Predictors of Detectable Viremia, Outcomes, and Implications for Management of People Living With HIV Who Are Receiving Antiretroviral Therapy in Southern Nigeria.

Background: This study examined the prevalence and factors associated with detectable viremia, as well as clinical outcomes among people with HIV (PWH) receiving antiretroviral therapy (ART) who initially achieved viral suppression in 2 southern states in Nigeria. Methods: The retrospective cohort study used data from the electronic medical records of 96 comprehensive ART centers. PWH were followed up who achieved viral suppression (viral load [VL] ≤50 copies/mL) upon starting ART based on the first VL test. We examined the presence of detectable viremia in follow-up VL results, graded by the absolute VL count from the second and third consecutive VL tests as follows: transient viremia (second follow-up VL, 51-999 copies/mL; third, ≤50 copies/mL), persistent viremia (second follow-up VL, 51-999 copies/mL or ≥1000 copies/mL; third, >50 copies/mL), and virologic failure (second and third follow-up VL, >1000 copies/mL). We analyzed demographic and clinical factors associated with detectable viremia using logistic regression analysis on Stata 14. Results: Overall, 15 050 PWH had achieved viral suppression following ART initiation (median age, 34 years; 71.3% female). On follow-up, 3101 (20.6%) had a viremic event: 11.6%, transient viremia; 8.8%, persistent viremia; 0.2%, virologic failure. Shorter duration of ART (P < .001), being 0 to 14 years of age (P < .001), and not being enrolled in a differentiated service delivery model (P < .001) were significantly associated with detectable viremia. Conclusions: Our study shows that people who initially attain vial suppression upon starting ART remain at risk of detectable viremia.

Prevalence and correlates of depressive symptoms, and points of intervention, in rural central Uganda: results from a cross-sectional population-based survey of women and men.

OBJECTIVES: The present study aimed to identify the prevalence and correlates of depressive symptoms and potential intervention points among women and men from a population-based sample in rural central Uganda. DESIGN: A cross-sectional study. SETTING: Four districts in rural Uganda. PARTICIPANTS: Women and men aged 15-59 residing in four districts in rural Uganda accepting home-based HIV testing who completed a baseline survey at the time of testing. PRIMARY OUTCOME MEASURES: Depressive symptoms measured by the 10-item Center for Epidemiological Studies Depression Scale using a cut-off score of 13 for significant depressive symptoms. RESULTS: Among a sample of 9609 women and 6059 men, 1415 (14.7%) women and 727 (12.0%) men met criteria for significant depressive symptoms. Having ever received mental health services was associated with lower odds of significant depressive symptoms (women: adjusted OR (adjOR)=0.32, 95% CI=0.22 to 0.47; men: adjOR=0.36, 95% CI=0.18 to 0.62). Having received outpatient (women: adjOR=3.64, 95% CI=3.14 to 4.22; men: adjOR=3.37, 95% CI=2.78 to 4.07) or inpatient (women: adjOR=5.44, 95% CI=4.24 to 6.97; men: adjOR=3.42, 95% CI=2.21 to 5.28) care in the prior 6 months was associated with greater odds of significant depressive symptoms. For women only, known HIV positive status (adjOR=1.37, 95% CI=1.05 to 1.77), and for men only, alcohol misuse (adjOR=1.38, 95% CI=1.12 to 1.70), were associated with increased odds of significant depressive symptoms. CONCLUSION: Our findings suggest that depression screening within outpatient and inpatient settings may help to identify people in need of mental health services. Routine screening in outpatient or inpatient clinics along with the implementation of evidence-based interventions could ultimately help close the mental health gap for depression in this and similar settings.

Perceived HIV stigma and HIV testing among men and women in rural Uganda: a population-based study.

BACKGROUND: Stigma is a formidable social structural barrier to HIV testing, and yet the effect of stigma on HIV testing is rarely examined at the community level. We aimed to examine the geospatial relationships of perceived HIV stigma and HIV testing among men and women living in rural Uganda. METHODS: Women and men (aged ≥18 years or emancipated minor) residing in rural areas of Uganda who self-identified as HIV negative completed interviews that included measures of HIV testing history and how participants perceived HIV stigma. We used geospatial cluster analyses to identify areas of higher perceived stigma and lower perceived stigma and the geographical dispersion of these areas. We used Poisson regression models stratified by gender to test individual-level and community-level perceived stigma in relation to frequency of HIV testing in the previous 2 years. FINDINGS: Between Nov 25, 2015, and May 26, 2017, we interviewed 9740 participants (4359 [45%] men and 5381 [55%] women]), among whom 940 (9%) had never been tested for HIV, and among those who had been tested, 1131 (12%) had not been tested in the previous 2 years. Men (3134 [72%] of 4359) were less likely to have been tested in the past 2 years than women (4535 [84%] of 5381) were (p<0·001). We used Poisson regression models, reporting B coefficients, to test study hypotheses regarding the effects of individual-level and community-level stigma on HIV testing frequency counts. Multilevel modelling showed that women showed significant individual-level (B=-0·173, p<0·001) and community-level (B=-0·223, p<0·001) associations between lower stigma predicting higher rates of HIV testing. For men, lower individual-level perceived stigma was also associated with higher testing frequency (B=-0·030, p=0·018), whereas higher community-level perceived stigma was associated with higher testing frequency (B=0·077, p=0·008). INTERPRETATION: Our results suggest that perceived HIV stigma at the community level exerts a differential influence on testing for women and men. HIV testing campaigns that are targeted to men and women in rural Uganda will require gender tailoring to fit local contexts. FUNDING: US National Institute of Mental Health.

Sustained high HIV case-finding through index testing and partner notification services: experiences from three provinces in Zimbabwe.

INTRODUCTION: Several countries in southern Africa have made significant progress towards reaching the Joint United Nations Programme on HIV/AIDS goal of ensuring that 90% of people living with HIV are aware of their status. In Zimbabwe, progress towards this "first 90" was estimated at 73% in 2016. To reach the remaining people living with HIV who have undiagnosed infection, the Zimbabwe Ministry of Health and Child Care has been promoting index testing and partner notification services (PNS). We describe the implementation of index testing and PNS under the Zimbabwe HIV Care and Treatment (ZHCT) project and the resulting uptake, HIV positivity rate and links to HIV treatment. METHODS: The ZHCT project has been implemented since March 2016, covering a total of 12 districts in three provinces. To assess the project's performance on index testing, we extracted data on HIV testing from the district health information system (DHIS 2) from March 2016 to May 2018, validated it using service registers and calculated monthly HIV positivity rates using Microsoft Excel. Data were disaggregated by district, province, sex and service delivery point. We used SPSS to assess for statistical differences in paired monthly HIV positivity rates by sex, testing site, and province. RESULTS: The average HIV positivity rate rose from 10% during the first six months of implementation to more than 30% by August 2016 and was sustained above 30% through May 2018. The overall facility HIV positivity rate was 4.1% during the same period. The high HIV positivity rate was achieved for both males and females (mean monthly HIV positivity rate of 31.3% for males and 33.7% for females), with females showing significantly higher positivity compared to males (p < 0.001). The ZHCT mean monthly HIV positivity rate from index testing (32.6%) was significantly higher than that achieved through provider-initiated testing and counselling and other facility HIV testing modalities (4.1%, p < 0.001). CONCLUSIONS: The ZHCT project has demonstrated successes in implementing index testing and PNS by attaining a high HIV positivity rate sustained over the study period. As the country moves towards HIV epidemic control, index testing and PNS are critical strategies for targeted HIV case identification.

Efficacy of an enhanced linkage to HIV care intervention at improving linkage to HIV care and achieving viral suppression following home-based HIV testing in rural Uganda: study protocol for the Ekkubo/PATH cluster randomized controlled trial.

BACKGROUND: Though home-based human immunodeficiency virus (HIV) counseling and testing (HBHCT) is implemented in many sub-Saharan African countries as part of their HIV programs, linkage to HIV care remains a challenge. The purpose of this study is to test an intervention to enhance linkage to HIV care and improve HIV viral suppression among individuals testing HIV positive during HBHCT in rural Uganda. METHODS: The PATH (Providing Access To HIV Care)/Ekkubo Study is a cluster-randomized controlled trial which compares the efficacy of an enhanced linkage to HIV care intervention vs. standard-of-care (paper-based referrals) at achieving individual and population-level HIV viral suppression, and intermediate outcomes of linkage to care, receipt of opportunistic infection prophylaxis, and antiretroviral therapy initiation following HBHCT. Approximately 600 men and women aged 18-59 who test HIV positive during district-wide HBHCT in rural Uganda will be enrolled in this study. Villages (clusters) are pair matched by population size and then randomly assigned to the intervention or standard-of-care arm. Study teams visit households and participants complete a baseline questionnaire, receive HIV counseling and testing, and have blood drawn for HIV viral load and CD4 testing. At baseline, standard-of-care arm participants receive referrals to HIV care including a paper-based referral and then receive their CD4 results via home visit 2 weeks later. Intervention arm participants receive an intervention counseling session at baseline, up to three follow-up counseling sessions at home, and a booster session at the HIV clinic if they present for care. These sessions each last approximately 30 min and consist of counseling to help clients: identify and reduce barriers to HIV care engagement, disclose their HIV status, identify a treatment supporter, and overcome HIV-related stigma through links to social support resources in the community. Participants in both arms complete interviewer-administered questionnaires at six and 12 months follow-up, HIV viral load and CD4 testing at 12 months follow-up, and allow access to their medical records. DISCUSSION: The findings of this study can inform the integration of a potentially cost-effective approach to improving rates of linkage to care and HIV viral suppression in HBHCT. If effective, this intervention can improve treatment outcomes, reduce mortality, and through its effect on individual and population-level HIV viral load, and decrease HIV incidence. TRIAL REGISTRATION: NCT02545673.

The Effect of Motivational Interviewing-Based Counseling During Outpatient Provider Initiated HIV Testing on High-Risk Sexual Behavior in Rural Uganda.

Provider-initiated HIV testing and counseling (PITC) has rapidly expanded in many countries including Uganda. However, because it provides HIV prevention information without individualized risk assessment and risk reduction counseling it may create missed opportunities for effective HIV prevention counseling. Our objective was to assess the effect of a brief motivational interviewing-based intervention during outpatient PITC in rural Uganda compared to Uganda's standard-of-care PITC at reducing HIV transmission-relevant sexual risk behavior. We enrolled 333 (160 control, 173 intervention) participants in a historical control trial to test the intervention vs. standard-of-care. Participants received PITC and standard-of-care or the intervention counseling and we assessed sexual risk behavior at baseline and 3 and 6 months follow-up. The intervention condition showed 1.5-2.4 times greater decreases in high risk sexual behavior over time compared to standard-of-care (p = 0.015 and p = 0.004). These data suggest that motivational interviewing based counseling during PITC may be a promising intervention to reduce high-risk sexual behavior and potentially reduce risk of HIV infection.

The impact of social services interventions in developing countries: a review of the evidence of impact on clinical outcomes in people living with HIV.

BACKGROUND: Social service interventions have been implemented in many countries to help people living with HIV (PLHIV) and household members cope with economic burden as a result of reduced earning or increased spending on health care. However, the evidence for specific interventions-economic strengthening and legal services-on key health outcomes has not been appraised. METHODS: We searched electronic databases from January 1995 to May 2014 and reviewed relevant literature from resource-limited settings on the impact of social service interventions on mortality, morbidity, retention in HIV care, quality of life, and ongoing HIV transmission and their cost-effectiveness. RESULTS: Of 1685 citations, 8 articles reported the health impact of economic strengthening interventions among PLHIV in resource-limited settings. None reported on legal services. Six of the 8 studies were conducted in sub-Saharan Africa: 1 reported on all 5 outcomes and 2 reported on 4 and 2 outcomes, respectively. The remaining 5 reported on 1 outcome each. Seven studies reported on quality of life. Although all studies reported some association between economic strengthening interventions and HIV care outcomes, the quality of evidence was rated fair or poor because studies were of low research rigor (observational or qualitative), had small sample size, or had other limitations. The expected impact of economic strengthening interventions was rated as high for quality of life but uncertain for all the other outcomes. CONCLUSIONS: Implementation of economic strengthening interventions is expected to have a high impact on the quality of life for PLHIV but uncertain impact on mortality, morbidity, retention in care, and HIV transmission. More rigorous research is needed to explore the impact of more targeted intervention components on health outcomes.

Impact of support groups for people living with HIV on clinical outcomes: a systematic review of the literature.

BACKGROUND: Support groups for people living with HIV are integrated into HIV care and treatment programs as a modality for increasing patient literacy and as an intervention to address the psychosocial needs of patients. However, the impact of support groups on key health outcomes has not been fully determined. METHODS: We searched electronic databases from January 1995 through May 2014 and reviewed relevant literature on the impact of support groups on mortality, morbidity, retention in HIV care, quality of life (QOL), and ongoing HIV transmission, as well as their cost-effectiveness. RESULTS: Of 1809 citations identified, 20 met the inclusion criteria. One reported on mortality, 7 on morbidity, 5 on retention in care, 7 on QOL, and 7 on ongoing HIV transmission. Eighteen (90%) of the articles reported largely positive results on the impact of support group interventions on key outcomes. Support groups were associated with reduced mortality and morbidity, increased retention in care, and improved QOL. Because of study limitations, the overall quality of evidence was rated as fair for mortality, morbidity, retention in care, and QOL, and poor for HIV transmission. CONCLUSIONS: Implementing support groups as an intervention is expected to have a high impact on morbidity and retention in care and a moderate impact on mortality and QOL of people living with HIV. Support groups improve disclosure with potential prevention benefits but the impact on ongoing transmission is uncertain. It is unclear whether this intervention is cost-effective given the paucity of studies in this area.

Barriers to and acceptability of provider-initiated HIV testing and counselling and adopting HIV-prevention behaviours in rural Uganda: a qualitative study.

In Uganda, a nationwide scale-up of provider-initiated HIV testing and counselling presents an opportunity to deliver HIV-prevention services to large numbers of people. In a rural Ugandan hospital, focus group discussions and key informant interviews were conducted with outpatients receiving provider-initiated HIV testing and counselling and staff to explore the HIV-prevention information, motivation and behavioural skills strengths and weaknesses, and community-level and structural barriers to provider-initiated HIV testing and counselling acceptability and HIV prevention among this population. Strengths and weakness occurred at all levels, and results suggest brief client-centred interventions during provider-initiated HIV testing and counselling may be an effective approach to increase prevention behaviours in outpatient settings.

Predictors of survival after a diagnosis of non-Hodgkin lymphoma in a resource-limited setting: a retrospective study on the impact of HIV infection and its treatment.

OBJECTIVE: We examined factors associated with survival among patients with newly diagnosed non-Hodgkin lymphoma (NHL) in Uganda. METHODS: Information was abstracted from medical records for all NHL patients >13 years of age at the Uganda Cancer Institute between January 2004 and August 2008. Cox proportional hazard models were used to identify predictors of NHL survival. RESULTS: One hundred sixty patients with NHL were identified; 51 (31.9%) were known to be HIV positive. Overall, 154 patients had records sufficient for further analysis. The median person-time observed was 104 days (interquartile range 26-222). Median survival after presentation among those whose mortality status was confirmed was 61 days (interquartile range 25-203). HIV-positive patients receiving antiretroviral therapy had survival rates approximating those of HIV-negative persons, but the adjusted hazard of death was significantly elevated among HIV-positive patients not receiving antiretroviral therapy [adjusted hazard ratio (HR) 8.99, P < 0.001] compared with HIV-negative patients. Both B-symptoms (HR 2.08, P = 0.05) and female gender (HR 1.72, P = 0.05) were associated with higher mortality. CONCLUSIONS: In Uganda, overall survival of NHL patients is poor, and predictors of survival differed from those described in resource-rich regions. HIV is a common comorbidity to NHL, and its lack of treatment was among the strongest predictors of mortality. Strategies are needed for optimal management of HIV-infected individuals with cancer in resource-limited settings.

A telemedicine service for HIV/AIDS physicians working in developing countries.

In 2003, the Institute of Tropical Medicine (ITM) in Antwerp set up an Internet-based decision support service to assist health-care workers in the management of difficult HIV/AIDS cases. This service is available to physicians working in resource-limited settings. Between April 2003 and December 2009, the telemedicine service received 1058 queries, from more than 40 countries, mostly resource-constrained. In the first six years there were 952 queries, of which 459 (49%) were posted on the web-based telemedicine discussion forum and the rest sent by email. All queries were handled by a co-ordinator who forwarded them to a network of specialists, based at the ITM and at other institutions. The average time to provide a first reply was 24 hours. Almost half of the queries received in the first six years (n = 466) were related to the use of antiretroviral medications. The response rate to a user questionnaire was 19% (73 questionnaires returned out of 387 delivered): half of those (n = 37) came from active users and the remainder (n = 36) from clinicians who had never used the system. The user survey showed that telemedicine advice was valuable in the management of specific cases, and significantly influenced the way that clinicians managed other similar cases subsequently. Nonetheless, there was a declining trend in the rate of use of the service.