Synthetic Controls for Implementation Science: Opportunities for HIV Program Evaluation Using Routinely Collected Data.

PURPOSE OF REVIEW: HIV service delivery programs are some of the largest funded public health programs in the world. Timely, efficient evaluation of these programs can be enhanced with methodologies designed to estimate the effects of policy. We propose using the synthetic control method (SCM) as an implementation science tool to evaluate these HIV programs. RECENT FINDINGS: SCM, introduced in econometrics, shows increasing utility across fields. Key benefits of this methodology over traditional design-based approaches for evaluation stem from directly approximating pre-intervention trends by weighting of candidate non-intervention units. We demonstrate SCM to evaluate the effectiveness of a public health intervention targeting HIV health facilities with high numbers of recent infections on trends in pre-exposure prophylaxis (PrEP) enrollment. This test case demonstrates SCM's feasibility for effectiveness evaluations of site-level HIV interventions. HIV programs collecting longitudinal, routine service delivery data for many facilities, with only some receiving a time-specified intervention, are well-suited for evaluation using SCM.

Hepatitis B virus infection (HBV) and HIV-HBV coinfection among men who have sex with men, transgender women, and genderqueer individuals in Harare and Bulawayo Zimbabwe, 2019.

Objectives: To measure HIV and Hepatitis B virus (HBV) prevalence and associated risk behaviors among men who have sex with men (MSM) and transgender women/genderqueer individuals (TGW/GQ) in Zimbabwe. Methods: We conducted a biobehavioral survey using respondent-driven sampling (RDS) among adult MSM and TGW/GQ in Harare and Bulawayo, Zimbabwe in 2019. Participants completed a questionnaire and underwent testing for HIV and HBV. Results: Overall, 1,510 (Harare: 694, Bulawayo 816) participants were enrolled and consented to testing; 3.8 % (58) tested positive for HBV, 22.5 % (339) tested positive for HIV, and 2.2 % (33) tested positive for both HIV and HBV. HBV prevalence was higher among participants with HIV compared to HIV-negative participants (9.7 % vs. 2.1 %, p < 0.0001). Overall, HBV prevalence was not statistically different between MSM and TGW/GQ (3.7 % vs 4.5 %, p = 0.49) nor between Harare and Bulawayo (3.3 % vs 4.3 %, p = 0.33). Conclusions: Our survey demonstrates the prevalence of HBV among MSM and TGW/GQ is lower than other estimates of HBV among MSM in Africa but remains high among our survey population living with HIV highlighting the need to expand HBV testing and treatment services, especially among people with HIV in Zimbabwe.

Factors Associated with Having both Male and Female Recent Sexual Partnerships Among Men Who Have Sex with Men in Harare and Bulawayo, Zimbabwe.

To better understand male and female sexual partnerships among men who have sex with men (MSM), we used data from a 2019 biobehavioral survey among MSM in Harare and Bulawayo, Zimbabwe to conduct bivariate analyses and multivariable logistic regression to determine whether sociodemographic characteristics and HIV-related factors were associated with having both male and female sexual partnerships within the last 6 months. Of included MSM (N = 1143), 31% reported both male and female partnerships in the last 6 months. Being married/cohabiting (adjusted odds ratio (aOR) = 8.58, 95% confidence interval (CI) = 4.92-14.95) or separated/divorced/widowed (aOR = 1.96, 95% CI = 1.24-3.08) vs. being single, and hazardous alcohol consumption (aOR = 1.58, 95% CI 1.19-2.09) were associated with higher odds of having both male and female recent partnerships. Being aged 35 + vs. 18-24 (aOR = 0.50, 95% CI = 0.31-0.81), condomless receptive anal intercourse at last sex with the main male partner (aOR = 0.43, 95% CI = 0.26-0.74), and positive HIV status (aOR = 0.46, 95% CI = 0.31-0.67) were associated with lower odds of recent male and female partnerships. MSM in Harare who reported harassment/abuse (aOR = 3.16, 95% CI = 1.72-5.79) had higher odds of both male and female partnerships than MSM in Bulawayo reporting harassment/abuse. The prevalence of both male and female recent partnerships (31%) was lower among MSM in this survey than in other biobehavioral surveys of MSM in sub-Saharan Africa. Findings suggest that MSM with recent male and female partnerships compared to MSM with only male recent partners have lower odds of positive HIV status and participate in behaviors that lower HIV risk; however, the direction of these relationships cannot be determined due to the cross-sectional nature of the data. The findings also suggest a possible connection between experiences of stigma of MSM behavior and not having both male and female partnerships that warrants further exploration. Accessible, stigma-free HIV testing and education programming that considers the potential overlap between the MSM and general populations via both male and female partnerships and the associated behaviors could be a key component of HIV elimination in Zimbabwe.

MPrEP+ study protocol: a prospective cohort study assessing the feasibility and acceptability of an HIV pre-exposure prophylaxis (PrEP) strategy for male clients of female sex workers in Kisumu, Kenya.

INTRODUCTION: Male clients (MCs) are integral to sex work-driven HIV transmission dynamics as sexual partners of female sex worker (FSW). MCs contribute disproportionately to incident HIV globally and in sub-Saharan Africa, with 27% of new infections attributed to MCs of FSW and other partners of key populations. Gaps in coverage of HIV testing and prevention services for men, including MCs, are well-documented, yet research and innovative interventions to improve MC uptake of effective prevention services, including pre-exposure prophylaxis (PrEP), are scarce. METHODS AND ANALYSIS: MPrEP+ is a cohort study designed to assess the feasibility and acceptability of a PrEP-focused HIV prevention strategy providing daily oral tenofovir/emtricitabine (TDF/FTC) in combination with three adherence self-management interventions: (1) use of a validated point-of-care urine drug-level assay with real-time feedback and tailored self-management counselling; (2) frequent HIV self-testing; and (3) weekly one-way text messaging. This package of interventions is being delivered to 120 MCs enrolled in the study in Kisumu, Kenya over a 6-month period. The primary outcome is PrEP adherence at 6 months as measured by PrEP drug levels. Bivariate and multivariable regression models will be used to identify predictors of PrEP adherence. We will also explore associations of sociodemographic characteristics and PrEP beliefs with PrEP adherence. ETHICS AND DISSEMINATION: The study was approved by the Columbia University Irving Medical Center Institutional Review Board and the Maseno University Ethical Review Committee. Study enrolment was initiated in November 2021 with participant follow-up planned through August 2022. Study results will be submitted for publication in peer-reviewed journals. Summaries and infographics of study findings will be developed and distributed to MC, FSW and stakeholders working in HIV prevention and support for people who sell and buy sex, including Kenya's Ministry of Health. TRIAL REGISTRATION NUMBER: NCT04898699; Registered on 24 May 2021.

HIV care cascade and associated factors among men who have sex with men, transgender women, and genderqueer individuals in Zimbabwe: findings from a biobehavioural survey using respondent-driven sampling.

BACKGROUND: Globally, men who have sex with men (MSM), transgender women, and genderqueer individuals are at greater risk for HIV than the general population although little data are available from these groups in Zimbabwe, a country with a national adult HIV prevalence of 12·9%. We aimed to examine progress towards the UNAIDS 90-90-90 treatment targets and factors associated with meeting the targets among a sample of MSM, transgender women, and genderqueer individuals in Zimbabwe. METHODS: In this cross-sectional survey in 2019, we used respondent-driven sampling to identify MSM, transgender women, and genderqueer individuals aged at least 18 years to participate in a biobehavioural survey in Harare and Bulawayo, Zimbabwe. Participants were eligible to participate if they were assigned male at birth; had engaged in anal or oral sex with a man in the past 12 months; resided in Harare or Bulawayo for at least 1 month; spoke English, Shona, or Ndebele; provided written informed consent; and were in possession of a valid recruitment coupon if applicable. Enrolled participants completed a questionnaire and underwent HIV testing, and off-site viral load testing was done on all HIV-positive samples. Unweighted bivariate analyses and multivariable logistic regression models were used to evaluate the association of sociodemographic, behavioural, and other factors with HIV-positive status awareness among MSM, transgender women, and genderqueer individuals, and with viral load suppression among MSM. Analyses were done firstly using self-reported information and then by classifying those with a viral load of less than 200 copies per mL as being aware of their status and on treatment (viral load recategorisation). FINDINGS: Among MSM, 248 (21%; 95% CI 19-24) of 1176 tested positive for HIV. Of those who tested positive, based on self-report, 119 (48%; 95% CI 42-54) reported knowing their HIV status, of whom 112 (94%; 88-98) reported using antiretroviral therapy (ART), of whom 89 (79%; 71-87) had viral load suppression. Based on viral load recategorisation, 180 (73%; 67-78) of 248 MSM testing HIV positive reported knowing their HIV status, of whom 174 (97%; 93-99) reported using ART, of whom 151 (87%; 81-91) had viral load suppression. 92 (28%; 23-33) of 335 transgender women and genderqueer individuals tested positive for HIV. Based on self-reports from these individuals 34 (37%; 27-48) of 92 participants reported knowing their HIV status, of whom 31 (91%; 76-98) reported using ART, of whom 27 (87%; 70-96%) had viral load suppression. Based on viral load recategorisation of data from transgender women and genderqueer participants, 53 (58%; 47-58) of 92 reported awareness of their HIV status, of whom 50 (94%; 84-99) reported using ART, of whom 46 (92%; 81-98) had viral load suppression. HIV-positive MSM aged 18-24 years had lower odds of being aware of their status than those aged at least 35 years (adjusted odds ratio [aOR] 0·34; 95% CI 0·13-0·92), as did HIV-positive MSM aged 25-34 years (aOR 0·26; 0·12-0·56). HIV-positive MSM aged 18-24 years also had a lower odds of having viral load suppression than those aged 35 years and older (aOR 0·35; 0·16-0·78), as did those aged 25-34 years (aOR 0·36; 0·19-0·67). No factors were significantly associated with awareness among transgender women and genderqueer individuals in multivariable models. INTERPRETATION: Our survey showed that HIV prevalence was high and the largest difference between our results and the 90-90-90 treatment targets was in HIV status awareness, indicating the need for improvements in engaging MSM (especially young MSM), transgender women, and genderqueer individuals in HIV testing services. FUNDING: US President's Emergency Plan for AIDS Relief through the US Centers for Disease Control and Prevention.

Prevalence and psychosocial factors associated with self-injurious thoughts among people living with HIV presenting for HIV testing in Mozambique.

Self-injurious thoughts have been associated with psychiatric morbidity and suicide. Little is known about psychosocial factors associated with self-injurious thoughts among people newly diagnosed with HIV in sub-Saharan Africa. This study examined whether food insufficiency, mental health symptoms, or social support were associated with recent self-injurious thoughts among people newly diagnosed with HIV in Mozambique. The sample included 2001 PLWH aged ≥ 18 newly diagnosed with HIV at 10 health clinics in Mozambique between April 2013 and June 2015. Data were collected at time of HIV diagnosis. Multivariable logistic regression modeled the association of social support, affective mental health symptom severity, somatic mental health symptom severity, and food insufficiency on recent self-injurious thoughts. Ten percent of respondents reported recent self-injurious thoughts, which was higher among women than men (11% vs 7%). In multivariable analyses, food insufficiency [adjusted odds ratio (aOR) 1.7 (95% CI 1.3, 2.2)], and low [aORvs no = 4.8, 95% CI 1.7, 13.4) and moderate/high affective symptom severity [aORvs no = 8.7, 95% CI 2.8, 27.6) were associated with greater odds of self-injurious thoughts. Interventions to address self-injurious thoughts should consider accompanying psychosocial stressors. Longitudinal research to examine mechanisms through which psychosocial stressors are associated with self-injurious thoughts is warranted.

Effects of the Coronavirus Disease 2019 Pandemic on Human Immunodeficiency Virus Services: Findings from 11 Sub-Saharan African Countries.

BACKGROUND: Due to concerns about the effects of the coronavirus disease 2019 (COVID-19 pandemic on health services, we examined its effects on human immunodeficiency virus (HIV) services in sub-Saharan Africa. METHODS: Quarterly data (Q1, 10/2019-12/2019; Q2, 1/2020-3/2020; Q3, 4/2020-6/2020; Q4, 7/2020-9/2020) from 1059 health facilities in 11 countries were analyzed and categorized by stringency of pandemic measures. We conducted a difference-in-differences assessment of HIV service changes from Q1-Q2 to Q3-Q4 by higher vs lower stringency. RESULTS: There was a 3.3% decrease in the number HIV tested from Q2 to Q3 (572 845 to 553 780), with the number testing HIV-positive declining by 4.9% from Q2 to Q3. From Q3 to Q4, the number tested increased by 10.6% (612 646), with an increase of 8.8% (23 457) in the number testing HIV-positive with similar yield (3.8%). New antiretroviral therapy (ART) initiations declined by 9.8% from Q2 to Q3 but increased in Q4 by 9.8%. Across all quarters, the number on ART increased (Q1, 419 028 to Q4, 476 010). The number receiving viral load (VL) testing in the prior 12 months increased (Q1, 255 290 to Q4, 312 869). No decrease was noted in VL suppression (Q1, 87.5% to Q4, 90.1%). HIV testing (P < .0001) and new ART initiations (P = .001) were inversely associated with stringency. CONCLUSIONS: After initial declines, rebound was brisk, with increases noted in the number HIV tested, newly initiated or currently on ART, VL testing, and VL suppression throughout the period, demonstrating HIV program resilience in the face of the COVID-19 crisis.

A randomized double-blind controlled trial of convalescent plasma in adults with severe COVID-19.

BACKGROUNDAlthough convalescent plasma has been widely used to treat severe coronavirus disease 2019 (COVID-19), data from randomized controlled trials that support its efficacy are limited.METHODSWe conducted a randomized, double-blind, controlled trial among adults hospitalized with severe and critical COVID-19 at 5 sites in New York City (USA) and Rio de Janeiro (Brazil). Patients were randomized 2:1 to receive a single transfusion of either convalescent plasma or normal control plasma. The primary outcome was clinical status at 28 days following randomization, measured using an ordinal scale and analyzed using a proportional odds model in the intention-to-treat population.RESULTSOf 223 participants enrolled, 150 were randomized to receive convalescent plasma and 73 to receive normal control plasma. At 28 days, no significant improvement in the clinical scale was observed in participants randomized to convalescent plasma (OR 1.50, 95% confidence interval [CI] 0.83-2.68, P = 0.180). However, 28-day mortality was significantly lower in participants randomized to convalescent plasma versus control plasma (19/150 [12.6%] versus 18/73 [24.6%], OR 0.44, 95% CI 0.22-0.91, P = 0.034). The median titer of anti-SARS-CoV-2 neutralizing antibody in infused convalescent plasma units was 1:160 (IQR 1:80-1:320). In a subset of nasopharyngeal swab samples from Brazil that underwent genomic sequencing, no evidence of neutralization-escape mutants was detected.CONCLUSIONIn adults hospitalized with severe COVID-19, use of convalescent plasma was not associated with significant improvement in day 28 clinical status. However, convalescent plasma was associated with significantly improved survival. A possible explanation is that survivors remained hospitalized at their baseline clinical status.TRIAL REGISTRATIONClinicalTrials.gov, NCT04359810.FUNDINGAmazon Foundation, Skoll Foundation.

Differential COVID-19 case positivity in New York City neighborhoods: Socioeconomic factors and mobility.

BACKGROUND: New York City (NYC) has been one of the hotspots of the COVID-19 pandemic in the United States. By the end of April 2020, close to 165 000 cases and 13 000 deaths were reported in the city with considerable variability across the city's ZIP codes. OBJECTIVES: In this study, we examine: (a) the extent to which the variability in ZIP code-level case positivity can be explained by aggregate markers of socioeconomic status (SES) and daily change in mobility; and (b) the extent to which daily change in mobility independently predicts case positivity. METHODS: COVID-19 case positivity by ZIP code was modeled using multivariable linear regression with generalized estimating equations to account for within-ZIP clustering. Daily case positivity was obtained from NYC Department of Health and Mental Hygiene and measures of SES were based on data from the American Community Survey. Changes in human mobility were estimated using anonymized aggregated mobile phone location systems. RESULTS: Our analysis indicates that the socioeconomic markers considered together explained 56% of the variability in case positivity through April 1 and their explanatory power decreased to 18% by April 30. Changes in mobility during this time period are not likely to be acting as a mediator of the relationship between ZIP-level SES and case positivity. During the middle of April, increases in mobility were independently associated with decreased case positivity. CONCLUSIONS: Together, these findings present evidence that heterogeneity in COVID-19 case positivity during NYC's spring outbreak was largely driven by residents' SES.

Optimizing Differentiated HIV Treatment Models in Urban Zimbabwe: Assessing Patient Preferences Using a Discrete Choice Experiment.

Differentiated service delivery holds great promise for streamlining the delivery of health services for HIV. This study used a discrete choice experiment to assess preferences for differentiated HIV treatment delivery model characteristics among 500 virally suppressed adults on antiretroviral therapy in Harare, Zimbabwe. Treatment model characteristics included location, consultation type, healthcare worker cadre, operation times, visit frequency and duration, and cost. A mixed effects logit model was used for parameter estimates to identify potential preference heterogeneity among participants, and interaction effects were estimated for sex and age as potential sources of divergence in preferences. Results indicated that participants preferred health facility-based services, less frequent visits, individual consultations, shorter waiting times, lower cost and, delivered by respectful and understanding healthcare workers. Some preference heterogeneity was found, particularly for location of service delivery and group vs. individual models; however, this was not fully explained by sex and age characteristics of participants. In urban areas, facility-based models, such as the Fast Track model requiring less frequent clinic visits, are likely to better align with patient preferences than some of the other community-based or group models that have been implemented. As Zimbabwe scales up differentiated treatment models for stable patients, a clear understanding of patient preferences can help in designing services that will ensure optimal utilization and improve the efficiency of service delivery.

RESUMEN: La entrega de servicios diferenciados representa una gran promesa para optimizar la prestación de servicios sanitarios para el VIH. Este estudio utilizó un experimento de elecciones discretas para evaluar las preferencias en cuanto a las características de los modelos diferenciados de prestación de tratamiento para el VIH entre 500 adultos con supresión viral bajo tratamiento antirretroviral en Harare, Zimbabue. Las características de los modelos de tratamientos incluyeron el lugar, el tipo de consulta, la estructura en la que estaba inserto el trabajador sanitario, los tiempos operativos, la frecuencia y duración de las visitas y los costos. Se utilizó un modelo de probabilidad de efectos mixtos para las estimaciones de los parámetros para identificar una posible heterogeneidad en las preferencias entre los participantes, y se estimaron los efectos de las interacciones por el sexo y la edad como fuentes potenciales de diferencia en las preferencias. Los resultados indicaron que los participantes preferían servicios basados en centros de salud, visitas menos frecuentes, consultas individuales, tiempos de espera más cortos y menores costos, proporcionados por trabajadores sanitarios respetuosos y comprensivos. Se hallaron algunas heterogeneidades en las preferencias, particularmente para el lugar de la prestación del servicio y para los modelos grupales frente a individuales; sin embargo, esto no se explicó totalmente por las características de sexo y edad de los participantes. En áreas urbanas, los modelos basados en los centros, como el modelo de atención rápida (Fast Track), que requieren visitas menos frecuentes a la clínica, probablemente concuerden mejor con las preferencias de los pacientes que los otros modelos grupales o comunitarios que se han propuesto. A medida que en Zimbabue se amplíen los modelos de tratamiento diferenciado para los pacientes estables, un claro conocimiento de las preferencias de los pacientes puede ayudar a diseñar servicios que garantizarán una utilización óptima y mejorarán la eficiencia de la prestación de servicios.

Household Decision-Making and HIV Care Continuum Outcomes Among Women Living with HIV in Mozambique.

Gender inequality has been associated with HIV infection among women. Less is known about the relationship between gender inequality and HIV care continuum outcomes. This study assessed whether household decision-making power (DMP), one component of gender inequality, was associated with linkage to HIV care, antiretroviral therapy (ART) initiation, or retention in care among women living with HIV in Mozambique. The sample included 600 women ≥18 years of age newly diagnosed with HIV in Mozambique. Data were collected between April 2013 and June 2016. DMP was assessed with three questions about participation in decisions regarding: major household decisions, routine household decisions, and visits to family. Women who did not contribute to decision making in any domain were categorized as having low DMP. HIV care information was obtained from electronic medical records. Multivariable log-Poisson regression analyses were conducted to assess the relationship between DMP and HIV care continuum outcomes. Almost half (49%) of participants reported medium DMP, followed by high (39%) and low DMP (12%). In multivariable regression analyses, when compared with respondents with medium DMP, those with low DMP had a lower likelihood of retention in care 12 months after diagnosis [adjusted risk ratio (aRR) 0.69 (95% CI 0.49-0.98)]. There was no significant relationship between low DMP and linkage to HIV care or ART initiation. High DMP was not significantly associated with HIV outcomes assessed. Women who report low DMP may face barriers to long-term engagement in HIV care. Interventions to improve retention in care among women should consider the role of household decision making and gender inequality.

Expansion and scale-up of HIV care and treatment services in four countries over ten years.

BACKGROUND: Scale-up and expansion of antiretroviral therapy (ART) for people living with HIV (PLHIV) have been a global priority for more than 15 years. METHODS: We describe PLHIV at enrollment in care and ART initiation in Ethiopia, Kenya, Mozambique and Tanzania from 2005-2014 and report on enrollment location, CD4 count and loss to follow-up (LTF), death, and combined attrition (LTF and death) pre- and post-ART initiation over time. Pre-ART outcomes were estimated using competing risk and post-ART using Kaplan-Meier estimators; LTF defined as no visit within six months pre-ART and 12 months after ART start. RESULTS: From 2005-2014, 884,328 PLHIV enrolled in care at 350 health facilities, median age was 32.0 years (interquartile range [IQR] 26.0-42.0), and majority were female (66.5%). The proportion of PLHIV enrolled at primary and rural facilities increased from 12.9% and 15.3% in 2005-2006 to 43.5% and 41.7% in 2013-2014 (p<0.0001). Median CD4+ cell count at enrollment increased from 171 cell/mm3 in 2005-2006 (IQR 71-339) to 289 cell/mm3 in 2013-2014 (IQR 133-485) (p<0.0001). A total of 460,758 (57.4%) PLHIV initiated treatment. Cumulative risk of LTF for PLHIV prior to ART initiation 12 months after enrollment was 33.5% (95%CI 33.36-33.58) and 21.98% (95%CI 21.9-22.1) after ART initiation. Pregnant women and the youngest PLHIV group had the highest attrition after ART initiation, at 24 months 40.8% (95%CI 40.1-41.6) of pregnant women and 47.4% (95%CI 46.4-48.4) of PLHIV 15-19 years were not retained. Attrition at 12 months after enrollment among PLHIV regardless of ART status was 38.5% (95%CI 38.4-38.6). CONCLUSION: Over 10 years of HIV scale-up in four sub-Saharan African countries, close to a million PLHIV were enrolled in care increasingly at rural and primary facilities with increasing CD4 count. Loss to follow-up from HIV care remains alarmingly high, particularly among pregnant women and younger PLHIV.

Optimizing differentiated treatment models for people living with HIV in urban Zimbabwe: Findings from a mixed methods study.

INTRODUCTION: Zimbabwe is scaling up HIV differentiated service delivery (DSD) to improve treatment outcomes and health system efficiencies. Shifting stable patients into less-intensive DSD models is a high priority in order to accommodate the large numbers of newly-diagnosed people living with HIV (PLHIV) needing treatment and to provide healthcare workers with the time and space needed to treat people with advanced HIV disease. DSD is also seen as a way to improve service quality and enhance retention in care. National guidelines support five differentiated antiretroviral treatment models (DART) for stable HIV-positive adults, but little is known about patient preferences, a critical element needed to guide DART scale-up and ensure person-centered care. We designed a mixed-methods study to explore treatment preferences of PLHIV in urban Zimbabwe. METHODS: The study was conducted in Harare, and included 35 health care worker (HCW) key informant interviews (KII); 8 focus group discussions (FGD) with 54 PLHIV; a discrete choice experiment (DCE) in which 500 adult DART-eligible PLHIV selected their preferences for health facility (HF) vs. community location, individual vs. group meetings, provider cadre and attitude, clinic operation times, visit frequency, visit duration and cost to patient; and a survey with the 500 DCE participants exploring DART knowledge and preferences. RESULTS: Patient preferences were consistent in the FGDs, DCE and survey. Participants strongly preferred respectful HCWs, HF-based services, individual DART models, and less costly services. Patients also preferred less frequent visits and shorter wait times. They were indifferent to variations in HCW cadre and distances from home to HF. These preferences were mostly homogenous, with only minor differences between male vs. female and older vs. younger patients. HCWs in the KII correctly characterized facility-based individual models as the one most favored by patients; HCWs also preferred this model, which they felt decongested HFs and reduced their workload. CONCLUSIONS: DART-eligible PLHIV in Harare found it relatively easy to access HFs, and preferred attributes associated with facility-based individual models. Prioritizing these for scale-up in urban areas may be the most efficient way to sustain positive patient outcomes and increase health system performance.

Cost-effectiveness of a combination strategy to enhance the HIV care continuum in Swaziland: Link4Health.

INTRODUCTION: Link4Health, a cluster-RCT, demonstrated the effectiveness of a combination strategy targeting barriers at various HIV continuum steps on linkage to and retention in care; showing effectiveness in achieving linkage to HIV care within 1 month plus retention in care at 12 months after HIV testing for people living with HIV (RR 1.48, 95% CI 1.19-1.96, p = 0.002). In addition to standard of care, Link4Health included: 1) Point-of-care CD4+ count testing; 2) Accelerated ART initiation; 3) Mobile phone appointment reminders; 4) Care and prevention package including commodities and informational materials; and 5) Non-cash financial incentive. Our objective was to evaluate the cost-effectiveness of a scale-up of the Link4Health strategy in Swaziland. METHODS AND FINDINGS: We incorporated the effects and costs of the Link4Health strategy into a computer simulation of the HIV epidemic in Swaziland, comparing a scenario where the strategy was scaled up to a scenario with no implementation. The simulation combined a deterministic compartmental model of HIV transmission with a stochastic microsimulation of HIV progression calibrated to Swaziland epidemiological data. It incorporated downstream health costs potentially saved and infections potentially prevented by improved linkage and treatment adherence. We assessed the incremental cost-effectiveness ratio of Link4Health compared to standard care from a health sector perspective reported in US$2015, a time horizon of 20 years, and a discount rate of 3% in accordance with WHO guidelines.[1] Our results suggest that scale-up of the Link4Health strategy would reduce new HIV infections over 20 years by 11,059 infections, a 7% reduction from the projected 169,019 cases and prevent 5,313 deaths, an 11% reduction from the projected 49,582 deaths. Link4Health resulted in an incremental cost per infection prevented of $13,310 and an incremental cost per QALY gained of $3,560/QALY from the health sector perspective. CONCLUSIONS: Using a threshold of <3 x per capita GDP, the Link4Health strategy is likely to be a cost-effective strategy for responding to the HIV epidemic in Swaziland.

Youth-friendly services and differentiated models of care are needed to improve outcomes for young people living with HIV.

PURPOSE OF REVIEW: Outcomes among young people living with HIV (YPLWH) remain disturbingly poor. We summarize recent research on youth-friendly services (YFS) and adolescent-specific differentiated care models, which may improve outcomes across the HIV care continuum for this vulnerable population. We further emphasize unique complexities that characterize the transition from childhood through adolescence to adulthood which must be considered when caring for YPLWH. RECENT FINDINGS: Studies suggest that YFS may improve outcomes in some but not all steps of the HIV care continuum. However, generalizability is compromised by the limited numbers of studies, frequent use of nonequivalent comparison groups, small sample sizes and/or short follow-up. Reproducibility and scale-up are further hindered by lack of insufficient details on operational aspects of YFS, an effective minimum package of YFS and contextual factors that may facilitate adoption of YFS. Differentiated models of care for YPLWH are in very early stages of development with positive preliminary outcomes, but most pilot models focus only on stable patients on antiretroviral therapy. SUMMARY: YFS and adolescent-specific differentiated models of care are needed to improve health outcomes among YPLWH, but scale-up should be guided by rigorous research and address the unique complexities that characterize the vulnerable period of adolescence.

Effectiveness of a combination strategy for linkage and retention in adult HIV care in Swaziland: The Link4Health cluster randomized trial.

BACKGROUND: Gaps in the HIV care continuum contribute to poor health outcomes and increase HIV transmission. A combination of interventions targeting multiple steps in the continuum is needed to achieve the full beneficial impact of HIV treatment. METHODS AND FINDINGS: Link4Health, a cluster-randomized controlled trial, evaluated the effectiveness of a combination intervention strategy (CIS) versus the standard of care (SOC) on the primary outcome of linkage to care within 1 month plus retention in care at 12 months after HIV-positive testing. Ten clusters of HIV clinics in Swaziland were randomized 1:1 to CIS versus SOC. The CIS included point-of-care CD4+ testing at the time of an HIV-positive test, accelerated antiretroviral therapy (ART) initiation for treatment-eligible participants, mobile phone appointment reminders, health educational packages, and noncash financial incentives. Secondary outcomes included each component of the primary outcome, mean time to linkage, assessment for ART eligibility, ART initiation and time to ART initiation, viral suppression defined as HIV-1 RNA < 1,000 copies/mL at 12 months after HIV testing among patients on ART ≥6 months, and loss to follow-up and death at 12 months after HIV testing. A total of 2,197 adults aged ≥18 years, newly tested HIV positive, were enrolled from 19 August 2013 to 21 November 2014 (1,096 CIS arm; 1,101 SOC arm) and followed for 12 months. The median participant age was 31 years (IQR 26-39), and 59% were women. In an intention-to-treat analysis, 64% (705/1,096) of participants at the CIS sites achieved the primary outcome versus 43% (477/1,101) at the SOC sites (adjusted relative risk [RR] 1.52, 95% CI 1.19-1.96, p = 0.002). Participants in the CIS arm versus the SOC arm had the following secondary outcomes: linkage to care regardless of retention at 12 months (RR 1.08, 95% CI 0.97-1.21, p = 0.13), mean time to linkage (2.5 days versus 7.5 days, p = 0.189), retention in care at 12 months regardless of time to linkage (RR 1.48, 95% CI 1.18-1.86, p = 0.002), assessment for ART eligibility (RR 1.20, 95% CI 1.07-1.34, p = 0.004), ART initiation (RR 1.16, 95% CI 0.96-1.40, p = 0.12), mean time to ART initiation from time of HIV testing (7 days versus 14 days, p < 0.001), viral suppression among those on ART for ≥6 months (RR 0.97, 95% CI 0.88-1.07, p = 0.55), loss to follow-up at 12 months after HIV testing (RR 0.56, 95% CI 0.40-0.79, p = 0.002), and death (N = 78) within 12 months of HIV testing (RR 0.80, 95% CI 0.46-1.35, p = 0.41). Limitations of this study include a small number of clusters and the inability to evaluate the incremental effectiveness of individual components of the combination strategy. CONCLUSIONS: A combination strategy inclusive of 5 evidence-based interventions aimed at multiple steps in the HIV care continuum was associated with significant increase in linkage to care plus 12-month retention. This strategy offers promise of enhanced outcomes for HIV-positive patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT01904994.

A combination intervention strategy to improve linkage to and retention in HIV care following diagnosis in Mozambique: A cluster-randomized study.

BACKGROUND: Concerning gaps in the HIV care continuum compromise individual and population health. We evaluated a combination intervention strategy (CIS) targeting prevalent barriers to timely linkage and sustained retention in HIV care in Mozambique. METHODS AND FINDINGS: In this cluster-randomized trial, 10 primary health facilities in the city of Maputo and Inhambane Province were randomly assigned to provide the CIS or the standard of care (SOC). The CIS included point-of-care CD4 testing at the time of diagnosis, accelerated ART initiation, and short message service (SMS) health messages and appointment reminders. A pre-post intervention 2-sample design was nested within the CIS arm to assess the effectiveness of CIS+, an enhanced version of the CIS that additionally included conditional non-cash financial incentives for linkage and retention. The primary outcome was a combined outcome of linkage to care within 1 month and retention at 12 months after diagnosis. From April 22, 2013, to June 30, 2015, we enrolled 2,004 out of 5,327 adults ≥18 years of age diagnosed with HIV in the voluntary counseling and testing clinics of participating health facilities: 744 (37%) in the CIS group, 493 (25%) in the CIS+ group, and 767 (38%) in the SOC group. Fifty-seven percent of the CIS group achieved the primary outcome versus 35% in the SOC group (relative risk [RR]CIS vs SOC = 1.58, 95% CI 1.05-2.39). Eighty-nine percent of the CIS group linked to care on the day of diagnosis versus 16% of the SOC group (RRCIS vs SOC = 9.13, 95% CI 1.65-50.40). There was no significant benefit of adding financial incentives to the CIS in terms of the combined outcome (55% of the CIS+ group achieved the primary outcome, RRCIS+ vs CIS = 0.96, 95% CI 0.81-1.16). Key limitations include the use of existing medical records to assess outcomes, the inability to isolate the effect of each component of the CIS, non-concurrent enrollment of the CIS+ group, and exclusion of many patients newly diagnosed with HIV. CONCLUSIONS: The CIS showed promise for making much needed gains in the HIV care continuum in our study, particularly in the critical first step of timely linkage to care following diagnosis. TRIAL REGISTRATION: ClinicalTrials.gov NCT01930084.

Advanced Human Immunodeficiency Virus Disease at Diagnosis in Mozambique and Swaziland.

BACKGROUND: Early diagnosis of human immunodeficiency virus (HIV) is a prerequisite to maximizing individual and societal benefits of antiretroviral therapy. METHODS: Adults ≥18 years of age testing HIV positive at 10 health facilities in Mozambique and Swaziland received point-of-care CD4+ cell count testing immediately after diagnosis. We examined median CD4+ cell count at diagnosis, the proportion diagnosed with advanced HIV disease (CD4+ cell count ≤350 cells/µL) and severe immunosuppression (CD4+ cell count ≤100 cells/µL), and determinants of the latter 2 measures. RESULTS: Among 2333 participants, the median CD4+ cell count at diagnosis was 313 cells/µL (interquartile range, 164-484), more than half (56.5%) had CD4+ ≤350 cells/µL, and 13.9% had CD4+ ≤100 cells/µL. The adjusted relative risk (aRR) of both advanced HIV disease and severe immunosuppression at diagnosis was higher in men versus women (advanced disease aRR = 1.31; 95% confidence interval [CI] = 1.16-1.48; severe immunosuppression aRR = 1.54, 95% CI = 1.17-2.02) and among those who sought HIV testing because they felt ill (advanced disease aRR = 1.30, 95% CI = 1.08-1.55; severe immunosuppression aRR = 2.10, 95% CI = 1.35-2.26). Age 18-24 versus 25-39 was associated with a lower risk of both outcomes (advanced disease aRR = 0.70, 95% CI = 0.59-0.84; severe immunosuppression aRR = 0.62, 95% CI = 0.41-0.95). CONCLUSIONS: More than 10 years into the global scale up of comprehensive HIV services, the majority of adults diagnosed with HIV at health facilities in 2 high-prevalence countries presented with advanced disease and 1 in 7 had severe immunosuppression. Innovative strategies for early identification of HIV-positive individuals are urgently needed.

Informing efforts to reach UNAIDS' 90-90-90 targets: a comparison of characteristics of people diagnosed with HIV in health facilities to the general population of people living with HIV in Mozambique.

Global targets aim to increase the number of people living with HIV (PLWH) who know their status. Using data from Mozambican facility-based HIV testing and counseling (HTC) and a population-based survey, we compared characteristics of PLWH diagnosed in HTC to the general population of PLWH to identify subgroups that are missing from the health system and may be undiagnosed. Male and female PLWH aged 50+ (PPR = 0.47, p = .0001) and with higher HIV knowledge (PPR = 0.52, p = .004) were underrepresented in HTC. A higher proportion of patients diagnosed in health facilities were aged 25-39 (PPR = 1.23, p = .02). Female PLWH with lower economic (PPR = 0.70, p = .04) and educational status (PPR = 0.86, p = .02) and male PLWH aged 18-24 (PPR = 0.47, p = .03) were underrepresented in HTC. Comparing HTC data to population-based data can inform efforts to increase HIV diagnoses and to ensure that all PLWH know their status.

Outcomes among HIV-infected children initiating HIV care and antiretroviral treatment in Ethiopia.

OBJECTIVE: To describe pediatric ART scale-up in Ethiopia, one of the 21 global priority countries for elimination of pediatric HIV infection. METHODS: A descriptive analysis of routinely collected HIV care and treatment data on HIV-infected children (<15 years) enrolled at 70 health facilities in four regions in Ethiopia, January 2006-September 2013. Characteristics at enrollment and ART initiation are described along with outcomes at 1 year after enrollment. Among children who initiated ART, cumulative incidence of death and loss to follow-up (LTF) were estimated using survival analysis. RESULTS: 11 695 children 0-14 years were enrolled in HIV care and 6815 (58.3%) initiated ART. At enrollment, 31.2% were WHO stage III and 6.3% stage IV. The majority (87.9%) were enrolled in secondary or tertiary facilities. At 1 year after enrollment, 17.9% of children were LTF prior to ART initiation. Among children initiating ART, cumulative incidence of death was 3.4%, 4.1% and 4.8%, and cumulative incidence of LTF was 7.7%, 11.8% and 16.6% at 6, 12 and 24 months, respectively. Children <2 years had higher risk of LTF and death than older children (P < 0.0001). Children with more advanced disease and those enrolled in rural settings were more likely to die. Children enrolled in more recent years were less likely to die but more likely to be LTF. CONCLUSIONS: Over the last decade large numbers of HIV-infected children have been successfully enrolled in HIV care and initiated on ART in Ethiopia. Retention prior to and after ART initiation remains a major challenge.