examined unadjusted and adjusted associations between baseline willingness to self-collect a sample for HPV testing and uptake of self-collection at follow-up using log-binomial models. RESULTS: Among 122 women who, at baseline, indicated willingness to self-collect, n = 65 (53%) agreed to self-collect a sample at follow-up. Of 64 women who stated unwillingness at baseline to self-collect, n = 30 (47%) self-collected a sample for testing at follow-up. We observed no association between women's willingness at baseline and their observed self-collection decision at follow-up (unadjusted prevalence ratio, 1.14; 95% confidence interval, 0.83-1.55). The association remained null after adjustment for age, awareness of cervical cancer, and perceived behavioral control. CONCLUSIONS: Our results suggest that evaluation of acceptability of self-collection should go beyond simply asking women if they would be willing to self-collect a vaginal sample. Given that half of this study's participants agreed to self-collect a sample when the opportunity was offered, regardless of their previously stated preferences, self-collection should be offered to everyone.

Who Has Yet to Test? A Risk Score for Predicting Never Having Tested for Human Immunodeficiency Virus Among Women and Men in Rural Malawi.

BACKGROUND: Human immunodeficiency virus (HIV) status awareness is important for preventing onward HIV transmission, and is one of the Joint United Nations Programme on HIV and AIDS (UNAIDS) 90-90-90 goals. Efforts to scale up HIV testing have generally been successful, but identifying at-risk individuals who have never tested for HIV-a population necessary to reach improved HIV status awareness-remains challenging. METHODS: Using data from a community-based cohort of people living in rural central Malawi, we identified demographic, socioeconomic, and sexual health correlates of never having tested for HIV. Correlates were assigned values from the logistic regression model to develop a risk score that identified who had never tested for HIV. RESULTS: Among 1310 ever sexually active participants, 7% of the women and 13% of the men had never tested for HIV. Of those who had tested for HIV, about 30% had tested more than 12 months ago. For women, younger age and poorer sexual health knowledge were correlated with never having tested for HIV, and the c-statistic for the risk score was 0.83. For men, their partner having not tested for HIV, low socioeconomic status, and poor sexual health knowledge were correlated with never testing for HIV (c-statistic, 0.81). Among those with a score of 3 or greater, the sensitivity and specificity for never having tested for HIV were 81% and 77% for women, and 82% and 66% for men, respectively. CONCLUSIONS: About 10% of participants had never tested for HIV. This risk score could help health professionals to identify never testers to increase HIV status awareness in line with 90-90-90 goals.

Feasibility, validity and acceptability of self-collected samples for human papillomavirus (HPV) testing in rural Malawi.

Aim: The World Health Organization (WHO) recently endorsed human papillomavirus (HPV) testing as a cervical cancer screening method in countries without established programs. Self-collection for HPV testing may be an effective way to expand screening. Our objective was to assess the feasibility, validity, and acceptability of self-collection for HPV testing in a population of care-seeking, unscreened women in rural Malawi. Methods: We enrolled women reporting to a rural Malawian clinic from January to August 2015. Participants were offered the option to self-collect a vaginal sample and the study clinician collected a cervical sample for HPV testing. Using the clinician-collected sample as the reference standard, we calculated a kappa statistic, sensitivity, and specificity by hr-HPV type. Participants also received a brief survey assessing acceptability of the procedure. Results: Among the 199 enrolled women, 22% had any high risk-HPV. Comparing self- and clinician-collected samples for HPV testing, we found generally high agreement (Ï° = 0.66-0.90) and high specificity (98%-100%), but varied sensitivity (50%-91%) for different types of hr-HPV. We also found that self-collection was acceptable, with 98% of women reporting it was easy to do and 99% reporting willingness to do so again. Conclusions: WHO guidelines recommend that treatment is available immediately after a positive screening test for clinic-based cervical cancer screening programs. Our findings demonstrate that self-collection of samples for HPV testing is a feasible and acceptable method of cervical cancer screening in this rural Malawian population. High agreement between the self- and clinician-collected samples and high levels of acceptability among women in the study suggest that self-collection of vaginal samples for HPV testing may be effectively incorporated into screening programs among rural, largely unscreened populations.

Factors influencing Malawian women's willingness to self-collect samples for human papillomavirus testing.

BACKGROUND: Malawi has the highest incidence of cervical cancer in the world. Only 3% of Malawian women have ever been screened for cervical cancer. Self-collection of samples for human papillomavirus (HPV) testing could increase screening among under-screened and hard-to-reach populations. However, little is known about the acceptability of self-collection in rural African settings. AIM: We aimed to characterise Malawian women's willingness to self-collect vaginal samples for HPV testing and to identify potential barriers. DESIGN: We used data from the baseline wave of a community-based cohort study, collected from July 2014 to February 2015. SETTING: Participants were enrolled from the catchment area of a clinic in rural Lilongwe District, Malawi. METHODS: We enrolled women aged 15-39 years (n=824). Participants answered questions assessing willingness to self-collect a sample for HPV testing, concerns about testing and other hypothesised correlates of willingness to self-collect. RESULTS: Two-thirds (67%) of the women reported willingness to self-collect a vaginal sample in their homes. Awareness of cervical cancer, supportive subjective norms, perceived behavioural control, and clinician recommendations were all positively associated with increased willingness to self-collect samples for HPV testing. Identified barriers to self-testing endorsed by women included: concerns that the test might hurt (22%), that they might not do the test correctly (21%), and that the test might not be accurate (17%). CONCLUSIONS: This study suggests that self-collection for HPV testing could be an acceptable cervical cancer screening method in this rural population. Findings identify modifiable beliefs and barriers that can inform the development of effective screening programmes.

Intravaginal Practices and Prevalence of Sexual and Reproductive Tract Infections Among Women in Rural Malawi.

BACKGROUND: Many women engage in intravaginal practices (IVP) with a goal of improving genital hygiene and increasing sexual pleasure. Intravaginal practices can disrupt the genital mucosa, and some studies have found that IVP increases risk of acquisition of HIV and bacterial vaginosis (BV). Limited prior research also suggests significant associations between IVP, herpes simplex virus type 2 (HSV-2), and high-risk types of human papillomavirus (HPV). METHODS: We examined associations between IVP and HPV, BV, and HSV-2 among 200 women in rural Malawi participating in a clinic-based study on sexual and reproductive tract infections. We calculated prevalence ratios for the associations between frequency and type of IVP and outcomes of HPV, BV, and HSV-2. RESULTS: Intravaginal practices were commonly performed, with 95% of women reporting current use of at least 1 practice. Infections were also frequently detected: Twenty-two percent of the sample had at least 1 high-risk HPV type, 51% had BV, and 50% were HSV-2 seropositive. We observed no significant associations between type of IVP, frequency of IVP, or a combined measure capturing type and frequency of IVP-and any of the infection outcomes. CONCLUSIONS: Although both IVP and our outcomes of interest (BV, HPV, and HSV-2) were common in the study population, we did not detect associations between IVP type or frequency and any of the 3 infections. However, the high prevalence and frequency of IVP may have limited our ability to detect significant associations.

Acceptability of home-based chlamydia and gonorrhea testing among a national sample of sexual minority young adults.

CONTEXT: STDs are common among older adolescents and young adults; hence, STD screening is a public health priority. Home-based STD testing could be a strategy to improve screening rates, particularly among at-risk populations, including sexual minority (i.e., nonheterosexual) young adults. METHODS: Data were collected from a national sample of 971 sexual minority young adults aged 18-26 through an online survey in the fall of 2013. Logistic regression analyses identified associations between respondents' characteristics and their willingness to use a home-based test for chlamydia and gonorrhea. RESULTS: A greater proportion of men than of women were willing to use a home-based STD test (81% vs. 68%). Willingness was more likely among gay than among bisexual men, among men insured through their parents than among the uninsured and among those who had had two or more sexual partners in the past year than among those who had had fewer (adjusted odds ratios, 2.0-2.2). Among men, students were less likely than the employed to report willingness for home-based testing (0.4). Among women, willingness was more likely among those who reported at least two partners in the past year than among those who reported fewer (1.6). Overall, respondents' most common concerns about home-based STD testing regarded test accuracy, their ability to do the test correctly and their preference to see a doctor for testing. CONCLUSIONS: Home-based STD testing may be a promising strategy for screening sexual minority young adults; understanding correlates of willingness and young adults' concerns may help inform self-testing programs.

High prevalence of rectal gonorrhea and Chlamydia infection in women attending a sexually transmitted disease clinic.

BACKGROUND: Testing women for urogenital Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) is common in sexually transmitted disease (STD) clinics. However, women may not be routinely tested for rectal GC/CT. This may lead to missed infections in women reporting anal intercourse (AI). METHODS: This was a retrospective review of all women who underwent rectal GC/CT testing from August 2012 to June 2013 at an STD clinic in Columbus, Ohio. All women who reported AI in the last year had a rectal swab collected for GC/CT nucleic acid amplification testing (n=331). Using log-binomial regression models, we computed unadjusted and adjusted associations for demographic and behavioral factors associated with rectal GC/CT infection. RESULTS: Participants (n=331) were 47% African-American, with median age of 29 years. Prevalence of rectal GC was 6%, rectal CT was 13%, and either rectal infection was 19%. Prevalence of urogenital GC and CT was 7% and 13% respectively. Among women with rectal GC, 14% tested negative for urogenital GC. Similarly, 14% of women with rectal CT tested negative for urogenital CT. In unadjusted analyses, there was increased rectal GC prevalence among women reporting sex in the last year with an injection drug user, with a person exchanging sex for drugs or money, with anonymous partners, and while intoxicated/high on alcohol or illicit drugs. After multivariable adjustment, no significant associations persisted, but a trend of increased rectal GC prevalence was observed for women <26 years of age (p=0.06) and those reporting sex while intoxicated/high on alcohol or drugs (p=0.05). For rectal CT, only age <26 years was associated with prevalent infection in unadjusted models; this association strengthened after multivariable adjustment (prevalence ratio: 6.03; 95% confidence interval: 2.29-15.90). CONCLUSION: Nearly one in five women who reported AI in the last year had rectal GC or CT infection. Urogenital testing alone would have missed 14% of rectal infections. Standardized guidelines would increase rectal GC/CT testing in women and help detect missed infections.

How might immunization rates change if cost sharing is eliminated?

OBJECTIVES: There is a debate regarding the effect of cost sharing on immunization, particularly as the Affordable Care Act will eliminate cost sharing for recommended vaccines. This study estimates changes in immunization rates and spending associated with extending first-dollar coverage to privately insured children for four childhood vaccines. METHODS: We used the 2008 National Immunization Survey and peer-reviewed literature to generate estimates of immunization status for each vaccine by age group and insurance type. We used the Truven Health Analytics 2006 MarketScan Commercial Claims and Encounters Database of line-item medical claims to estimate changes in immunization rates that would result from eliminating cost sharing, and we used the Kaiser Family Foundation/Health Research and Educational Trust Employer Health Benefits Survey to determine the prevalence of coverage for patients with first-dollar coverage, patients who face office visit cost sharing, and patients who face cost sharing for all vaccine cost components. We assumed that once cost sharing is removed, coverage rates in plans that impose cost sharing will rise to the level of plans that do not. RESULTS: We estimate that immunization rates would increase modestly and result in additional direct spending of $26.0 million to insurers/employers. Further, these payers would have an additional $11.0 million in spending associated with eliminating cost sharing for children already receiving immunizations. CONCLUSIONS: The effects of eliminating cost sharing for vaccines vary by vaccine. Overall, immunization rates will rise modestly given high insurance coverage for vaccinations, and these increases would be more substantial for those currently facing cost sharing. However, in addition to the removal of cost sharing for immunizations, these findings suggest other strategies to consider to further increase immunization rates.