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1.
AIDS Behav ; 2020 Jan 18.
Artigo em Inglês | MEDLINE | ID: mdl-31955361

RESUMO

Few studies have sought to understand factors influencing uptake and continuation of pre-exposure prophylaxis (PrEP) among young adults in sub-Saharan Africa in the context of population-based delivery of open-label PrEP. To address this gap, this qualitative study was implemented within the SEARCH study (NCT#01864603) in Kenya and Uganda, which achieved near-universal HIV testing, and offered PrEP in 16 intervention communities beginning in 2016-2017. Focus group discussions (8 groups, n = 88 participants) and in-depth interviews (n = 23) with young adults who initiated or declined PrEP were conducted in five communities, to explore PrEP-related beliefs and attitudes, HIV risk perceptions, motivations for uptake and continuation, and experiences. Grounded theoretical methods were used to analyze data. Young people felt personally vulnerable to HIV, but perceived the severity of HIV to be low, due to the success of antiretroviral therapy (ART): daily pill-taking was more threatening than the disease itself. Motivations for PrEP were highly gendered: young men viewed PrEP as a vehicle for safely pursuing multiple partners, while young women saw PrEP as a means to control risks in the context of engagement in transactional sex and limited agency to negotiate condom use and partner testing. Rumors, HIV/ART-related stigma, and desire for "proof" of efficacy militated against uptake, and many women required partners' permission to take PrEP. Uptake was motivated by high perceived HIV risk, and beliefs that PrEP use supported life goals. PrEP was often discontinued due to dissolution of partnerships/changing risk, unsupportive partners/peers, or early side effects/pill burden. Despite high perceived risks and interest, PrEP was received with moral ambivalence because of its associations with HIV/ART and stigmatized behaviors. Delivery models that promote youth access, frame messaging on wellness and goals, and foster partner and peer support, may facilitate uptake among young people.

2.
PLoS One ; 15(1): e0228102, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31995631

RESUMO

BACKGROUND: The age-specific epidemiology of child and adolescent tuberculosis (TB) is poorly understood, especially in rural areas of East Africa. We sought to characterize the age-specific prevalence and predictors of TB infection among children and adolescents living in rural Uganda, and to explore the contribution of household TB exposure on TB infection. METHODS: From 2015-2016 we placed and read 3,121 tuberculin skin tests (TST) in children (5-11 years old) and adolescents (12-19 years old) participating in a nested household survey in 9 rural Eastern Ugandan communities. TB infection was defined as a positive TST (induration ≥10mm or ≥5mm if living with HIV). Age-specific prevalence was estimated using inverse probability weighting to adjust for incomplete measurement. Generalized estimating equations were used to assess the association between TB infection and multi-level predictors. RESULTS: The adjusted prevalence of TB infection was 8.5% (95%CI: 6.9-10.4) in children and 16.7% (95% CI:14.0-19.7) in adolescents. Nine percent of children and adolescents with a prevalent TB infection had a household TB contact. Among children, having a household TB contact was strongly associated with TB infection (aOR 5.5, 95% CI: 1.7-16.9), but the strength of this association declined among adolescents and did not meet significance (aOR 2.3, 95% CI: 0.8-7.0). The population attributable faction of TB infection due to a household TB contact was 8% for children and 4% among adolescents. Mobile children and adolescents who travel outside of their community for school had a 1.7 (95% CI 1.0-2.9) fold higher odds of TB infection than those who attended school in the community. CONCLUSION: Children and adolescents in this area of rural eastern Uganda suffer a significant burden of TB. The majority of TB infections are not explained by a known household TB contact. Our findings underscore the need for community-based TB prevention interventions, especially among mobile youth.

3.
AIDS ; 34(2): 311-315, 2020 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-31634186

RESUMO

BACKGROUND: Intensified viral load monitoring for pregnant and breastfeeding women has been proposed to help address concerns around antiretroviral therapy (ART) adherence, viraemia and transmission risk, but there have been no systematic evaluations of existing policies. METHODS: We used an individual Monte Carlo simulation to describe longitudinal ART adherence and viral load from conception until 2 years' postpartum. We applied national and international guidelines for viral load monitoring to the simulated data. We compared guidelines on the percentage of women receiving viral load monitoring and the percentage of women monitored at the time of elevated viral load. RESULTS: Coverage of viral load monitoring in pregnancy and breastfeeding varied markedly, with between 14% and 100% of women monitored antenatally and 38-98% monitored during breastfeeding. Specific recommendations for testing at either a fixed gestation or a short, fixed period after ART initiation achieved more than 95% testing in pregnancy but this was much lower (14-83%) among guidelines with no special stipulations. By the end of breastfeeding, only a small proportion of simulated episodes of elevated viral load more than 1000 copies/ml were successfully detected by monitoring (range, 20-50%). DISCUSSION: Although further research is needed to understand optimal viral load frequency and timing in this population, these results suggest that current policies yield suboptimal detection of elevated viral load in pregnant and breastfeeding women.

4.
AIDS ; 34(3): 405-413, 2020 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-31725431

RESUMO

OBJECTIVE: To assess the impact of alcohol use on HIV care cascade outcomes. DESIGN: Cross-sectional analyses. METHODS: We evaluated HIV care cascade outcomes and alcohol use in adults (≥15 years) during baseline (2013--2014) population-based HIV testing in 28 Kenyan and Ugandan communities. 'Alcohol use' included any current use and was stratified by Alcohol Use Disorders Identification Test-Concise (AUDIT-C) scores: nonhazardous/low (1--3 men/1--2 women), hazardous/medium (4--5 men/3--5 women), hazardous/high (6--7), hazardous/very-high (8--12). We estimated cascade outcomes and relative risks associated with each drinking level using targeted maximum likelihood estimation, adjusting for confounding and missing measures. RESULTS: Among 118 923 adults, 10 268 (9%) tested HIV-positive. Of those, 10 067 (98%) completed alcohol screening: 1626 (16%) reported drinking, representing 7% of women (467/6499) and 33% of men (1 159/3568). Drinking levels were: low (48%), medium (34%), high (11%), very high (7%). Drinkers were less likely to be previously HIV diagnosed (58% [95% CI: 55--61%]) than nondrinkers [66% (95% CI: 65-67%); RR: 0.87 (95% CI: 0.83-0.92)]. If previously diagnosed, drinkers were less likely to be on ART [77% (95% CI: 73-80%)] than nondrinkers [83% (95% CI 82-84%); RR: 0.93 (95% CI: 0.89-0.97)]. If on ART, there was no association between alcohol use and viral suppression; however, very-high-level users were less likely to be suppressed [RR: 0.80 (95% CI: 0.68-0.94)] versus nondrinkers. On a population level, viral suppression was 38% (95% CI: 36-41%) among drinkers and 44% (95% CI: 43-45%) among nondrinkers [RR: 0.87 (95% CI 0.82-0.94)], an association seen at all drinking levels. CONCLUSION: Alcohol use was associated with lower viral suppression; this may be because of decreased HIV diagnosis and ART use.

5.
J Acquir Immune Defic Syndr ; 83(1): 9-15, 2020 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-31809357

RESUMO

BACKGROUND: HIV-infected youth in sub-Saharan Africa are less likely to initiate antiretroviral therapy (ART) than older adults. SETTING AND METHODS: Adult (≥15 years) residents enumerated during a census in 32 communities in rural Kenya and Uganda named social contacts in 5 domains: health, money, emotional support, food, and free time. Named contacts were matched to other enumerated residents to build social networks among 150,395 adults; 90% were tested for HIV at baseline. Among youth (15-24 years) who were ART naive at baseline (2013-2014), we evaluated whether having ≥1 network contact who was HIV infected predicted ART initiation within 3 years and modification of this association by age and strength of contact, using logistic regression with robust standard errors. RESULTS: Among 1120 HIV-infected youth who were ART naive at baseline, 805 remained alive and community residents after 3 years. Of these, 270 (33.5%) named at least one baseline HIV-infected contact; 70% (569/805) subsequently initiated ART. Youth with ≥1 HIV-infected same-age baseline contact were more likely to initiate ART [adjusted odds ratio (aOR), 2.95; 95% confidence interval (CI): 1.49 to 5.86] than those with no HIV-infected contact, particularly if the contact was a strong tie (named in >1 domain; aOR, 5.33; 95% CI: 3.34 to 8.52). When nonhousehold contacts were excluded, having an HIV-infected same age contact who was a strong tie remained associated with ART initiation (aOR, 2.81; 95% CI: 1.76 to 4.49). CONCLUSIONS: Interventions that increase and strengthen existing social connections to other HIV-infected peers at the time of HIV diagnosis may increase ART initiation among HIV-infected youth.

6.
AIDS Care ; 32(1): 119-127, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31181961

RESUMO

Rates of Isoniazid Preventive Therapy (IPT) completion remain low in programmatic settings in sub-Saharan Africa. Differentiated HIV care models may improve IPT completion by addressing joint barriers to IPT and HIV treatment. However, the impact of differentiated care on IPT completion remains unknown. In a cross-sectional study of people with HIV on antiretroviral therapy in 5 communities in rural Uganda, we compared IPT completion between patients receiving HIV care via a differentiated care model versus a standard HIV care model and assessed multi-level predictors of IPT completion. A total of 103/144 (72%) patients received differentiated care and 85/161 (53%) received standard care completed IPT (p < 0.01). Adjusting for age, gender and community, patients receiving differentiated care had higher odds of completing IPT (aOR: 2.6, 95% CI: 1.5-4.5, p < 0.01). Predictors of IPT completion varied by the care model, and differentiated care modified the positive association between treatment completion and the belief in the efficacy of IPT and the negative association with side-effects. Patients receiving a multi-component differentiated care model had a higher odds of IPT completion than standard care, and the model's impact on health beliefs, social support, and perceived side effects to IPT may underlie this positive association.

7.
J Acquir Immune Defic Syndr ; 82 Suppl 3: S176-S182, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31764252

RESUMO

BACKGROUND: Building on several decades of innovative HIV prevention and treatment programming in San Francisco, in 2014, a small group of academic, civic, and community leaders launched Getting to Zero San Francisco, a city-wide consortium focused on getting to zero HIV infections, zero HIV-related deaths, and zero HIV stigma and discrimination. SETTING: San Francisco city and county. METHODS: The consortium operates under the principles of collective impact composed of 5 components: a common agenda, shared measurement, mutually reinforcing activities, continuous communication, and organization backbone. Two flagship initiatives are described: citywide scale-up of pre-exposure prophylaxis and rapid antiretroviral therapy upon diagnosis. RESULTS: The number of new HIV diagnoses declined by over 50% from 399 to 197 from 2013 to 2018; the time from diagnosis to viral suppression decreased from 134 to 62 days during that period. However, continued racial/ethnic disparities in new HIV diagnoses and viral suppression rates point to the need for the Getting to Zero San Francisco committees to focus on racial/ethnic equity as a primary focus. Cisgender and transgender women, people who inject drugs, and people who are homeless also have lower viral suppression rates; ongoing initiatives are attempting to address these disparities. CONCLUSION: A collective impact implementation strategy that operates by unifying municipal organizations toward a common goal was associated with citywide gains in reducing new HIV diagnosis and time to viral suppression in San Francisco. Formal evaluation of this strategy will help elucidate under which conditions this approach is most likely to succeed.

8.
Clin Infect Dis ; 2019 Nov 07.
Artigo em Inglês | MEDLINE | ID: mdl-31697383

RESUMO

BACKGROUND: In generalized epidemic settings, strategies are needed to prioritize individuals at higher risk of HIV acquisition for prevention services such as pre-exposure prophylaxis. We used population-level HIV testing data from rural Kenya and Uganda to construct HIV risk scores and assessed their ability to identify seroconversions. METHODS: Between 2013-2017, >75% of residents in 16 communities in the SEARCH Study tested annually for HIV. In this population, we evaluated three strategies for using demographic factors to predict the one-year risk of HIV seroconversion: (1) membership in ≥1 known "Risk Group" (e.g., young woman or HIV-infected spouse); (2) a "Model-based" risk score constructed with logistic regression; (3) a "Machine Learning" risk score constructed with the Super Learner algorithm. We hypothesized Machine Learning would identify high-risk individuals more efficiently (fewer persons targeted for a fixed sensitivity) and with higher sensitivity (for a fixed number of persons targeted) than either other approach. RESULTS: 75,558 HIV-negative persons contributed 166,723 person-years of follow-up; 519 seroconverted. Machine Learning improved efficiency; to achieve a fixed sensitivity of 50%, the Risk Group strategy targeted 42% of the population, Model-based 27%, and Machine Learning 18%. Machine Learning also improved sensitivity; with an upper limit of 45% targeted, the Risk Group strategy correctly classified 58% of seroconversions, Model-based 68%, and Machine Learning 78%. CONCLUSIONS: Machine learning improved classification of individuals at risk of HIV acquisition compared to a model-based approach or reliance on known risk groups, and could inform targeting of prevention strategies in generalized epidemic settings.

9.
Curr Opin HIV AIDS ; 2019 Sep 25.
Artigo em Inglês | MEDLINE | ID: mdl-31584888

RESUMO

PURPOSE OF REVIEW: There is an urgent need to understand new population-level approaches that achieve high levels of treatment and viral suppression for persons living with HIV. RECENT FINDINGS: The SEARCH Universal test and treat (UTT) trial conducted in Kenya and Uganda aimed to reduce HIV incidence and improve community health. SEARCH offered HIV and multidisease testing at health fairs followed by home testing for nonparticipants in 32 communities, each with approximately 10 000 persons. In the 16 intervention communities, UNAIDS 90-90-90 targets were achieved within 3 years, reaching '92-95-90' and 79% population-level viral suppression. HIV incidence declined by 32% between year 1 and 3 of follow-up. Key principles of SEARCH's approach included community engagement, integration of HIV with multidisease services, rapid ART start upon HIV diagnosis, and patient-centered, streamlined care. SEARCH's community health approach also reduced HIV mortality, annual TB incidence, and uncontrolled hypertension compared with a country standard of care. Population-level viral suppression increased beyond the UNAIDS 73% target in women and men and reached levels well above recent country estimates across much of sub-Saharan Africa. SUMMARY: SEARCH provides one example of how to rapidly surpass UNAIDS 90-90-90 targets while addressing community health on the path to HIV epidemic control.

10.
Curr Opin HIV AIDS ; 14(6): 449-454, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31589172

RESUMO

PURPOSE OF REVIEW: There is an urgent need to understand new population-level approaches that achieve high levels of treatment and viral suppression for persons living with HIV. RECENT FINDINGS: The SEARCH Universal test and treat (UTT) trial conducted in Kenya and Uganda aimed to reduce HIV incidence and improve community health. SEARCH offered HIV and multidisease testing at health fairs followed by home testing for nonparticipants in 32 communities, each with approximately 10 000 persons. In the 16 intervention communities, UNAIDS 90-90-90 targets were achieved within 3 years, reaching '92-95-90' and 79% population-level viral suppression. HIV incidence declined by 32% between year 1 and 3 of follow-up. Key principles of SEARCH's approach included community engagement, integration of HIV with multidisease services, rapid ART start upon HIV diagnosis, and patient-centered, streamlined care. SEARCH's community health approach also reduced HIV mortality, annual TB incidence, and uncontrolled hypertension compared with a country standard of care. Population-level viral suppression increased beyond the UNAIDS 73% target in women and men and reached levels well above recent country estimates across much of sub-Saharan Africa. SUMMARY: SEARCH provides one example of how to rapidly surpass UNAIDS 90-90-90 targets while addressing community health on the path to HIV epidemic control.

12.
13.
N Engl J Med ; 381(3): 219-229, 2019 07 18.
Artigo em Inglês | MEDLINE | ID: mdl-31314966

RESUMO

BACKGROUND: Universal antiretroviral therapy (ART) with annual population testing and a multidisease, patient-centered strategy could reduce new human immunodeficiency virus (HIV) infections and improve community health. METHODS: We randomly assigned 32 rural communities in Uganda and Kenya to baseline HIV and multidisease testing and national guideline-restricted ART (control group) or to baseline testing plus annual testing, eligibility for universal ART, and patient-centered care (intervention group). The primary end point was the cumulative incidence of HIV infection at 3 years. Secondary end points included viral suppression, death, tuberculosis, hypertension control, and the change in the annual incidence of HIV infection (which was evaluated in the intervention group only). RESULTS: A total of 150,395 persons were included in the analyses. Population-level viral suppression among 15,399 HIV-infected persons was 42% at baseline and was higher in the intervention group than in the control group at 3 years (79% vs. 68%; relative prevalence, 1.15; 95% confidence interval [CI], 1.11 to 1.20). The annual incidence of HIV infection in the intervention group decreased by 32% over 3 years (from 0.43 to 0.31 cases per 100 person-years; relative rate, 0.68; 95% CI, 0.56 to 0.84). However, the 3-year cumulative incidence (704 incident HIV infections) did not differ significantly between the intervention group and the control group (0.77% and 0.81%, respectively; relative risk, 0.95; 95% CI, 0.77 to 1.17). Among HIV-infected persons, the risk of death by year 3 was 3% in the intervention group and 4% in the control group (0.99 vs. 1.29 deaths per 100 person-years; relative risk, 0.77; 95% CI, 0.64 to 0.93). The risk of HIV-associated tuberculosis or death by year 3 among HIV-infected persons was 4% in the intervention group and 5% in the control group (1.19 vs. 1.50 events per 100 person-years; relative risk, 0.79; 95% CI, 0.67 to 0.94). At 3 years, 47% of adults with hypertension in the intervention group and 37% in the control group had hypertension control (relative prevalence, 1.26; 95% CI, 1.15 to 1.39). CONCLUSIONS: Universal HIV treatment did not result in a significantly lower incidence of HIV infection than standard care, probably owing to the availability of comprehensive baseline HIV testing and the rapid expansion of ART eligibility in the control group. (Funded by the National Institutes of Health and others; SEARCH ClinicalTrials.gov number, NCT01864603.).


Assuntos
Antirretrovirais/uso terapêutico , Serviços de Saúde Comunitária , Infecções por HIV/tratamento farmacológico , Administração Massiva de Medicamentos , Programas de Rastreamento , Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Infecções Oportunistas Relacionadas com a AIDS/epidemiologia , Adolescente , Adulto , Feminino , Infecções por HIV/diagnóstico , Infecções por HIV/epidemiologia , Infecções por HIV/mortalidade , Humanos , Incidência , Quênia/epidemiologia , Masculino , Pessoa de Meia-Idade , Assistência Centrada no Paciente , Prevalência , Fatores Socioeconômicos , Tuberculose/diagnóstico , Tuberculose/epidemiologia , Uganda/epidemiologia , Carga Viral , Adulto Jovem
14.
Lancet Infect Dis ; 19(9): 962-972, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31307883

RESUMO

BACKGROUND: Intermittent preventive treatment (IPT) of malaria with dihydroartemisinin-piperaquine is a promising strategy for malaria prevention in young African children. However, the optimal dosing strategy is unclear and conflicting evidence exists regarding the risk of malaria after cessation of chemoprevention. We aimed to compare two dosing strategies of IPT with dihydroartemisinin-piperaquine in young Ugandan children, and to evaluate the risk of malaria after cessation of IPT. METHODS: In this double-blind, randomised controlled phase 2 trial, women and their unborn children were recruited at Tororo District Hospital (Tororo, Uganda). Eligible participants were HIV-negative women aged 16 years or older with a viable pregnancy (gestational age 12-20 weeks). Women and their unborn children were randomly assigned (1:1:1:1) to one of four treatment groups, all receiving dihydroartemisinin-piperaquine, on the basis of the IPT intervention received by the woman during pregnancy: women every 8 weeks, children every 4 weeks; women every 4 weeks, children every 4 weeks; women every 8 weeks, children every 12 weeks; and women every 4 weeks, children every 12 weeks. Block randomisation was done by an independent investigator using a computer-generated randomisation list (permuted block sizes of six and 12). We analysed children on the basis of their random assignment to receive dihydroartemisinin-piperaquine (20 mg/160 mg tablets) once daily for 3 consecutive days every 4 weeks or 12 weeks. Children received study drugs from age 8 weeks to 24 months and were followed-up to age 36 months. Participants and investigators were masked to treatment allocation. The primary outcome was the incidence of symptomatic malaria during the intervention and following cessation of the intervention, adjusted for potential confounders. The primary outcome and safety were assessed in the modified intention-to-treat population, which included all children who reached 8 weeks of age and received at least one dose of study drug. This trial is registered with ClinicalTrials.gov, number NCT02163447. FINDINGS: Between Oct 21, 2014, and May 18, 2015, 191 children were born, of whom 183 reached 8 weeks of age and received at least one dose of study drug and thus were included in the primary analysis (96 children in the 4-week group and 87 in the 12-week group). During the intervention, the incidence of symptomatic malaria was significantly lower among children treated every 4 weeks than children treated every 12 weeks; three episodes occurred among children treated every 4 weeks (incidence 0·018 episodes per person-year) compared with 61 episodes among children treated every 12 weeks (incidence 0·39 episodes per person-year; adjusted incidence rate ratio [aIRR] 0·041, 95% CI 0·012-0·150, p<0·0001). After cessation of IPT, children who had previously received dihydroartemisinin-piperaquine every 4 weeks had a lower incidence of symptomatic malaria than children who were treated every 12 weeks; 62 episodes occurred among children previously treated every 4 weeks (incidence 0·73 episodes per person-year) compared with 83 episodes among children treated every 12 weeks (incidence 1·1 episodes per person-year; aIRR 0·62, 0·40-0·95, p=0·028). In the 4-week group, 94 (98%) of 96 children had adverse events versus 87 (100%) of 87 children in the 12-week group. The most commonly reported adverse event was cough in both treatment groups (94 [98%] in the 4-week group vs 87 [100%] in the 12-week group). 16 children had severe adverse events (seven [7%] children in the 4-week group vs nine [10%] children in the 12-week group). No severe adverse events were thought to be related to study drug administration. One death occurred during the intervention (age 8 weeks to 24 months), which was due to respiratory failure unrelated to malaria. INTERPRETATION: IPT with dihydroartemisinin-piperaquine given every 4 weeks was superior to treatment every 12 weeks for the prevention of malaria during childhood, and this protection was extended for up to 1 year after cessation of IPT. FUNDING: Eunice Kennedy Shriver National Institute of Child Health and Human Development.

15.
Health Place ; 57: 339-351, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-31152972

RESUMO

Mobility in sub-Saharan Africa links geographically-separate HIV epidemics, intensifies transmission by enabling higher-risk sexual behavior, and disrupts care. This population-based observational cohort study measured complex dimensions of mobility in rural Uganda and Kenya. Survey data were collected every 6 months beginning in 2016 from a random sample of 2308 adults in 12 communities across three regions, stratified by intervention arm, baseline residential stability and HIV status. Analyses were survey-weighted and stratified by sex, region, and HIV status. In this study, there were large differences in the forms and magnitude of mobility across regions, between men and women, and by HIV status. We found that adult migration varied widely by region, higher proportions of men than women migrated within the past one and five years, and men predominated across all but the most localized scales of migration: a higher proportion of women than men migrated within county of origin. Labor-related mobility was more common among men than women, while women were more likely to travel for non-labor reasons. Labor-related mobility was associated with HIV positive status for both men and women, adjusting for age and region, but the association was especially pronounced in women. The forms, drivers, and correlates of mobility in eastern Africa are complex and highly gendered. An in-depth understanding of mobility may help improve implementation and address gaps in the HIV prevention and care continua.

16.
17.
AIDS Behav ; 2019 May 09.
Artigo em Inglês | MEDLINE | ID: mdl-31073946

RESUMO

Few studies in sub-Saharan Africa have assessed men's knowledge about the likelihood of serodiscordance in couples with an HIV-positive partner and how this is affected by antiretroviral therapy (ART). Using a Likert scale and probabilistic scale, we elicited beliefs of 2532 rural Ugandan men about the likelihood of seroconcordance in married couples with an HIV-positive female partner who is either taking ART or not taking ART. Logistic regression analyses explored associations between beliefs and various health behaviors. Probabilistic scale responses were consistent with Likert scale responses. Seroconcordance was believed to be likely in the scenarios without ART and with ART, with mean seroconcordance likelihood of 8.1 and 6.6, respectively, on a scale of 0-10. The majority of participants (57%) believed the likelihood of seroconcordance was lower in the scenario with ART. The results suggest a need for enhanced education among men about serodiscordance in stable relationships and about the preventive effects of ART.

18.
Sci Rep ; 9(1): 6758, 2019 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-31043691

RESUMO

Women living with HIV (WLHIV) have an increased risk of malaria in pregnancy (MiP). It is unclear if MiP in WLHIV causes a systemic inflammatory response and increases the risk of adverse birth outcomes, especially for women receiving antiretroviral therapy (ART) and daily trimethoprim-sulfamethoxazole (TMP/SXT). We analyzed repeated plasma samples in a cohort of malaria-exposed Ugandan WLHIV receiving ART and daily TMP/SXT to examine changes in inflammatory markers across pregnancy and their association with birth outcomes. Concentrations of CHI3L1, CRP, IL-18BP, IL-6, sICAM-1, and sTNFR2 were quantified by ELISA in 1115 plasma samples collected over pregnancy from 326 women. MiP was associated with increased sTNFR2, sICAM-1 and IL-18BP concentrations across pregnancy. Women who delivered preterm had elevated concentrations of sTNFR2 and altered levels of IL-6 during pregnancy. Women with sTNFR2 concentrations in the highest quartile within 6 weeks of delivery had an increased relative risk of preterm birth. Our results indicate that despite daily TMP/SXT, MiP in WLHIV induced a systemic inflammatory response that was associated with an increased risk of preterm birth. These findings highlight the need for additional strategies to protect WLHIV from malaria infection in pregnancy to promote healthy outcomes for mother and child.

19.
J Int AIDS Soc ; 22(4): e25276, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-31037845

RESUMO

INTRODUCTION: Geographic and transportation barriers are associated with poorer HIV-related health outcomes in sub-Saharan Africa, but data on the impact of these barriers on prevention interventions are limited. We estimated the association between distance to clinic and other transportation-related barriers on pre-exposure prophylaxis (PrEP) uptake and initial clinic visit attendance in a rural community in southwestern Uganda enrolled in the ongoing SEARCH study (NCT01864603). METHODS: Community-wide HIV testing was conducted and offered to adult (≥15 years) participants in Ruhoko. Participants were eligible for PrEP based on an empiric risk score, having an HIV-discordant partner, or self-referral at either the community health campaign or during home-based testing from March to April 2017. We collected data from PrEP-eligible households on GPS-measured distance to clinic, walking time to clinic and road difficulty. A sample of participants was also asked to identify their primary barriers to PrEP use with a semi-quantitative questionnaire. We used multivariable logistic regression to evaluate the association between transportation barriers and (1) PrEP uptake among PrEP-eligible individuals and (2) four-week clinic visit attendance among PrEP initiators. RESULTS: Of the 701 PrEP-eligible participants, 272 (39%) started PrEP within four weeks; of these, 45 (17%) were retained at four weeks. Participants with a distance to clinic of ≥2 km were less likely to start PrEP (aOR 0.34; 95% CI 0.15 to 0.79, p = 0.012) and less likely to be retained on PrEP once initiated (aOR 0.29; 95% CI 0.10 to 0.84; p = 0.024). Participants who were deemed eligible during home-based testing and did not have the option of same-day PrEP start were also substantially less likely to initiate PrEP (aOR 0.16, 95% CI 0.07 to 0.37, p < 0.001). Of participants asked to name barriers to PrEP use (N = 98), the most frequently cited were "needing to take PrEP every day" (N = 18) and "low/no risk of getting HIV" (N = 18). Transportation-related barriers, including "clinic is too far away" (N = 6) and "travel away from home" (N = 4) were also reported. CONCLUSIONS: Distance to clinic is a significant predictor of PrEP uptake and four-week follow-up visit attendance in a community in rural Uganda. Interventions that address geographic and transportation barriers may improve PrEP uptake and retention in sub-Saharan Africa.

20.
BMC Public Health ; 19(1): 511, 2019 May 06.
Artigo em Inglês | MEDLINE | ID: mdl-31060545

RESUMO

BACKGROUND: There is an increasing burden of hypertension (HTN) across sub-Saharan Africa where HIV prevalence is the highest in the world, but current care models are inadequate to address the dual epidemics. HIV treatment infrastructure could be leveraged for the care of other chronic diseases, including HTN. However, little data exist on the effectiveness of integrated HIV and chronic disease care delivery systems on blood pressure control over time. METHODS: Population screening for HIV and HTN, among other diseases, was conducted in ten communities in rural Uganda as part of the SEARCH study (NCT01864603). Individuals with either HIV, HTN, or both were referred to an integrated chronic disease clinic. Based on Uganda treatment guidelines, follow-up visits were scheduled every 4 weeks when blood pressure was uncontrolled, and either every 3 months, or in the case of drug stock-outs more frequently, when blood pressure was controlled. We describe demographic and clinical variables among all patients and used multilevel mixed-effects logistic regression to evaluate predictors of HTN control. RESULTS: Following population screening (2013-2014) of 34,704 adults age ≥ 18 years, 4554 individuals with HTN alone or both HIV and HTN were referred to an integrated chronic disease clinic. Within 1 year 2038 participants with HTN linked to care and contributed 15,653 follow-up visits over 3 years. HTN was controlled at 15% of baseline visits and at 46% (95% CI: 44-48%) of post-baseline follow-up visits. Scheduled visit interval more frequent than clinical indication among patients with controlled HTN was associated with lower HTN control at the subsequent visit (aOR = 0.89; 95% CI 0.79-0.99). Hypertension control at follow-up visits was higher among HIV-infected patients than uninfected patients to have controlled blood pressure at follow-up visits (48% vs 46%; aOR 1.28; 95% CI 0.95-1.71). CONCLUSIONS: Improved HTN control was achieved in an integrated HIV and chronic care model. Similar to HIV care, visit frequency determined by drug supply chain rather than clinical indication is associated with worse HTN control. TRIAL REGISTRATION: The SEARCH Trial was prospectively registered with ClinicalTrials.gov : NCT01864603.


Assuntos
Prestação Integrada de Cuidados de Saúde , Hipertensão/prevenção & controle , Adulto , Idoso , Doença Crônica/terapia , Feminino , Infecções por HIV/terapia , Humanos , Hipertensão/epidemiologia , Masculino , Pessoa de Meia-Idade , População Rural/estatística & dados numéricos , Uganda/epidemiologia
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