Impact of HIV treat-all and complementary policies on ART linkage in 13 PEPFAR-supported African countries.

BACKGROUND: In 2015, the World Health Organization recommended that all people living with HIV begin antiretroviral treatment (ART) regardless of immune status, a policy known as 'Treat-All to end AIDS', commonly referred to as Treat-All. Almost all low- and middle-income countries adopted this policy by 2019. This study describes how linkage to treatment of newly diagnosed persons changed between 2015 and 2018 and how complementary policies may have similarly increased linkage for 13 African countries. These countries adopted and implemented Treat-All policies between 2015 and 2018 and were supported by the U.S. Government's President's Emergency Plan for AIDS Relief (PEPFAR). The focuses of this research were to understand 1) linkage rates to ART initiation before and after the adoption of Treat-All in each country; 2) how Treat-All implementation differed across these countries; and 3) whether complementary policies (including same-day treatment initiation, task-shifting, reduced ART visits, and reduced ART pickups) implemented around the same time may have increased ART linkage. METHODS: HIV testing and treatment data were collected by PEPFAR country programs in 13 African countries from 2015 to 2018. These countries were chosen based on the completeness of policy data and availability of program data during the study period. Program data were used to calculate proxy linkage rates. These rates were compared relative to the Treat All adoption period and the adoption of complementary policies. RESULTS: The 13 countries experienced an average increase in ART linkage of 29.3% over the entire study period. In examining individual countries, all but two showed increases in linkage to treatment immediately after Treat All adoption. Across all countries, those that had adopted four or more complementary policies showed an average increased linkage of 39.8% compared to 13.9% in countries with fewer than four complementary policies. CONCLUSIONS: Eleven of 13 country programs examined in this study demonstrated an increase in ART linkage after Treat-All policy adoption. Increases in linkage were associated with complementary policies. When exploring new public health policies, policymakers may consider which complementary policies might also help achieve the desired outcome of the public health policy.

Low-level viraemia among people living with HIV in Nigeria: a retrospective longitudinal cohort study.

BACKGROUND: HIV transmission can occur with a viral load of at least 200 copies per mL of blood and low-level viraemia can lead to virological failure; the threshold level at which risk for virological failure is conferred is uncertain. To better understand low-level viraemia prevalence and outcomes, we analysed retrospective longitudinal data from a large cohort of people living with HIV on antiretroviral therapy (ART) in Nigeria. METHODS: In this retrospective cohort study using previously collected longitudinal patient data, we estimated rates of virological suppression (≤50 copies per mL), low-level viraemia (51-999 copies per mL), virological non-suppression (≥1000 copies per mL), and virological failure (≥2 consecutive virological non-suppression results) among people living with HIV aged 18 years and older who initiated and received at least 24 weeks of ART at 1005 facilities in 18 Nigerian states. We analysed risk for low-level viraemia, virological non-suppression, and virological failure using log-binomial regression and mixed-effects logistic regression. FINDINGS: At first viral load for 402 668 patients during 2016-21, low-level viraemia was present in 64 480 (16·0%) individuals and virological non-suppression occurred in 46 051 (11·4%) individuals. Patients with low-level viraemia had increased risk of virological failure (adjusted relative risk 2·20, 95% CI 1·98-2·43; p<0·0001). Compared with patients with virological suppression, patients with low-level viraemia, even at 51-199 copies per mL, had increased odds of low-level viraemia and virological non-suppression at next viral load; patients on optimised ART (ie, integrase strand transfer inhibitors) had lower odds than those on non-integrase strand transfer inhibitors for the same low-level viraemia range (eg, viral load ≥1000 copies per mL following viral load 400-999 copies per mL, integrase strand transfer inhibitor: odds ratio 1·96, 95% CI 1·79-2·13; p<0·0001; non-integrase strand transfer inhibitor: 3·21, 2·90-3·55; p<0·0001). INTERPRETATION: Patients with low-level viraemia had increased risk of virological non-suppression and failure. Programmes should revise monitoring benchmarks and targets from less than 1000 copies per mL to less than 50 copies per mL to strengthen clinical outcomes and track progress to epidemic control. FUNDING: None.

Outcomes of HIV Positive Children and Adolescents Initiated on Antiretroviral Treatment in Nigeria (2007-2016).

Background: This manuscript aimed to examine treatment outcomes of HIV-positive children and adolescents. Methods: We retrospectively analyzed data of a sample of patients aged 0-19 years who initiated ART (October 2007-September 2016) in participating sites in 30 states and the Federal Capital Territory in Nigeria. Results: Among 4006 patients alive at the end of the follow up period, 138 (3.4%) were LTFU. Adolescents had a significantly higher risk of being LTFU than children aged 3-5 years (HR 2.47 [95% CI 1.40-4.34]). Patients with advanced disease had a significantly higher risk of being LTFU (Stage IV HR, 3.66 [95% CI: 2.00-6.68]). On average, optimal ART refill adherence was met by 67.3% of patients. Conclusion: Our findings suggest that focusing on preventing and managing advanced disease and interventions supporting adolescents when transferring to adult care is warranted.

Pediatric HIV Case Identification Across 22 PEPFAR-Supported Countries During the COVID-19 Pandemic, October 2019-September 2020.

During 2020, an estimated 150,000 persons aged 0-14 years acquired HIV globally (1). Case identification is the first step to ensure children living with HIV are linked to life-saving treatment, achieve viral suppression, and live long, healthy lives. Successful interventions to optimize pediatric HIV testing during the COVID-19 pandemic are needed to sustain progress toward achieving Joint United Nations Programme on HIV/AIDS (UNAIDS) 95-95-95 targets.* Changes in HIV testing and diagnoses among persons aged 1-14 years (children) were assessed in 22 U.S. President's Emergency Plan for AIDS Relief (PEPFAR)-supported countries during October 1, 2019-September 30, 2020. This period corresponds to the two fiscal quarters before the COVID-19 pandemic (i.e., Q1 and Q2) and the two quarters after the pandemic began (i.e., Q3 and Q4). Testing was disaggregated by age group, testing strategy, and fiscal year quarter. During October 2019-September 2020, PEPFAR supported 4,312,343 HIV tests and identified 74,658 children living with HIV (CLHIV). The number of HIV tests performed was similar during Q1 and Q2, decreased 40.1% from Q2 to Q3, and increased 19.7% from Q3 to Q4. The number of HIV cases identified among children aged 1-14 years (cases identified) increased 7.4% from Q1 to Q2, decreased 29.4% from Q2 to Q3, and increased 3.3% from Q3 to Q4. Although testing in outpatient departments decreased 21% from Q1 to Q4, testing from other strategies increased during the same period, including mobile testing by 38%, facility-based index testing (offering an HIV test to partners and biological children of persons living with HIV) by 8%, and testing children with signs or symptoms of malnutrition within health facilities by 7%. In addition, most tests (61.3%) and cases identified (60.9%) were among children aged 5-14 years (school-aged children), highlighting the need to continue offering HIV testing to older children. These findings provide important information on the most effective strategies for identifying CLHIV during the COVID-19 pandemic. HIV testing programs should continue to use programmatic, surveillance, and financial data at both national and subnational levels to determine the optimal mix of testing strategies to minimize disruptions in pediatric case identification during the COVID-19 pandemic.

Sexual Violence Prevalence and Related Pregnancy Among Girls and Young Women: A Multicountry Analysis.

This study aims to quantify the prevalence of forced sex, pressured sex, and related pregnancy among adolescent girls and young women in five low- and middle-income countries. Nationally representative, cross-sectional household surveys were conducted in Haiti, Malawi, Nigeria, Zambia, and Uganda among girls and young women aged 13 to 24 years. A stratified three-stage cluster sample design was used. Respondents were interviewed to assess prevalence of sexual violence, pregnancy related to the first or most recent experience of forced or pressured sex, relationship to perpetrator, mean age at sexual debut, mean age at pregnancy related to forced or pressured sex, and prevalence of forced/coerced sexual debut. Frequencies, weighted percentages, and weighted means are presented. The lifetime prevalence of forced or pressured sex ranged from 10.4% to 18.0%. Among these adolescent girls and young women, the percentage who experienced pregnancy related to their first or most recent experience of forced or pressured sex ranged from 13.2% to 36.6%. In three countries, the most common perpetrator associated with the first pregnancy related to forced or pressured sex was a current or previous intimate partner. Mean age at pregnancy related to forced or pressured sex was similar to mean age at sexual debut in all countries. Preventing sexual violence against girls and young women will prevent a significant proportion of adverse effects on health, including unintended pregnancy. Implementation of strategies to prevent and respond to sexual violence against adolescent girls and young women is urgently needed.

Expanding access to HIV services during the COVID-19 pandemic-Nigeria, 2020.

BACKGROUND: To accelerate progress toward the UNAIDS 90-90-90 targets, US Centers for Disease Control and Prevention Nigeria country office (CDC Nigeria) initiated an Antiretroviral Treatment (ART) Surge in 2019 to identify and link 340,000 people living with HIV/AIDS (PLHIV) to ART. Coronavirus disease 2019 (COVID-19) threatened to interrupt ART Surge progress following the detection of the first case in Nigeria in February 2020. To overcome this disruption, CDC Nigeria designed and implemented adapted ART Surge strategies during February-September 2020. METHODS: Adapted ART Surge strategies focused on continuing expansion of HIV services while mitigating COVID-19 transmission. Key strategies included an intensified focus on community-based, rather than facility-based, HIV case-finding; immediate initiation of newly-diagnosed PLHIV on 3-month ART starter packs (first ART dispense of 3 months of ART); expansion of ART distribution through community refill sites; and broadened access to multi-month dispensing (MMD) (3-6 months ART) among PLHIV established in care. State-level weekly data reporting through an Excel-based dashboard and individual PLHIV-level data from the Nigeria National Data Repository facilitated program monitoring. RESULTS: During February-September 2020, the reported number of PLHIV initiating ART per month increased from 11,407 to 25,560, with the proportion found in the community increasing from 59 to 75%. The percentage of newly-identified PLHIV initiating ART with a 3-month ART starter pack increased from 60 to 98%. The percentage of on-time ART refill pick-ups increased from 89 to 100%. The percentage of PLHIV established in care receiving at least 3-month MMD increased from 77 to 93%. Among PLHIV initiating ART, 6-month retention increased from 74 to 92%. CONCLUSIONS: A rapid and flexible HIV program response, focused on reducing facility-based interactions while ensuring delivery of lifesaving ART, was critical in overcoming COVID-19-related service disruptions to expand access to HIV services in Nigeria during the first eight months of the pandemic. High retention on ART among PLHIV initiating treatment indicates immediate MMD in this population may be a sustainable practice. HIV program infrastructure can be leveraged and adapted to respond to the COVID-19 pandemic.

Scale-up of antiretroviral treatment access among people living with HIV in Rivers State, Nigeria, 2019--2020.

OBJECTIVE: The aim of this study was to describe and evaluate the impact of the programme intervention of the Rivers State Antiretroviral Treatment (ART) Surge, a collaboration between the US President's Emergency Plan for AIDS Relief (PEPFAR) and the State Ministry of Health, to increase HIV case-finding and ART access in Rivers State, the state with the largest ART gap among people living with HIV (PWH) in Nigeria. DESIGN: During April 2019-September 2020, the intervention included six specific strategies: using local government area-level ART gap analysis to guide case-finding; expanding targeted community testing; tailoring comprehensive key population HIV services; engaging HIV treatment programme stakeholders; synchronizing team efforts; and using near real-time data for programme action. METHODS: Weekly reported facility and community data on tests conducted, PWH diagnosed, and PWH initiated on ART were aggregated. The total number of PWH maintained on ART was reported quarterly. RESULTS: During May 2019-September 2020, the weekly number of newly diagnosed PWH initiated on ART supported by PEPFAR in Rivers State increased from 82 to 1723. During October 2019-September 2020, the monthly number of people screened for HIV testing eligibility in the community increased from 44 000 to 360 000. During April 2019-September 2020, the total number of PWH on ART supported by PEPFAR statewide increased by 3.8 times, from 26 041 to 99 733. CONCLUSION: The strategies applied by HIV program stakeholders contributed to scale-up of PWH identification and ART linkage within the Rivers State ART Surge. Continued gains through time indicate the importance of the application of a quality improvement approach to maintain programme flexibility and effectiveness.

Rapid Scale-up of an Antiretroviral Therapy Program Before and During the COVID-19 Pandemic - Nine States, Nigeria, March 31, 2019-September 30, 2020.

In 2018, an estimated 1.8 million persons living in Nigeria had HIV infection (1.3% of the total population), including 1.1 million (64%) who were receiving antiretroviral therapy (ART) (1). Effective ART reduces morbidity and mortality rates among persons with HIV infection and prevents HIV transmission once viral load is suppressed to undetectable levels (2,3). In April 2019, through the U.S. President's Emergency Plan for AIDS Relief (PEPFAR),* CDC launched an 18-month ART Surge program in nine Nigerian states to rapidly increase the number of persons with HIV infection receiving ART. CDC analyzed programmatic data gathered during March 31, 2019-September 30, 2020, to describe the ART Surge program's progress on case finding, ART initiation, patient retention, and ART Surge program growth. Overall, the weekly number of newly identified persons with HIV infection who initiated ART increased approximately eightfold, from 587 (week ending May 4, 2019) to 5,329 (week ending September 26, 2020). The ART Surge program resulted in 208,202 more HIV-infected persons receiving PEPFAR-supported ART despite the COVID-19 pandemic (97,387 more persons during March 31, 2019-March 31, 2020 and an additional 110,815 persons during April 2020-September 2020). Comprehensive, data-guided, locally adapted interventions and the use of incident command structures can help increase the number of persons with HIV infection who receive ART, reducing HIV-related morbidity and mortality as well as decreasing HIV transmission.

Disclosure of Sexual Violence Among Girls and Young Women Aged 13 to 24 Years: Results From the Violence Against Children Surveys in Nigeria and Malawi.

Understanding factors that are associated with disclosure of sexual violence (SV) is important for the delivery of health services as well as developing strategies for prevention and response. The Violence Against Children Surveys were conducted in Malawi and Nigeria. We examined the prevalence of SV, help-seeking behaviors, and factors associated with disclosure among girls and young women aged 13 to 24. The self-reported prevalence of SV was similar in Nigeria (26%) and Malawi (27%). Among females who experienced SV, approximately one third (37%) in Nigeria and one half (55%) in Malawi ever disclosed their experience of SV. Females in Nigeria were significantly more likely to disclose to their parents (31.8%) than females in Malawi (9.5%). The most common reason for nondisclosure in Nigeria was not feeling a need or desire to tell anyone (34.9%) and in Malawi was embarrassment (29.3%). Very close relationships with one or both parents were significantly associated with disclosure among Nigerian females (odds ratio [OR] = 5.5, 95% confidence interval [CI] = [2.1, 14.6]) but were inversely associated with disclosure among Malawian females (OR = 0.05, 95% CI = [0.01, 0.33]). Reasons for nondisclosure of SV and factors associated with disclosure among females differ in the African nations studied. The stigma associated with shame of SV may prevent females from disclosing and thus receiving necessary support and health, social, and other services. This study demonstrates a need to reduce barriers for disclosure to improve the delivery of health, social, and other response services across African nations, as well as to develop culturally appropriate strategies for its response.

Brief Report: Programmatic Scale-up of Tuberculosis Preventive Treatment Among People Living With HIV Through Targeted Technical Assistance to High-Volume Antiretroviral Treatment Sites-Nigeria, 2018-2019.

BACKGROUND: Tuberculosis preventive treatment (TPT) is a critical intervention to reduce tuberculosis mortality among people living with HIV (PLHIV). To facilitate scale-up of TPT among PLHIV, the Nigeria Ministry of Health and the US Centers for Disease Control and Prevention (CDC) Nigeria, supported by US President's Emergency Plan for AIDS Relief implementing partners, launched a TPT-focused technical assistance strategy in high-volume antiretroviral treatment (ART) sites during 2018. SETTING: Nigeria has an estimated 1.9 million PLHIV, representing the second largest national burden of PLHIV in the world, and an estimated 53% of PLHIV are on ART. METHODS: In 50 high-volume ART sites, we assessed readiness for TPT scale-up through use of a standardized tool across the following 5 areas: clinical training, community education, patient management, commodities and logistics management, and recording and reporting. We deployed a site-level continuous quality improvement strategy to facilitate TPT scale-up. Implementing partners rapidly disseminated best practices from these sites to across all CDC-supported sites and reported aggregate data on monthly TPT initiations. RESULTS: Through this targeted assistance and rapid dissemination of best practices to all other sites, the number of PLHIV who initiated TPT across all CDC-supported sites increased from 6622 in May 2018, when the approach was implemented, to 48,661 in September 2018. Gains in monthly TPT initiations were sustained through March 2019. CONCLUSIONS: Use of a standardized tool for assessing readiness for TPT scale-up provided a "checklist" of potential barriers to TPT scale-up to address at each site. The quality improvement approach allowed each site to design a specific plan to achieve desired TPT scale-up, and best practices were implemented concurrently at other, smaller sites. The approach could assist scale-up of TPT among PLHIV in other countries.

Increasing pediatric HIV testing positivity rates through focused testing in high-yield points of service in health facilities-Nigeria, 2016-2017.

BACKGROUND: In 2017, UNAIDS estimated that 140,000 children aged 0-14 years are living with HIV in Nigeria, but only 35% have been diagnosed and are receiving antiretroviral therapy. Children are tested primarily in outpatient clinics, which show low HIV-positive rates. To demonstrate efficient facility-based HIV testing among children aged 0-14 years, we evaluated pediatric HIV-positivity rates in points of service in select health facilities in Nigeria. METHODS: We conducted a retrospective analysis of HIV testing and case identification among children aged 0-14 years at all points of service at nine purposively sampled hospitals (November 2016-March 2017). Points of service included family index testing, pediatric outpatient department (POPD), tuberculosis (TB) clinics, immunization clinics, and pediatric inpatient ward. Eligibility for testing at POPD was done using a screening tool while all children with unknown status were eligible for HIV test at other points of service. The main outcome was HIV positivity rates stratified by the testing point of service and by age group. Predictors of an HIV-positive result were assessed using logistic regression. All analyses were done using Stata 15 statistical software. RESULTS: Of 2,180 children seen at all facility points of service with unknown HIV status, 1,822 (83.6%) were tested for HIV, of whom 43 (2.4%) tested HIV positive. The numbers of children tested by age group were <1 years = 230 (12.6%); 1-4 years = 752 (41.3%); 5-9 years = 520 (28.5%); and 10-14 years = 320 (17.6%). The number of children tested by point of service were POPD = 906 (49.7%); family index testing = 693 (38.0%); pediatric inpatient ward = 192 (10.5%); immunization clinic = 16 (0.9%); and TB clinic = 15 (0.8%). HIV positivity rates by point of service were TB clinic = 6.7% (95% Confidence Interval (CI): 0.9-35.2%); pediatric inpatient ward = 4.7% (95%CI: 2.5-8.8%); family index testing = 3.5% (95%CI: 2.3-5.1%); POPD = 1.0% (95%CI: 0.5-1.9%); and immunization clinic = 0%. The percentage contribution to total HIV positive children found by point of services was: family index testing = 55.8% (95%CI: 40.9-69.8%); POPD = 20.9% (95%CI: 11.3-35.6%); inpatient ward = 20.9 (95%CI: 11.3-35.6%) and TB Clinic = 2.3% (95%CI: 0.3-14.8%). Compared with the POPD, the adjusted odds ratio (95% CI) for finding an HIV positive child by point of service were TB clinic = 7.2 (95% CI: 0.9-60.9); pediatric inpatient ward = 4.9 (95% CI: 1.9-12.8); and family index testing = 3.7 (95% CI: 1.5-8.8). HIV-positivity rates did not significantly differ by age group. CONCLUSION: In Nigeria, to improve facility-based HIV positivity rates among children aged 0-14 years, an increased focus on HIV testing among children seeking care in pediatric inpatient wards, through family index testing, and perhaps TB clinics is appropriate.

Emotional violence in childhood and health conditions, risk-taking behaviors, and violence perpetration among young adults in Nigeria.

BACKGROUND: Globally, over 1 billion children are victims of violence against children annually. Studies examining the health consequences of childhood violence have mostly focused on childhood physical violence (PV) and sexual violence (SV). Recent evidence suggests that childhood emotional violence (EV) may also be deleterious to the health and wellbeing of victims. OBJECTIVE: This study examines the independent association between EV and some health conditions, risk taking behaviors, and violence perpetration among Nigerian young adults ages 18-24 years. PARTICIPANTS AND SETTING: Data from 2014 Nigeria Violence Against Children Survey (n = 4,203), a nationally representative cross-sectional survey of individuals ages 13-24 were used. METHODS: Childhood EV was defined as EV victimization before age 18 perpetrated by a parent, adult caregiver or other adult relative. Logistic regression analyses assessed the association between EV in childhood and mental distress in the past 30 days, ever self-harm behaviors and history of sexually transmitted infections; risk behaviors such as having multiple sex partners in the past 12 months; and ever violence perpetration. RESULTS: After controlling for study covariates, EV in childhood was associated with mental distress in both males and females, and self-harm behaviors in females; excessive alcohol use and infrequent condom use in males, and multiple sexual partners in females; and PV perpetration in males and SV perpetration in females. CONCLUSION: EV in childhood is associated with some health conditions, risk taking behaviors, and violence perpetration. Implementing programs that address all forms of violence in childhood, including EV may benefit children.

Perpetration of intimate partner violence and mental health outcomes: sex- and gender-disaggregated associations among adolescents and young adults in Nigeria.

BACKGROUND: The association between intimate partner violence (IPV) victimisation and poor mental health outcomes is well established. Less is known about the correlation between IPV perpetration and mental health, particularly among adolescents and young adults. Using data from the nationally representative Violence Against Children Survey, this analysis examines the association between IPV perpetration and mental health for male and female adolescents and young adults in Nigeria. METHODS: Multivariate logistic regression models were used to examine associations between ever-perpetration of IPV and four self-reported mental health variables: severe sadness, feelings of worthlessness, suicide ideation, and alcohol use. Models were sex-disaggregated, controlled for age, marital status, and schooling, and tested with and without past exposure to violence. Standard errors were adjusted for sampling stratification and clustering. Observations were weighted to be representative of 13-24 year-olds in Nigeria. RESULTS: Males were nearly twice as likely as females to perpetrate IPV (9% v. 5%, respectively; P < 0.001), while odds of perpetration for both sexes were higher for those ever experiencing IPV (adjusted odds ratio (aOR) = 4.60 for males; aOR = 2.71 for females). Female perpetrators had 2.73 higher odds of reporting severe sadness (95% confidence interval CI = 1.44, 5.17; P = 0.002) and 2.72 times greater odds of reporting suicide ideation (1.28, 5.79; P = 0.010) than non-perpetrating females, even when controlling for past-year violence victimisation. In contrast, male perpetrators had 2.65 times greater odds of feeling worthless (1.09, 6.43; P = 0.031), and 2.36 times greater odds of reporting alcohol use in the last 30 days (1.50, 3.73; P < 0.001), as compared to non-perpetrating males. CONCLUSIONS: Among adolescents and young adults in Nigeria, IPV perpetration and negative mental health outcomes are associated but differ for males and females. Mindful of the cross-sectional nature of the data, it is possible that socially determined gender norms may shape the ways in which distress from IPV perpetration is understood and expressed. Additional research is needed to clarify these associations and inform violence prevention efforts.

Coerced and forced sexual initiation and its association with negative health outcomes among youth: Results from the Nigeria, Uganda, and Zambia Violence Against Children Surveys.

INTRODUCTION: Coerced and forced sexual initiation (FSI) can have detrimental effects on children and youth. Understanding health outcomes that are associated with experiences of FSI is important for developing appropriate strategies for prevention and treatment of FSI and its consequences. METHODS: The Violence Against Children Surveys were conducted in Nigeria, Uganda, and Zambia in 2014 and 2015. We examined the prevalence of FSI and its consequences (sexual high-risk behaviors, violence experiences, mental health outcomes, and sexually transmitted infections (STI)) associated with FSI among youth aged 13-24 years in three countries in sub-Saharan Africa. RESULTS: Over one in ten youth aged 13-24 years who had ever had sex experienced FSI in Nigeria, Uganda, and Zambia. In multivariable logistic regression, FSI was significantly associated with infrequent condom use (OR = 1.4, 95%CI = 1.1-2.1), recent experiences of sexual violence (OR = 1.6, 95%CI: 1.1-2.3), physical violence (OR = 2.2, 95%CI: 1.6-3.0), and emotional violence (OR = 2.0, 95%CI: 1.3-2.9), moderate/serious mental distress (OR = 1.5, 95%CI: 1.1-2.0), hurting oneself (OR = 2.0, 95%CI: 1.3-3.1), and thoughts of suicide (OR = 1.5, 95%CI: 1.1-2.3), after controlling for demographic characteristics. FSI was not statistically associated with engaging in transactional sex, having multiple sex partners, or having a STI. CONCLUSION: FSI is associated with infrequent condom use, recent experiences of violence and mental health outcomes among youth in sub-Saharan Africa, which may increase the risk for HIV and other consequences. Developing strategies for prevention is important for reducing the prevalence of FSI and its effects on children and youth.

Evaluation of the clinical outcomes of the Test and Treat strategy to implement Treat All in Nigeria: Results from the Nigeria Multi-Center ART Study.

In December 2016, the Nigerian Federal Ministry of Health updated its HIV guidelines to a Treat All approach, expanding antiretroviral therapy (ART) eligibility to all individuals with HIV infection, regardless of CD4+ cell count, and recommending ART be initiated within two weeks of HIV diagnosis (i.e., the Test and Treat strategy). The Test and Treat policy was first piloted in 32 local government areas (LGAs). The primary objective of this study was to evaluate the clinical outcomes of adult patients initiated on ART within two weeks of HIV diagnosis during this pilot. We conducted a retrospective cohort analysis of patients who initiated ART within two weeks of new HIV diagnosis between October 2015 and September 2016 in eight randomly selected LGAs participating in the Test and Treat pilot study. 2,652 adults were newly diagnosed and initiated on ART within two weeks of HIV diagnosis. Of these patients, 8% had documentation of a 12-month viral load measurement, and 13% had documentation of a six-month viral load measurement. Among Test and Treat patients with a documented viral load, 79% were suppressed (≤400 copies/ml) at six months and 78% were suppressed at 12 months. By 12 months post-ART initiation, 34% of the patients who initiated ART under the Test and Treat strategy were lost to follow-up. The median CD4 cell count among patients initiating ART within two weeks of HIV diagnosis was 323 cells/mm3 (interquartile range, 161-518). While randomized controlled trials have demonstrated that Test and Treat strategies can improve patient retention and increase viral suppression compared to standard of care, these findings indicate that the effectiveness of Test and Treat in some settings may be far lower than the efficacy demonstrated in randomized controlled trials. Significant attention to the way Test and Treat strategies are implemented, monitored, and improved particularly related to early retention, can help expand access to ART for all patients.

Health Workers' Perspectives on the Outcomes, Enablers, and Barriers to the Implementation of HIV "Test and Treat" Guidelines in Abuja, Nigeria.

We evaluated health workers' perspectives on the implementation of the 2016 HIV "Test and Treat" guidelines in Nigeria. Using semi-structured interviews, qualitative data was collected from twenty health workers meeting inclusion criteria in six study sites. Data exploration was conducted using thematic content analysis. Participants perceived that the "Test and Treat" guidelines improved care for PLHIV, though they also perceived possible congested clinics. Perceived key factors enabling guidelines use were perceived patient benefits, availability of policy document and trainings. Perceived key barriers to guidelines use were poverty among patients, inadequate human resources and stock-outs of HIV testing kits. Further improvements in uptake of guidelines could be achieved by effecting an efficient supply chain system for HIV testing kits, and improved guidelines distribution and capacity building prior to implementation. Additionally, implementing differentiated approaches that decongest clinics, and programs that economically empower patients, could improve guidelines use, as Nigeria scales "Test and Treat" nationwide.

High rates of loss to follow-up during the first year of pre-antiretroviral therapy for HIV patients at sites providing pre-ART care in Nigeria, 2004-2012.

BACKGROUND: With about 3.4 million HIV-infected persons, Nigeria has the second highest number of people living with HIV (PLHIV) in the world. However, antiretroviral treatment (ART) coverage in Nigeria remains low with only 748,846 (22%) of PLHIV on ART by the end of 2014. Retention of HIV-infected patients in pre-ART care is essential to ensure timely ART initiation. We assessed outcomes of patients enrolled in Nigeria's pre-ART program during 2004-2012. METHODS: We conducted a nationally representative retrospective cohort study among adults (≥15 years old), enrolling in pre-ART programs supported by the U.S. President's Emergency Plan for AIDS Relief in Nigeria. A total of 35 sites enrolling ≥50 patients in pre-ART were selected using probability proportional-to-size sampling; 2,415 eligible medical records at these sites were randomly selected for abstraction. Determinants of loss to follow-up (LTFU) and mortality during pre-ART care were estimated using Cox proportional hazards regression models. RESULTS: The median age at enrollment was 32 years (interquartile range (IQR) 27-40). A total of 1,216 (51.4%) initiated ART by the time of data abstraction. Among the remaining 1,199 patients, 898 (74.9%) had been LTFU, 180 (15.0%) were alive and in pre-ART care, 71 (5.9%) had died, 50 (4.2%) had transferred out or stopped care. Baseline markers of advanced disease, including weight <45 kg (adjusted hazard ration (AHR) = 4.23; 95% confidence interval (CI): 1.51-15.58) and more advanced WHO disease stage, were predictive of pre-ART mortality. Compared with patients aged 15-24, patients aged 35-44 (AHR = 0.67; 95% CI: 1.0.47-0.95) and age 45-54 (AHR = 0.66; 95% CI: 0.48-0.91) had lower LTFU rates. Compared with attending facilities in North Central geopolitical zone, attending facility locations in South East (AHR = 0.44; 95% CI: 0.24-0.83) was protective against LTFU. CONCLUSIONS: About half of patients enrolling in HIV program during 2004-2012 in Nigeria had not initiated ART by 2013. Key strategies to improve early ART initiation among pre-ART enrollees include implementation of the WHO test and treat guidelines, earlier HIV testing, and better monitoring to improve ART initiation rates. Further research to understand regional variations in pre-ART outcomes is warranted.

Trends in Prevalence of Advanced HIV Disease at Antiretroviral Therapy Enrollment - 10 Countries, 2004-2015.

Monitoring prevalence of advanced human immunodeficiency virus (HIV) disease (i.e., CD4+ T-cell count <200 cells/µL) among persons starting antiretroviral therapy (ART) is important to understand ART program outcomes, inform HIV prevention strategy, and forecast need for adjunctive therapies.*,†,§ To assess trends in prevalence of advanced disease at ART initiation in 10 high-burden countries during 2004-2015, records of 694,138 ART enrollees aged ≥15 years from 797 ART facilities were analyzed. Availability of national electronic medical record systems allowed up-to-date evaluation of trends in Haiti (2004-2015), Mozambique (2004-2014), and Namibia (2004-2012), where prevalence of advanced disease at ART initiation declined from 75% to 34% (p<0.001), 73% to 37% (p<0.001), and 80% to 41% (p<0.001), respectively. Significant declines in prevalence of advanced disease during 2004-2011 were observed in Nigeria, Swaziland, Uganda, Vietnam, and Zimbabwe. The encouraging declines in prevalence of advanced disease at ART enrollment are likely due to scale-up of testing and treatment services and ART-eligibility guidelines encouraging earlier ART initiation. However, in 2015, approximately a third of new ART patients still initiated ART with advanced HIV disease. To reduce prevalence of advanced disease at ART initiation, adoption of World Health Organization (WHO)-recommended "treat-all" guidelines and strategies to facilitate earlier HIV testing and treatment are needed to reduce HIV-related mortality and HIV incidence.

Incidence and predictors of tuberculosis among HIV-infected adults after initiation of antiretroviral therapy in Nigeria, 2004-2012.

BACKGROUND: Nigeria had the most AIDS-related deaths worldwide in 2014 (170,000), and 46% were associated with tuberculosis (TB). Although treatment of people living with HIV (PLHIV) with antiretroviral therapy (ART) reduces TB-associated morbidity and mortality, incident TB can occur while on ART. We estimated incidence and characterized factors associated with TB after ART initiation in Nigeria. METHODS: We analyzed retrospective cohort data from a nationally representative sample of adult patients on ART. Data were abstracted from 3,496 patient records, and analyses were weighted and controlled for a complex survey design. We performed domain analyses on patients without documented TB disease and used a Cox proportional hazard model to assess factors associated with TB incidence after ART. RESULTS: At ART initiation, 3,350 patients (95.8%) were not receiving TB treatment. TB incidence after ART initiation was 0.57 per 100 person-years, and significantly higher for patients with CD4<50/µL (adjusted hazard ratio [AHR]: 4.2, 95% confidence interval [CI]: 1.4-12.7) compared with CD4≥200/µL. Patients with suspected but untreated TB at ART initiation and those with a history of prior TB were more likely to develop incident TB (AHR: 12.2, 95% CI: 4.5-33.5 and AHR: 17.6, 95% CI: 3.5-87.9, respectively). CONCLUSION: Incidence of TB among PLHIV after ART initiation was low, and predicted by advanced HIV, prior TB, and suspected but untreated TB. Study results suggest a need for improved TB screening and diagnosis, particularly among high-risk PLHIV initiating ART, and reinforce the benefit of early ART and other TB prevention efforts.

Correction: Outcomes of Nigeria's HIV/AIDS Treatment Program for Patients Initiated on Antiretroviral Treatment between 2004-2012.

[This corrects the article DOI: 10.1371/journal.pone.0165528.].