Cervical Cancer Screening Positivity Among Women Living With HIV in CDC-PEPFAR Programs 2018-2022.

BACKGROUND: The US President's Emergency Plan for AIDS Relief aims to address the higher risk of cervical cancer among women living with HIV by offering high-quality screening services in the highest burden regions of the world. METHODS: We analyzed the US President's Emergency Plan for AIDS Relief Monitoring, Evaluation, and Reporting data from Centers for Disease Control and Prevention-supported sites in 13 countries in sub-Saharan Africa for women living with HIV aged older than 15 years who accessed cervical cancer screening services (mostly visual inspection, with ablative or excisional treatment offered for precancerous lesions), April 2018-March 2022. We calculated the positivity by age, country, and clinical visit type (first lifetime screen or routine rescreening). We fitted negative binomial random coefficient models of log-linear trends in time to estimate the probabilities of testing positive and any temporal trends in positivity. RESULTS: Among the 2.8 million completed cancer screens, 5.4% identified precancerous lesions, and 0.8% were positive for suspected invasive cervical cancers (6.1% overall). The positivity rates declined over the study period among those women screening for cervical cancer for the first time and among those women presenting to antiretroviral therapy clinics for routine rescreening. CONCLUSIONS: These positivity rates are lower than expectations set by the published literature. Further research is needed to determine whether these lower rates are attributable to the high level of consistent antiretroviral therapy use among these populations, and systematic program monitoring and quality assurance activities are essential to ensure women living with HIV have access to the highest possible quality prevention services.

Preexposure Prophylaxis Among Pregnant and Lactating People in 18 PEPFAR-Supported Countries: A Review of HIV Strategies and Guidelines.

INTRODUCTION: Pregnant and lactating people (PLP) experience heightened risk of acquiring HIV, which adversely impacts their health and increases the risk for vertical HIV transmission. Preexposure prophylaxis (PrEP), as part of a combination prevention package, including condoms, sexually transmitted infection prevention, and regular HIV testing, is a safe, efficacious method to prevent HIV infections among PLP and their infants. This article examines the evolution of strategies and guidance on PrEP services for PLP from 18 countries supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). METHODS: The 18 countries implement PEPFAR-supported prevention of vertical transmission of HIV and PrEP programs. We reviewed a total of 18 national HIV strategic plans, 28 national HIV guidelines, and 54 PEPFAR country operational plans (COPs) published in 2013-2020. We compared documents from 2013 to 2017 to those from 2017 to 2020 to assess for differences after the release of the 2017 World Health Organization recommendations supporting the use of PrEP by PLP at substantial risk of acquiring HIV. RESULTS: National HIV guidelines and PEPFAR COPs that endorsed PrEP for PLP through any categorization increased from 41% to 73% and 11% to 83%, respectively, in the pre-2017 and post-2017 periods. While many documents approved PrEP but not specifically for PLP (10 national strategic plans, 6 national guidelines, and 28 COPs), none of the documents explicitly prohibited PrEP for PLP. CONCLUSION: National HIV guidelines and PEPFAR COPs expanded inclusion of PLP in PrEP eligibility when comparing the pre-2017 and the post-2017 groups. However, policy gaps remain as only 36% (4/11) of the post-2017 national HIV guidelines included PLP as a specific priority population for PrEP. Inclusive national HIV strategic plans and guidelines on PrEP for PLP, together with effective program implementation, remain critical for reducing new infections in PLP and eliminating vertical transmission of HIV.

Improving uptake of prevention of mother-to-child HIV transmission services in Benue State, Nigeria through a faith-based congregational strategy.

BACKGROUND: Nigeria has low antiretroviral therapy (ART) coverage among HIV-positive pregnant women. In a previous cluster-randomized trial in Nigeria, Baby Shower events resulted in higher HIV testing coverage and linkage of pregnant women to ART; here, we assess outcomes of Baby Shower events in a non-research setting. METHODS: Baby Shower events, including a prayer ceremony, group education, music, gifting of a "mama pack" with safe delivery supplies, and HIV testing with ART linkage support for HIV-positive pregnant women, were conducted in eighty sites in Benue State, Nigeria. Client questionnaires (including demographics, ANC attendance, and HIV testing history), HIV test results, and reported linkage to ART were analyzed. Descriptive data on HIV testing and ART linkage data for facility-based care at ANC clinics in Benue State were also analyzed for comparison. RESULTS: Between July 2016 and October 2017, 10,056 pregnant women and 6,187 male partners participated in Baby Shower events; 61.5% of women attended with a male partner. Nearly half of female participants (n = 4515, 44.9%) were not enrolled in ANC for the current pregnancy, and 22.3% (n = 2,241) of female and 24.8% (n = 1,532) of male participants reported they had never been tested for HIV. Over 99% (n = 16,240) of participants had their HIV status ascertained, with 7.2% of females (n = 724) and 4.0% of males (n = 249) testing HIV-positive, and 2.9% of females (n = 274) and 2.3% of males (n = 138) receiving new HIV-positive diagnoses. The majority of HIV-positive pregnant women (93.0%, 673/724) were linked to ART. By comparison, at health facilities in Benue State during a similar time period, 99.7% of pregnant women had HIV status ascertained, 8.4% had a HIV-positive status, 2.1% were newly diagnosed HIV-positive, and 100% were linked to ART. CONCLUSION: Community-based programs such as the faith-based Baby Shower intervention complement facility-based approaches and can reach individuals who would not otherwise access facility-based care. Future Baby Showers implementation should incorporate enhanced support for ART linkage and retention to maximize the impact of this intervention on vertical HIV transmission.

Evaluating the effect of a community score card among pregnant and breastfeeding women living with HIV in two districts in Malawi.

Malawi faces challenges with retaining women in prevention of mother-to-child HIV transmission (PMTCT) services. We evaluated Cooperative for Assistance and Relief Everywhere, Inc. (CARE's) community score card (CSC) in 11 purposively selected health facilities, assessing the effect on: (1) retention in PMTCT services, (2) uptake of early infant diagnosis (EID), (3) collective efficacy among clients, and (4) self-efficacy among health care workers (HCWs) in delivering quality services. The CSC is a participatory community approach. In this study, HCWs and PMTCT clients identified issues impacting PMTCT service quality and uptake and implemented actions for improvement. A mixed-methods, pre- and post-intervention design was used to evaluate the intervention. We abstracted routine clinical data on retention in PMTCT services for HIV-positive clients attending their first antenatal care visit and EID uptake for their infants for 8-month periods before and after implementation. To assess collective efficacy and self-efficacy, we administered questionnaires and conducted focus group discussions (FGDs) pre- and post-intervention with PMTCT clients recruited from CSC participants, and HCWs providing HIV care from facilities. Retention of HIV-positive women in PMTCT services at three and six months and EID uptake was not significantly different pre- and post-implementation. For the clients, the collective efficacy scale average improved significantly post-intervention, (p = 0.003). HCW self-efficacy scale average did not improve. Results from the FGDs highlighted a strengthened relationship between HCWs and PMTCT clients, with clients reporting increased satisfaction with services. However, the data indicated continued challenges with stigma and fear of disclosure. While CSC may foster mutual trust and respect between HCWs and PMTCT clients, we did not find it improved PMTCT retention or EID uptake within the short duration of the study period. More research is needed on ways to improve service quality and decrease stigmatized behaviors, such as HIV testing and treatment services, as well as the longer-term impacts of interventions like the CSC on clinical outcomes.

Update: Interim Guidance for Health Care Providers for Managing Patients with Suspected E-cigarette, or Vaping, Product Use-Associated Lung Injury - United States, November 2019.

CDC, the Food and Drug Administration (FDA), state and local health departments, and public health and clinical stakeholders are investigating a nationwide outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) (1). CDC has published recommendations for health care providers regarding EVALI (2-4). Recently, researchers from Utah and New York published proposed diagnosis and treatment algorithms for EVALI (5,6). EVALI remains a diagnosis of exclusion because, at present, no specific test or marker exists for its diagnosis, and evaluation should be guided by clinical judgment. Because patients with EVALI can experience symptoms similar to those associated with influenza or other respiratory infections (e.g., fever, cough, headache, myalgias, or fatigue), it might be difficult to differentiate EVALI from influenza or community-acquired pneumonia on initial assessment; EVALI might also co-occur with respiratory infections. This report summarizes recommendations for health care providers managing patients with suspected or known EVALI when respiratory infections such as influenza are more prevalent in the community than they have been in recent months (7). Recommendations include 1) asking patients with respiratory, gastrointestinal, or constitutional symptoms about the use of e-cigarette, or vaping, products; 2) evaluating those suspected to have EVALI with pulse oximetry and obtaining chest imaging, as clinically indicated; 3) considering outpatient management for clinically stable EVALI patients who meet certain criteria; 4) testing patients for influenza, particularly during influenza season, and administering antimicrobials, including antivirals, in accordance with established guidelines; 5) using caution when considering prescribing corticosteroids for outpatients, because this treatment modality has not been well studied among outpatients, and corticosteroids could worsen respiratory infections; 6) recommending evidence-based treatment strategies, including behavioral counseling, to help patients discontinue using e-cigarette, or vaping, products; and 7) emphasizing the importance of annual influenza vaccination for all persons aged ≥6 months, including patients who use e-cigarette, or vaping products.

Beyond Early Infant Diagnosis: Changing the Approach to HIV-Exposed Infants.

Despite dramatic global progress with implementing prevention of mother-to-child HIV transmission (PMTCT) programs, there were 160,000 new pediatric HIV infections in 2016. More than 50% of infant HIV infections now occur in the postpartum period, reflecting the relatively high coverage of interventions in the antenatal period and the need for greater attention to the breastfeeding mother and her HIV-exposed infant (HEI). Early diagnosis and treatment are critical to prevent morbidity and mortality in HIV-infected children; however, early infant HIV testing rates remain low in most high HIV-burden countries. Furthermore, systematic retention and follow-up of HEI in the postpartum period and ascertainment of final HIV status remain major program gaps. Despite multiple calls to action to improve infant HIV testing rates, progress has been marginal due to a lack of focus on the critical health care needs of HEI coupled with health system barriers that result in fragmented services for HIV-infected mothers and their families. In this paper, we describe the available evidence on the health outcomes of HEI, define a comprehensive care package for HEI that extends beyond early HIV testing, and describe successful examples of integrated services for HEI.

Attitudes and beliefs about anti-retroviral therapy are associated with high risk sexual behaviors among the general population of Kisumu, Kenya.

Attitudes and beliefs about antiretroviral therapy (ART) may affect sexual risk behaviors among the general population in sub-Saharan Africa. We performed a cross-sectional population-based study in Kisumu, Kenya to test this hypothesis in October 2006. A total of 1655 participants were interviewed regarding attitudes and beliefs about ART and their sexual risk behaviors. The majority of participants, (71%) men and (70%) women, had heard of ART. Of these, 20% of men and 29% of women believed ART cures HIV. Among women, an attitude that "HIV is more controllable now that ART is available" was associated with sex with a non-spousal partner, increased lifetime number of sexual partners as well as a younger age at sexual debut. No significant associations with this factor were found among men. The belief that "ART cures HIV" was associated with younger age of sexual debut among women. The same belief was associated with an increased likelihood of exchanging sex for money/gifts and decreased likelihood of condom use at last sex among men. These findings were most significant for people aged 15-29 years. In high HIV seroprevalence populations with expanding access to ART, prevention programs must ensure their content counteracts misconceptions of ART in order to reduce high risk sexual behaviors, especially among youth.

The association of HIV counseling and testing with HIV risk behaviors in a random population-based survey in Kisumu, Kenya.

HIV testing has been promoted as a key HIV prevention strategy in low-resource settings, despite studies showing variable impact on risk behavior. We sought to examine rates of HIV testing and the association between testing and sexual risk behaviors in Kisumu, Kenya. Participants were interviewed about HIV testing and sexual risk behaviors. They then underwent HIV serologic testing. We found that 47% of women and 36% of men reported prior testing. Two-thirds of participants who tested HIV-positive in this study reported no prior HIV test. Women who had undergone recent testing were less likely to report high-risk behaviors than women who had never been tested; this was not seen among men. Although rates of HIV testing were higher than seen in previous studies, the majority of HIV-infected people were unaware of their status. Efforts should be made to increase HIV testing among this population.

Prevalence of forced sex and associated factors among women and men in Kisumu, Kenya.

Sexual violence is a well-recognized global health problem, albeit with limited population-based data available from sub-Saharan Africa. We sought to measure the prevalence of forced sex in Kisumu, Kenya, and identify its associated factors. The data were drawn from a population-based cross-sectional survey. A two-stage sampling design was used: 40 clusters within Kisumu municipality were enumerated and households within each cluster selected by systematic random sampling. Demographic and sexual histories, including questions on forced sex, were collected privately using a structured questionnaire. The prevalence of forced sex was 13% (women) and 4.5% (men). After adjusting for age and cluster, forced sex among women was associated with transactional sex (OR 2.33; 95%CI 1.38-3.95), having more than two lifetime partners (OR 1.9; 95%CI 1.20-3.30), having postprimary education (OR 1.49; 95%CI 1.04-2.14) and a high economic status (OR 1.87; 95%CI 1.2-2.9). No factors were significantly associated with forced sex among the male respondents. Intimate partners were the most common perpetrators of forced sex among both women (50%) and men (62.1%). Forced sex prevention programs need to target the identified associated factors, and educate the public on the high rate of forced sex perpetrated by intimate partners.

Male circumcision in the general population of Kisumu, Kenya: beliefs about protection, risk behaviors, HIV, and STIs.

Using a population-based survey we examined the behaviors, beliefs, and HIV/HSV-2 serostatus of men and women in the traditionally non-circumcising community of Kisumu, Kenya prior to establishment of voluntary medical male circumcision services. A total of 749 men and 906 women participated. Circumcision status was not associated with HIV/HSV-2 infection nor increased high risk sexual behaviors. In males, preference for being or becoming circumcised was associated with inconsistent condom use and increased lifetime number of sexual partners. Preference for circumcision was increased with understanding that circumcised men are less likely to become infected with HIV.

Association of attitudes and beliefs towards antiretroviral therapy with HIV-seroprevalence in the general population of Kisumu, Kenya.

BACKGROUND: Since antiretroviral therapy (ART) became available in the developed world, the prevalence of unprotected sex and the incidence of sexually transmitted infections (STIs) and HIV have increased. We hypothesized that a similar phenomenon may be occurring in sub-Saharan Africa concomitant with the scale-up of HIV treatment. METHODS: We conducted a general population-based survey in Kisumu, Kenya. Participants completed an interview that included demographics as well as ART-related attitudes and beliefs (AB) and then underwent HIV serological testing. Exploratory and confirmatory factor analyses of AB about ART indicated two factors: 1) ART-related risk compensation (increased sexual risk taking now that ART is available); and 2) a perception that HIV is more controllable now that ART is available. Logistic regression was used to determine associations of these factors with HIV-seroprevalence after controlling for age. FINDINGS: 1,655 (90%) of 1,844 people aged 15-49 contacted, including 749 men and 906 women, consented to participate in the study. Most participants (n = 1164; 71%) had heard of ART. Of those who had heard of ART, 23% believed ART was a cure for HIV. ART-related risk compensation (Adjusted (A)OR = 1.45, 95% CI 1.16-1.81), and a belief that ART cures HIV (AOR = 2.14, 95% CI 1.22-3.76) were associated with an increased HIV seroprevalence in men but not women after controlling for age. In particular, ART-related risk compensation was associated with an increased HIV-seroprevalence in young (aged 15-24 years) men (OR = 1.56; 95% CI 1.12-2.19). CONCLUSIONS: ART-related risk compensation and a belief that ART cures HIV were associated with an increased HIV seroprevalence among men but not women. HIV prevention programs in sub-Saharan Africa that target the general population should include educational messages about ART and address the changing beliefs about HIV in the era of greater ART availability.

Sexuality, HIV risk and potential acceptability of involving adolescent girls in microbicide research in Kisumu, Kenya.

BACKGROUND: Current microbicide clinical trials primarily enroll adult participants; however, females under the age of 18, because of their high rates of HIV acquisition, represent an important population for future microbicide clinical research. We sought to understand the individual, family and community-level factors that may influence the acceptability of microbicide use and research involving adolescent girls. METHODS: We conducted 30 interviews with adolescent girls aged 14-17 and nine focus group discussions with adolescent girls, parents and community leaders in Kisumu, Kenya. Participants discussed adolescent sexuality, HIV prevention methods, perceptions about microbicide use and views about microbicide research involving adolescent girls. RESULTS: Adolescent sexual activity is stigmatised yet acknowledged to be a natural part of the 'adolescent stage.' Desperation to stop the spread of HIV among youth and support for female-initiated HIV prevention methods led to enthusiasm about microbicides and future microbicide research. Yet concerns about microbicides were numerous and included: difficulty using it in a timely manner due to the rushed, unplanned nature of adolescent sex; a fear of trying experimental products; concerns about microbicide efficacy; and parental worry that supporting microbicide use in youth would defy societal pressures that denounce adolescent sexual activity. CONCLUSIONS: Microbicide acceptability for youth in sub-Saharan Africa may be bolstered by desperation for new methods to stop the spread of HIV, yet hindered by misgivings about experimental HIV prevention methods for youth. Understanding and addressing the microbicide's perceived benefits and shortcomings, as well as the broader context of adolescent sexuality and HIV prevention, may facilitate future research and promotion of microbicides in this high-risk group.