Scaling-up PrEP Delivery in Sub-Saharan Africa: What Can We Learn from the Scale-up of ART?
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ABSTRACT:
SUBMITTER: O'Malley G
PROVIDER: S-EPMC6469867 | biostudies-literature | 2019 Apr
REPOSITORIES: biostudies-literature
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Scaling-up PrEP Delivery in Sub-Saharan Africa: What Can We Learn from the Scale-up of ART?
O'Malley Gabrielle G Barnabee Gena G Mugwanya Kenneth K
Current HIV/AIDS reports 20190401 2
<h4>Purpose of review</h4>Clinical trials have found that PrEP is highly effective in reducing risk of HIV acquisition across types of exposure, gender, PrEP regimens, and dosing schemes. Evidence is urgently needed to inform scale-up of PrEP to meet the ambitious WHO/UNAIDS prevention target of 3,000,000 individuals on PrEP by 2020.<h4>Recent findings</h4>Successful models of delivering HIV services at scale evolved from years of formal research and programmatic evidence. These efforts produced ...[more]
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Project description:IntroductionARV-based pre-exposure prophylaxis (PrEP) has the potential to avert many new HIV infections, yet little is known about how to reach women at high risk for HIV infection and motivate them to initiate PrEP. Clinical trials have succeeded in recruiting at-risk participants, evidenced by control arm HIV incidence ≥3% (defined by the World Health Organization as "substantial risk"). We examined experiences from HIV prevention trials to document recruitment strategies and identify practical, potentially effective strategies for reaching women in real-world PrEP delivery.MethodsWe conducted semi-structured qualitative phone interviews with 31 staff from five countries who had worked on one or more of seven ARV-based HIV prevention clinical trials. Questions explored recruitment strategies used to reach women at risk of HIV and to successfully communicate about PrEP (inclusive of oral and vaginal formulations). We structurally coded data in NVivo and analyzed codes to derive themes. We conducted results interpretation webinars with research and programmatic stakeholders to validate findings and develop recommendations.ResultsClinical trial researchers employed a range of recruitment strategies to recruit at-risk women. They recommended engaging the local community and potential PrEP users via community events, meetings with gatekeepers, and use of community advisory boards; and they encouraged interpersonal communication like presentations in waiting rooms and door-to-door recruitment to address personal concerns and prevent misinformation. Participants also stressed the importance of addressing the challenges that already exist within the health system to create a more enabling environment and delivering positive messages through a variety of communication channels to normalize PrEP.ConclusionsFindings from this study provide important insights into potentially effective ways for countries currently rolling out oral PrEP to reach at-risk women with information about PrEP and promote uptake.
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Project description:Purpose of reviewHIV self-testing (HIVST) can provide complementary coverage to existing HIV testing services and improve knowledge of status among HIV-infected individuals. This review summarizes the current technology, policy and evidence landscape in sub-Saharan Africa and priorities within a rapidly evolving field.Recent findingsHIVST is moving towards scaled implementation, with the release of WHO guidelines, WHO prequalification of the first HIVST product, price reductions of HIVST products and a growing product pipeline. Multicountry evidence from southern and eastern Africa confirms high feasibility, acceptability and accuracy across many delivery models and populations, with minimal harms. Evidence on the effectiveness of HIVST on increased testing coverage is strong, while evidence on demand generation for follow-on HIV prevention and treatment services and cost-effective delivery is emerging. Despite these developments, HIVST delivery remains limited outside of pilot implementation.SummaryImportant technology gaps include increasing availability of more sensitive HIVST products in low and middle-income countries. Regulatory and postmarket surveillance systems for HIVST also require further development. Randomized trials evaluating the effectiveness and cost-effectiveness under multiple distribution models, including unrestricted delivery and with a focus on linkage to HIV prevention and treatment, remain priorities. Diversification of studies from west and central Africa and around blood-based products should be addressed.
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Project description:BackgroundEvaluation of antiretroviral treatment (ART) programmes in sub-Saharan Africa is difficult because many patients are lost to follow-up. Outcomes in these patients are generally unknown but studies tracing patients have shown mortality to be high. We adjusted programme-level mortality in the first year of antiretroviral treatment (ART) for excess mortality in patients lost to follow-up.Methods and findingsTreatment-naïve patients starting combination ART in five programmes in Côte d'Ivoire, Kenya, Malawi and South Africa were eligible. Patients whose last visit was at least nine months before the closure of the database were considered lost to follow-up. We filled missing survival times in these patients by multiple imputation, using estimates of mortality from studies that traced patients lost to follow-up. Data were analyzed using Weibull models, adjusting for age, sex, ART regimen, CD4 cell count, clinical stage and treatment programme. A total of 15,915 HIV-infected patients (median CD4 cell count 110 cells/µL, median age 35 years, 68% female) were included; 1,001 (6.3%) were known to have died and 1,285 (14.3%) were lost to follow-up in the first year of ART. Crude estimates of mortality at one year ranged from 5.7% (95% CI 4.9-6.5%) to 10.9% (9.6-12.4%) across the five programmes. Estimated mortality hazard ratios comparing patients lost to follow-up with those remaining in care ranged from 6 to 23. Adjusted estimates based on these hazard ratios ranged from 10.2% (8.9-11.6%) to 16.9% (15.0-19.1%), with relative increases in mortality ranging from 27% to 73% across programmes.ConclusionsNaïve survival analysis ignoring excess mortality in patients lost to follow-up may greatly underestimate overall mortality, and bias ART programme evaluations. Adjusted mortality estimates can be obtained based on excess mortality rates in patients lost to follow-up.
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Project description:Konzo, a disease characterized by sudden, irreversible spastic paraparesis, affecting up to 10% of the population in some regions of Sub-Saharan Africa during outbreaks and is strongly associated with dietary exposure to cyanogenic bitter cassava. The molecular mechanisms underlying the development of konzo, remain largely unknown. Here, through an analysis of 16 individuals with konzo and matched healthy controls from the same outbreak zones, we identified 117 differentially methylated loci involved in numerous biological processes that may identify cyanogenic- sensitive regions of the genome, providing the first study of epigenomic alterations associated with sub-lethal cyanide exposure and a clinical phenotype.
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Project description:BackgroundInterventions based around objective measurement of adherence to antiretroviral drugs for HIV have potential to improve adherence and to enable differentiation of care such that clinical visits are reduced in those with high adherence. It would be useful to understand the approximate upper limit of cost that could be considered for such interventions of a given effectiveness in order to be cost effective. Such information can guide whether to implement an intervention in the light of a trial showing a certain effectiveness and cost.MethodsAn individual-based model, calibrated to Zimbabwe, which incorporates effects of adherence and resistance to antiretroviral therapy, was used to model the potential impact of adherence monitoring-based interventions on viral suppression, death rates, disability adjusted life years and costs. Potential component effects of the intervention were: enhanced average adherence when on ART, reduced risk of ART discontinuation, and reduced risk of resistance acquisition. We considered a situation in which viral load monitoring is not available and one in which it is. In the former case, it was assumed that care would be differentiated based on the adherence level, with fewer clinic visits in those demonstrated to have high adherence. In the latter case, care was assumed to be primarily differentiated according to viral load level. The maximum intervention cost required to be cost effective was calculated based on a cost effectiveness threshold of $500 per DALY averted.FindingsIn the absence of viral load monitoring, an adherence monitoring-based intervention which results in a durable 6% increase in the proportion of ART experienced people with viral load < 1000 cps/mL was cost effective if it cost up to $50 per person-year on ART, mainly driven by the cost savings of differentiation of care. In the presence of viral load monitoring availability, an intervention with a similar effect on viral load suppression was cost-effective when costing $23-$32 per year, depending on whether the adherence intervention is used to reduce the level of need for viral load measurement.ConclusionThe cost thresholds identified suggest that there is clear scope for adherence monitoring-based interventions to provide net population health gain, with potential cost-effective use in situations where viral load monitoring is or is not available. Our results guide the implementation of future adherence monitoring interventions found in randomized trials to have health benefit.
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Project description:This review aims at providing synthetic information with scientific evidence on the trends in the malaria events from 1960 to 2011, with the hope that it will help policy makers to take informed decisions on public health issues and intervention designs on malaria control towards elimination in both Sub-Sahara Africa and in the People's Republic of China by highlighting the achievements, progress and challenges in research on moving malaria from epidemic status towards elimination. Our findings showed that since 1960, malaria control programmes in most countries have been disjointed and not harmonized. Interestingly, during the last decade, the causal factors of the unprecedented and substantial decline in malaria morbidity and mortality rates in most vulnerable groups in these endemic areas are multifaceted, including not only the spread of malaria and its related effects but also political and financial willingness, commitment and funding by governments and international donors. The benefits of scaling up the impact of malaria coverage interventions, improvement of health system approaches and sustained commitment of stakeholders are highlighted, although considerable efforts are still necessary in Sub-Sahara Africa. Furthermore, novel integrated control strategies aiming at moving malaria from epidemic status to control towards elimination, require solid research priorities both for sustainability of the most efficient existing tools and intervention coverage, and in gaining more insights in the understanding of the epidemiology, pathogenesis, vector dynamics, and socioeconomic aspects of the disease. In conclusion, political commitment and financial investment of stakeholders in sustaining the scaling up impact of malaria control interventions, networking between African and Chinese scientists, and their Western partners are urgently needed in upholding the recent gains, and in translating lessons learnt from the Chinese malaria control achievements and successes into practical interventions in malaria endemic countries in Africa and elsewhere.
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Project description:BackgroundHome deliveries, where most births take place, are significantly responsible for the majority of maternal mortality. In order to develop appropriate policies and methods that could aid in addressing the issue, it is important to understand the scope of home delivery and its determinants in developing countries. Therefore, this study aims to ascertain the prevalence and factors associated with home delivery among women who had optimal ANC follow up in the Sub-Saharan Africa countries.MethodsA population based cross-sectional study was conducted. Data from the most recent Demographic and Health Surveys, which covered 23 Sub-Saharan Africa countries from 2014 to 2020, were used. The study used a total of 180,551 women who had optimal ANC follow up weighted sample. Stata 14 was used to analyze the data. The determinants of home delivery were determined using a multilevel mixed-effects logistic regression model. Factors associated with home delivery in the multilevel logistic regression model were declared significant at p-values <0.05. The adjusted odds ratio and confidence interval were used to interpret the results.ResultsIn Sub-Saharan Africa, three in ten (30%) women who had optimal ANC follow-up gave birth at home. Individual-level variables such as maternal age (20 to 35 years) (AOR = 1.27, 95% CI: 1.10, 1.46), no formal education (AOR = 3.10, 95% CI: 2.68, 3.59), pregnancy complications (AOR = 0.74, 95% CI: 0.67, 0.82), distance to a health facility (AOR = 1.43, 95% CI: 1.30, 1.58), and poor wealth status (AOR = 2.71, 95% CI: 2.37, 3.10) had higher odds of home delivery. Community-level variables such as rural residence (AOR = 2.83, 95% CI: 2.48, 3.22), living in central Sub-Saharan Africa (AOR = 7.95, 95% CI: 5.81, 10.9), and eastern Sub-Saharan Africa (AOR = 2.74, 95% CI: 2.09, 3.59), were significantly associated with home delivery.Conclusions and recommendationThis study concludes that home delivery in sub-Saharan Africa among women who had optimal ANC follow-up were high. The study identified that both individual and community-level variables were determinants of home delivery. Therefore, the Government and ministries of health in Sub-Saharan Africa countries should give attention to those women who reported distance as a big problem to health facilities and for rural resident women while designing policies and strategies targeting reducing home delivery in sub-Saharan Africa.
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