Investigating the addition of oral HIV self-tests among populations with high testing coverage - Do they add value? Lessons from a study in Khayelitsha, South Africa.

INTRODUCTION: HIV self-testing (HIVST) offers a useful addition to HIV testing services and enables individuals to test privately. Despite recommendations to the contrary, repeat HIV testing is frequent among people already on anti-retroviral treatment (ART) and there are concerns that oral self-testing might lead to false negative results. A study was conducted in Khayelitsha, South Africa, to assess feasibility and uptake of HIVST and linkage-to-care following HIVST. METHODS: Participants were recruited at two health facilities from 1 March 2016 to 31 March 2017. People under 18 years, or with self-reported previously-diagnosed HIV infection, were excluded. Participants received an OraQuick Rapid HIV-1/2 Antibody kit, and reported their HIVST results by pre-paid text message (SMS) or by returning to the facility. Those not reporting within 7 days were contacted by phone. Electronic and paper-based clinical and laboratory records were retrospectively examined for all participants to identify known HIV outcomes, after matching for name, date of birth, and sex. These findings were compared with self-reported HIVST results where available. RESULTS: Of 639 participants, 401 (62.8%) self-reported a negative HIVST result, 27 (4.2%) a positive result, and 211 (33.0%) did not report. The record search identified that of the 401 participants self-reporting a negative HIVST result, 19 (4.7%) were already known to be HIV positive; of the 27 self-reporting positive, 12 (44%) were known HIV positive. Overall, records showed 57/639 (8.9%) were HIV positive of whom 39/57 (68.4%) had previously-diagnosed infection and 18/57 (31.6%) newly-diagnosed infection. Of the 428 participants who self-reported a result, 366 (85.5%) reported by SMS. CONCLUSIONS: HIVST can improve HIV testing uptake and linkage to care. SMS is acceptable for reporting HIVST results but negative self-reports by participants may be unreliable. Use of HIVST by individuals on ART is frequent despite recommendations to the contrary and its implications need further consideration.

"We are part of a family". Benefits and limitations of community ART groups (CAGs) in Thyolo, Malawi: a qualitative study.

INTRODUCTION: In 2012 Community ART Groups (CAGs), a community-based model of antiretroviral therapy (ART) delivery were piloted in Thyolo District, Malawi as a way to overcome patient barriers to accessing treatment, and to decrease healthcare workers' workload. CAGs are self-formed groups of patients on ART taking turns to collect ART refills for all group members from the health facility. We conducted a qualitative study to assess the benefits and challenges of CAGs from patients' and healthcare workers' (HCWs) perspectives. METHODS: Data were collected by means of 15 focus group discussions, 15 individual in-depth interviews, and participant observation in 2 health centres. The 94 study participants included CAG members, ART patients eligible for CAGs who remained in conventional care, former CAG members who returned to conventional care and HCWs responsible for providing HIV care. Patient participants were purposively selected from ART registers, taking into account age and gender. Narratives were audio-recorded, transcribed, and translated from Chichewa to English. Data were analyzed through a thematic analysis. RESULTS: Patients and HCWs spoke favourably about the practical benefits of CAGs. Patient benefits included a reduced frequency of clinic visits, resulting in reduced transportation costs and time savings. HCW benefits included a reduced workload. Additionally peer support was perceived as an added value of the groups allowing not only sharing of the logistical constraints of drugs refills, but also enhanced emotional support. Identified barriers to joining a CAG included a lack of information on CAGs, unwillingness to disclose one's HIV status, change of residence and conflicts among CAG members. Participants reported that HIV-related stigma persists and CAGs were seen as an effective strategy to reduce exposure to discriminatory labelling by community members. CONCLUSION: In this setting, patients and HCWs perceived CAGs to be an acceptable model of ART delivery. Despite addressing important practical barriers to accessing ART, and providing peer support, CAGs were not well known by patients and had a limited impact on reducing HIV-related stigma. The CAG model of ART delivery should be considered in similar settings. Further measures need to be devised and implemented to address HIV-related stigma.

'We keep her status to ourselves': experiences of stigma and discrimination among HIV-discordant couples in South Africa, Tanzania and Ukraine.

In HIV-discordant relationships, the HIV-negative partner also carries the burden of a stigmatised disease. For this reason, couples often hide their HIV-discordant status from family, friends and community members. This perpetuates the silence around HIV-discordant relationships and impacts on targeted HIV prevention, treatment and counselling efforts. This article reports on experiences of stigma and discrimination among HIV-discordant couples in South Africa, Tanzania and Ukraine. During 2008, HIV-discordant couples who had been in a relationship for at least one year were recruited purposively through health-care providers and civil society organisations in the three countries. Participants completed a brief self-administered questionnaire, while semi-structured interviews were conducted with each partner separately and with both partners together. Interviews were analysed using thematic content analysis. Fifty-one couples were recruited: 26 from South Africa, 10 from Tanzania, and 15 from Ukraine. Although most participants had disclosed their HIV status to someone other than their partner, few were living openly with HIV discordance. Experiences of stigma were common and included being subjected to gossip, rumours and name-calling, and HIV-negative partners being labelled as HIV-positive. Perpetrators of discrimination included family members and health workers. Stigma and discrimination present unique and complex challenges to couples in HIV sero-discordant relationships in these three diverse countries. Addressing stigmatisation of HIV-discordant couples requires a holistic human rights approach and specific programme efforts to address discrimination in the health system.

We Keep her Status to ourselves': Experiences of Stigma and Discrimination among HIV-Discordant Couples in South Africa; Tanzania and Ukraine

In HIV-discordant relationships; the HIV-negative partner also carries the burden of a stigmatised disease. For this reason; couples often hide their HIV-discordant status from family; friends and community members. This perpetuates the silence around HIV-discordant relationships and impacts on targeted HIV prevention; treatment and counselling efforts. This article reports on experiences of stigma and discrimination among HIV-discordant couples in South Africa; Tanzania and Ukraine. During 2008; HIV-discordant couples who had been in a relationship for at least one year were recruited purposively through health-care providers and civil society organisations in the three countries. Participants completed a brief self-administered questionnaire; while semi-structured interviews were conducted with each partner separately and with both partners together. Interviews were analysed using thematic content analysis. Fifty-one couples were recruited: 26 from South Africa; 10 from Tanzania; and 15 from Ukraine. Although most participants had disclosed their HIV status to someone other than their partner; few were living openly with HIV discordance. Experiences of stigma were common and included being subjected to gossip; rumours and name-calling; and HIV-negative partners being labelled as HIV-positive. Perpetrators of discrimination included family members and health workers. Stigma and discrimination present unique and complex challenges to couples in HIV sero-discordant relationships in these three diverse countries. Addressing stigmatisation of HIV-discordant couples requires a holistic human rights approach and specific programme efforts to address discrimination in the health system

Prospective evaluation of diagnostic accuracy of dried blood spots from finger prick samples for determination of HIV-1 load with the NucliSENS Easy-Q HIV-1 version 2.0 assay in Malawi.

HIV-1 viral load (VL) testing is not widely available in resource-limited settings. The use of finger prick dried blood spot (FP-DBS) samples could remove barriers related to sample collection and transport. Measurement of VL using DBS from EDTA venous blood (VB-DBS) in place of plasma has previously been validated using the NucliSENS Easy-Q HIV-1 v2.0 assay, but information on the accuracy of FP-DBS samples for measuring VL is limited. This prospective study, conducted at Thyolo District Hospital in southern Malawi, compared VL levels measured on FP-DBS samples and plasma using the NucliSENS Easy-Q HIV-1 v2.0 assay. Comparability was assessed by means of agreement and correlation (131 patients with VLs of ≥100 copies/ml), sensitivity, and specificity (612 patients on antiretroviral treatment [ART]). Samples of EDTA venous blood and FP-DBS from 1,009 HIV-infected individuals were collected and prepared in the laboratory. Bland-Altman analysis found good agreement between plasma and FP-DBS VL levels, with a mean difference of -0.35 log10, and 95% limits of agreement from -1.26 to 0.55 log10. FP-DBS had a sensitivity of 88.7% (95% confidence interval [CI], 81.1 to 94.4%) and a specificity of 97.8% (95% CI, 96.1 to 98.9%) using a 1,000-copies/ml cut point and a sensitivity of 83.0% (95% CI, 73.4 to 90.1%) and a specificity of 100% (95% CI, 99.3 to 100%) using a 5,000-copies/ml cut point. This study shows that FP-DBS is an acceptable alternative to plasma for measuring VL using the NucliSENS Easy-Q HIV-1 v2.0. We are conducting a second study to assess the proficiency of health workers at preparing FP-DBS in primary health care clinics.

'It [HIV] is part of the relationship': exploring communication among HIV-serodiscordant couples in South Africa and Tanzania.

In many sub-Saharan African countries, a high proportion of people living with HIV are in long-term serodiscordant relationships. This paper explores how HIV serodiscordance shapes communication among couples in long-term HIV-serodiscordant relationships. A total of 36 couples were purposively recruited through healthcare providers and civil society organisations in South Africa (26) and Tanzania (10). We explored couples' portrayal of living in a serodiscordant relationship by conducting semi-structured interviews with each partner separately, followed by a joint interview with both partners. Using an adaptation of Persson's model on sero-silence and sero-sharing, we categorised coping style as 'sero-silent' if partners reported that they did not talk much with each other about issues related to their serodiscordant status or as 'sero-sharing' if they portrayed HIV as being an issue which they dealt with together. Some couples exhibited features of both coping styles and, at times, partners differed in their ways of coping.

You become afraid to tell them that you are gay: health service utilization by men who have sex with men in South African cities.

We describe the utilization of health services by men who have sex with men (MSM) in South African cities, their perceptions of available health services, and their service preferences. We triangulated data from 32 key informant interviews (KIIs), 18 focus group discussions (FGDs) with MSM in four cities, and a survey of 285 MSM in two cities, recruited through respondent-driven sampling in 2008. FGDs and KIIs revealed that targeted public health sector programs for MSM were limited, and that MSM experienced stigma, discrimination, and negative health worker attitudes. Fifty-seven per cent of the survey participants had used public health services in the previous 12 months, and 69 per cent had no private health insurance, with no difference by HIV status. Despite these findings, South Africa is well placed to take the lead in sub-Saharan Africa in providing responsive and appropriate HIV services for MSM.

Sexual relations and childbearing decisions of HIV-discordant couples: an exploratory study in South Africa and Tanzania.

This article reports on the influence of HIV on sexual relations and childbearing decisions of 36 HIV-discordant couples, 26 in South Africa and 10 in Tanzania, recruited into an exploratory study through hospital antiretroviral treatment clinics and civil society organisations working with people living with HIV. Self-administered questionnaires were used to obtain social and demographic information, while couples' sexual relations and childbearing decisions were explored through in-depth, semi-structured individual and couple interviews. The majority of the HIV-positive partners were women, who were on antiretroviral treatment. Almost one-third of South African respondents and half of those in Tanzania reported experiences of tension related to HIV-discordance, while more than half of the South Africans and almost three-quarters of the Tanzanians reported that intimacy had been affected by their discordant status. Those without children were more likely to desire children (17/23) than those who already had children (16/44), although this desire was influenced by fear of HIV transmission to the negative partner and medical professional advice. The study points to the need for targeted information for HIV discordant couples, as well as couple counselling and support services.

Breaking the silence: South African HIV policies and the needs of men who have sex with men.

Although the HIV epidemic among men who have sex with men (MSM) in South Africa preceded the onset of the generalised HIV epidemic by several years, current policies and programmes focus on heterosexual transmission and mother-to-child transmission. We used an adaptation of the UNAIDS Country Harmonised Alignment Tool (CHAT) to assess whether existing HIV policies and programmes in South Africa address the needs of MSM. This covered mapping of key risk factors and epidemiology of HIV among MSM; participation of MSM in the HIV response; and an enabling environment for service provision, funding and human resources. We found that current policies and programmes are unresponsive to the needs of MSM and that epidemiologic information is lacking, in spite of policy on MSM in the National Strategic Plan. We recommend that government initiate sentinel surveillance to determine HIV prevalence among MSM, social science research on the contexts of HIV transmission among MSM, and appropriate HIV prevention and care strategies. MSM should be closely involved in the design of policies and programmes. Supportive programme development should include dedicated financial and human resources, appropriate guidelines, and improved access to and coverage of HIV prevention, treatment and care services for MSM.

Risk factors for prevalent and incident Trichomonas vaginalis among women attending three sexually transmitted disease clinics.

GOAL: Trichomonas vaginalis is the most common nonviral sexually transmitted infection in the United States and may be associated with adverse birth outcomes and may also increase susceptibility to or transmissibility of human immunodeficiency virus. The purpose of this analysis is to describe the epidemiology of T. vaginalis in Sexually Transmitted Disease clinics and characterize the risk factors associated with prevalent and incident T. vaginalis within the same population. METHODS: We analyzed data from visits occurring during February 1999-December 2001 from 3 sexually transmitted disease clinics in Newark, NJ; Long Beach, CA; and Denver, CO. Data were analyzed from 1462 women aged 15 to 39 years who were tested by culture at their initial visit for T. vaginalis, and for 1269 women with at least 1 follow-up visit. Risk factors for prevalent infections at baseline and incident infections among treated or previously uninfected women were assessed. RESULTS: At baseline, 13.0% of the women had a prevalent infection; risk factors included the following: older age (> or =20 years), black race, having less than 12 years of education, and having a concurrent chlamydial infection. At follow-up, 4.6% of women had an incident infection; risk factors included the following: older age (35-39 years), black race, having a concurrent chlamydial infection, having had multiple sexual partners in the 3 months before incident infection, and having had T. vaginalis at the visit before their incident infection. CONCLUSIONS: T. vaginalis incidence is high in women. Risk factors for prevalent and incident infection are similar. T. vaginalis was associated with older age in women, unlike other sexually transmitted infections.

High incidence of new sexually transmitted infections in the year following a sexually transmitted infection: a case for rescreening.

BACKGROUND: Studies show 11% to 15% of women treated for Chlamydia trachomatis are reinfected 3 to 4 months after treatment, suggesting the need for rescreening. There is little information on infections among men, infections with Neisseria gonorrhoeae or Trichomonas vaginalis, or long-term follow-up. OBJECTIVE: To determine the incidence of new sexually transmitted infections during the year after a visit to a sexually transmitted disease (STD) clinic and associated risk factors. DESIGN: Secondary analysis of data from a randomized, controlled trial (RESPECT-2). SETTING: 3 urban STD clinics. PATIENTS: Sexually active patients enrolled in an HIV prevention counseling trial. MEASUREMENTS: Patient characteristics at the initial visit; behaviors during follow-up; and new infections with C. trachomatis, N. gonorrhoeae, or T. vaginalis (women only) detected during 4 scheduled return visits and any other interim visits. RESULTS: 2419 persons had 8129 three-month follow-up intervals. Among 1236 women, 25.8% had 1 or more new infections (11.9% acquired C. trachomatis, 6.3% acquired N. gonorrhoeae, and 12.8% acquired T. vaginalis); among 1183 men, 14.7% had 1 or more new infections (9.4% acquired C. trachomatis, and 7.1% acquired N. gonorrhoeae). Black persons and those with sexually transmitted infections at baseline were at highest risk for recurrent infection (adjusted odds ratio, 2.5 and 2.4, respectively). For persons infected at baseline, the risk for infection was high at 3 and 6 months (16.3 per 100 three-month intervals) and remained high at 9 and 12 months (12.0 per 100 three-month intervals). Most (67.2%) infections were diagnosed during study-related visits, and 66.2% of these patients reported no symptoms. LIMITATIONS: Because patients were recruited from STD clinics, results may not be generalizable. CONCLUSIONS: Men and women who receive diagnoses of C. trachomatis, N. gonorrhoeae, or T. vaginalis infections should return in 3 months for rescreening because they are at high risk for new asymptomatic sexually transmitted infections. Although single-dose therapy may adequately treat the infection, it often does not adequately treat the patient.

Efficacy of a booster counseling session 6 months after HIV testing and counseling: a randomized, controlled trial (RESPECT-2).

BACKGROUND: HIV counseling prevents sexually transmitted diseases (STDs), with most of the benefit accumulating in the first 6 months. STUDY: The authors conducted a multicenter, randomized, controlled trial of a 20-minute additional (booster) counseling session 6 months after HIV counseling compared with no additional counseling for prevention of STDs (gonorrhea, chlamydia, trichomoniasis). Participants were 15- to 39-year-old STD clinic patients in Denver, Long Beach, and Newark. RESULTS: Booster counseling was completed by 1120 (67.8%) of 1653 assigned to receive it. An incident STD during the 6 to 12 months after initial counseling (and within the 6 months after scheduled booster counseling) was detected in 141 of 1653 (8.5%) participants in the booster counseling group and 144 of 1644 (8.8%) in the no-booster group (relative risk, 0.97; 95% confidence interval, 0.78-1.22). Three months after booster counseling, sexual risk behaviors were reported less frequently by the booster group than the no-booster group. CONCLUSIONS: Booster counseling 6 months after HIV testing and counseling reduced reported sexual risk behavior but did not prevent STDs.

Relative efficacy of prevention counseling with rapid and standard HIV testing: a randomized, controlled trial (RESPECT-2).

BACKGROUND: Two risk-reduction counseling sessions can prevent sexually transmitted diseases (STDs); however, return rates for test results are low. STUDY: A randomized, controlled trial compared rapid HIV testing and counseling in 1 visit with standard HIV testing and counseling in 2 visits. Main outcomes were STDs (gonorrhea, chlamydia, trichomoniasis, syphilis, HIV) within 12 months. Participants were 15- to 39-year-old STD clinic patients in Denver, Long Beach, and Newark. STD screening and questionnaires were administered every 3 months. RESULTS: Counseling was completed by 1632 of 1648 (99.0%) of the rapid-test group and 1144 of 1649 (69.4%) of the standard-test group. By 12 months, STD was acquired by 19.1% of the rapid group and 17.1% of the standard group (relative risk [RR], 1.11; confidence interval [CI], 0.96-1.29). STD incidence was higher in the rapid-test group than in the standard-test group among men (RR, 1.34; CI, 1.06-1.70), men who had sex with men (RR, 1.86; 95% CI, 0.92-3.76), and persons with no STDs at enrollment (RR, 1.21; 95% CI, 0.99-1.48). Behavior was similar in both groups. CONCLUSIONS: Counseling with either test had similar effects on STD incidence. For some persons, counseling with standard testing may be more effective than counseling with rapid testing.