• Higher risk Sexual Behaviour is associated with Unawareness of HIV-positivity and lack of Viral Suppression - implications for Treatment as Prevention

      Huerga, H; Venables, E; Ben-Farhat, J; van Cutsem, G; Ellman, T; Kenyon, C (Nature Publishing Group, 2017-11-23)
      Efficacy of Treatment as Prevention Strategy depends on a variety of factors including individuals' likelihood to test and initiate treatment, viral load and sexual behaviour. We tested the hypothesis that people with higher risk sexual behaviour are less likely to know their HIV-positive status and be virologically suppressed. A cross-sectional population-based survey of individuals aged 15-59 years old was conducted in 2013 in KwaZulu-Natal, South Africa. A two-stage cluster probability sampling was used. After adjustment for age and sex, lack of awareness of HIV-positivity was strongly associated with having more than one sexual partner in the preceding year (aOR: 2.1, 95%CI: 1.5-3.1). Inconsistent condom use was more common in individuals with more than one sexual partner (aOR: 16.6, 95%CI: 7.6-36.7) and those unaware (aOR: 3.7, 95%CI: 2.6-5.4). Among people aware of their HIV-positivity, higher risk sexual behaviour was associated with lack of viral suppression (aOR: 2.2, 95%CI: 1.1-4.5). Risky sexual behaviour seems associated with factors linked to poor health-seeking behaviour which may have negative implications for HIV testing and Treatment as Prevention. Innovative strategies, driven by improved epidemiological and anthropological understanding, are needed to enable comprehensive approaches to HIV prevention.
    • Sustainable HIV Treatment in Africa Through Viral-Load-Informed Differentiated Care

      Phillips, A; Shroufi, A; Vojnov, L; Cohn, J; Roberts, T; Ellman, T; Bonner, K; Rousseau, C; Garnett, G; Cambiano, V; Nakagawa, F; Ford, D; Bansi-Matharu, L; Miners, A; Lundgren, JD; Eaton, JW; Parkes-Ratanshi, R; Katz, Z; Maman, D; Ford, N; Vitoria, M; Doherty, M; Dowdy, D; Nichols, B; Murtagh, M; Wareham, M; Palamountain, KM; Chakanyuka Musanhu, C; Stevens, W; Katzenstein, D; Ciaranello, A; Barnabas, R; Braithwaite, RS; Bendavid, E; Nathoo, KJ; van de Vijver, D; Wilson, DP; Holmes, C; Bershteyn, A; Walker, S; Raizes, E; Jani, I; Nelson, LJ; Peeling, R; Terris-Prestholt, F; Murungu, J; Mutasa-Apollo, T; Hallett, TB; Revill, P (Nature Publishing Group, 2015-12-03)
      There are inefficiencies in current approaches to monitoring patients on antiretroviral therapy in sub-Saharan Africa. Patients typically attend clinics every 1 to 3 months for clinical assessment. The clinic costs are comparable with the costs of the drugs themselves and CD4 counts are measured every 6 months, but patients are rarely switched to second-line therapies. To ensure sustainability of treatment programmes, a transition to more cost-effective delivery of antiretroviral therapy is needed. In contrast to the CD4 count, measurement of the level of HIV RNA in plasma (the viral load) provides a direct measure of the current treatment effect. Viral-load-informed differentiated care is a means of tailoring care so that those with suppressed viral load visit the clinic less frequently and attention is focussed on those with unsuppressed viral load to promote adherence and timely switching to a second-line regimen. The most feasible approach to measuring viral load in many countries is to collect dried blood spot samples for testing in regional laboratories; however, there have been concerns over the sensitivity and specificity of this approach to define treatment failure and the delay in returning results to the clinic. We use modelling to synthesize evidence and evaluate the cost-effectiveness of viral-load-informed differentiated care, accounting for limitations of dried blood sample testing. We find that viral-load-informed differentiated care using dried blood sample testing is cost-effective and is a recommended strategy for patient monitoring, although further empirical evidence as the approach is rolled out would be of value. We also explore the potential benefits of point-of-care viral load tests that may become available in the future.