Suchergebnisse

IntroductionLittle is known about people diagnosed as HIV‐positive who access HIV care early in their disease. In pre‐ART studies published to date, only a minority of the participants have CD4>500 cells/µl.MethodsThis cross‐sectional study compared individuals presenting for HIV care with CD4>500 cells/µl, "pre‐ART" (N=247), with individuals who had CD4<200 cells/µl or WHO Stage IV, "ART‐eligible" (N=385). Baseline characteristics were contrasted between the two groups and logistic regression models used to explore group differences in: (a) being sexually active in the last month; (b) disclosure of HIV status to current partner; (c) knowing the HIV status of one's current partner; and (d) condom use at last sex.ResultsPre‐ART and ART‐eligible individuals were similar in terms of a wide range of socio‐demographic characteristics. Controlling for gender, only current sexual behaviour and HIV‐testing history were significantly different between ART groups. In multivariable models, participants in the pre‐ART group were twice as likely to be sexually active in the last month, OR 2.06 95% CI (1.32, 3.21), and to know their partner's status, OR 1.95 (1.18, 3.22) compared to those in the ART‐eligible group. Self‐reported disclosure of HIV status to current sexual partner (71%), condom use at last sex (61%) and HIV concordancy within relationships were not significantly different between the two ART groups. Overall, 39% of the study participants reported knowing that they were in concordant HIV‐positive relationships. Fifty‐five percent of all participants reported not knowing their partner's HIV status, only half of whom reported using a condom at last sex. Pre‐ART individuals were significantly less likely to have tested HIV‐positive for the first time in the last year and to have tested for sickness‐related reasons than the ART‐eligible group.ConclusionsReported sexual risk behaviours by pre‐ART individuals with CD4>500 cells/µl suggest a continued risk of onward HIV transmission. There is a need for positive prevention efforts to target this group given that current treatment guidelines do not provide them with ART. Strengthening support regarding disclosure, partner HIV testing and consistent condom use, and further promotion of HIV testing in the community to assist earlier diagnosis are urgently required.

The scale-up of antiretroviral therapy (ART) is expected to raise adult life expectancy in populations with high HIV prevalence. Using data from a population cohort of over 101,000 individuals in rural KwaZulu-Natal, South Africa, we measured changes in adult life expectancy for 2000–2011. In 2003, the year before ART became available in the public sector health system, adult life expectancy was 49.2 years; by 2011, adult life expectancy had increased to 60.5 years – an 11.3-year gain. Based on standard monetary valuation of life, the survival benefits of ART far outweigh the costs of providing treatment in this community. These gains in adult life expectancy signify the social value of ART and have implications for investment decisions of individuals, governments, and donors.

AbstractIntroduction: To systematically review the literature on mother‐to‐child transmission in breastfed infants whose mothers received antiretroviral therapy and support the process of updating the World Health Organization infant feeding guidelines in the context of HIV and ART.Methods: We reviewed experimental and observational studies; exposure was maternal HIV antiretroviral therapy (and duration) and infant feeding modality; outcomes were overall and postnatal HIV transmission rates in the infant at 6, 9, 12 and 18 months. English literature from 2005 to 2015 was systematically searched in multiple electronic databases. Papers were analysed by narrative synthesis; data were pooled in random effects meta‐analyses. Postnatal transmission was assessed from four to six weeks of life. Study quality was assessed using a modified Newcastle‐Ottawa Scale (NOS) and GRADE.Results and discussion: Eleven studies were identified, from 1439 citations and review of 72 abstracts. Heterogeneity in study methodology and pooled estimates was considerable. Overall pooled transmission rates at 6 months for breastfed infants with mothers on antiretroviral treatment (ART) was 3.54% (95% CI: 1.15–5.93%) and at 12 months 4.23% (95% CI: 2.97–5.49%). Postnatal transmission rates were 1.08 (95% CI: 0.32–1.85) at six and 2.93 (95% CI: 0.68–5.18) at 12 months. ART was mostly provided for PMTCT only and did not continue beyond six months postpartum. No study provided data on mixed feeding and transmission risk.Conclusions: There is evidence of substantially reduced postnatal HIV transmission risk under the cover of maternal ART. However, transmission risk increased once PMTCT ART stopped at six months, which supports the current World Health Organization recommendations of life‐long ART for all.

Stalled fertility declines have been identified in several regions across the developing world, but the current conceptualization of a stalled fertility decline is poorly theorized and does not lend itself to objective measurement. We propose a more rigorous and statistically testable definition of stalled fertility decline that can be applied to time‐series data. We then illustrate the utility of our definition through its application to data from rural South Africa for the period 1990‐2005 collected from a demographic surveillance site. Application of the approach suggests that fertility decline has indeed stalled in rural KwaZulu‐Natal, at about three children per woman. The stall, some 20 percent above the replacement fertility level, does not appear to be associated with a rise in wanted fertility or attenuated access to contraceptive methods. This identification of a stalled fertility decline provides the first evidence of such a stall in southern Africa, the region with the lowest fertility levels in sub‐Saharan Africa.

IntroductionHIV testing is a cornerstone of efforts to combat the HIV epidemic, and testing conducted as part of surveillance provides invaluable data on the spread of infection and the effectiveness of campaigns to reduce the transmission of HIV. However, participation in HIV testing can be low, and if respondents systematically select not to be tested because they know or suspect they are HIV positive (and fear disclosure), standard approaches to deal with missing data will fail to remove selection bias. We implemented Heckman‐type selection models, which can be used to adjust for missing data that are not missing at random, and established the extent of selection bias in a population‐based HIV survey in an HIV hyperendemic community in rural South Africa.MethodsWe used data from a population‐based HIV survey carried out in 2009 in rural KwaZulu‐Natal, South Africa. In this survey, 5565 women (35%) and 2567 men (27%) provided blood for an HIV test. We accounted for missing data using interviewer identity as a selection variable which predicted consent to HIV testing but was unlikely to be independently associated with HIV status. Our approach involved using this selection variable to examine the HIV status of residents who would ordinarily refuse to test, except that they were allocated a persuasive interviewer. Our copula model allows for flexibility when modelling the dependence structure between HIV survey participation and HIV status.ResultsFor women, our selection model generated an HIV prevalence estimate of 33% (95% CI 27–40) for all people eligible to consent to HIV testing in the survey. This estimate is higher than the estimate of 24% generated when only information from respondents who participated in testing is used in the analysis, and the estimate of 27% when imputation analysis is used to predict missing data on HIV status. For men, we found an HIV prevalence of 25% (95% CI 15–35) using the selection model, compared to 16% among those who participated in testing, and 18% estimated with imputation. We provide new confidence intervals that correct for the fact that the relationship between testing and HIV status is unknown and requires estimation.ConclusionsWe confirm the feasibility and value of adopting selection models to account for missing data in population‐based HIV surveys and surveillance systems. Elements of survey design, such as interviewer identity, present the opportunity to adopt this approach in routine applications. Where non‐participation is high, true confidence intervals are much wider than those generated by standard approaches to dealing with missing data suggest.

AbstractIntroductionHIV treatment guidelines now recommend antiretroviral therapy (ART) initiation regardless of CD4 count to maximize benefit both for the individual and society. It is unknown whether the initiation of ART at higher CD4 counts would affect adherence levels. We investigated whether initiating ART at higher CD4 counts was associated with sub‐optimal adherence (<95%) during the first 12 months of ART.MethodsA prospective cohort study nested within a two‐arm cluster‐randomized trial of universal test and treat was implemented from March 2012 to June 2016 to measure the impact of ART on HIV incidence in rural KwaZulu‐Natal. ART was initiated regardless of CD4 count in the intervention arm and according to national guidelines in the control arm. ART adherence was measured monthly using a visual analogue scale (VAS) and pill counts (PC). HIV viral load was measured at ART initiation, three and six months, and six‐monthly thereafter. We pooled data from participants in both arms and used random‐effects logistic regression models to examine the association between CD4 count at ART initiation and sub‐optimal adherence, and assessed if adherence levels were associated with virological suppression.ResultsAmong 900 individuals who initiated ART ≥12 months before study end, median (IQR) CD4 at ART initiation was 350 cells/mm3 (234, 503); median age was 34.6 years (IQR 27.4 to 46.4) and 71.7% were female. Adherence was sub‐optimal in 14.7% of visits as measured by VAS and 20.7% by PC. In both the crude analyses and after adjusting for potential confounders, adherence was not significantly associated with CD4 count at ART initiation (adjusted OR for linear trend in sub‐optimal adherence with every 100 cells/mm3 increase in CD4 count: 1.00, 95% CI 0.95 to 1.05, for VAS, and 1.03, 95% CI 0.99 to 1.07, for PC). Virological suppression at 12 months was 97%. Optimal adherence by both measures was significantly associated with virological suppression (p < 0.001 for VAS; p = 0.006 for PC).ConclusionsWe found no evidence that higher CD4 counts at ART initiation were associated with sub‐optimal ART adherence in the first 12 months. Our findings should alleviate concerns about adherence in individuals initiating ART at higher CD4 counts, however long‐term outcomes are needed. ClinicalTrials.gov NCT01509508.

IntroductionHigh rates of hepatotoxicity have been observed among HIV‐positive pregnant women using antiretroviral therapy (ART). However, the extent to which pregnancy affects the risk of ART‐induced hepatotoxicity is unclear since studies in this area have generated conflicting results.Material and MethodsCombined data from the UK Collaborative HIV Cohort (UK CHIC) study and the UK and Ireland National Study of HIV in Pregnancy and Childhood (NSHPC) were used. Alanine aminotransferase (ALT) data were assessed according to the Division of AIDS toxicity guidelines to identify factors associated with liver enzyme elevation (LEE) (grade 1–4). Women starting ART in 2000–11 aged 16–49 years were included irrespective of pregnancy status at ART start. Cox proportional hazards were used to assess the associations between fixed (ethnicity, exposure group, HBV/HCV co‐infection, prior ART use, and age, year, pregnancy status, viral load and CD4 count at ART start) and time‐dependent covariates (pregnancy status, age, year, CD4 count, viral load, duration on ART) and the risk of LEE.ResultsOf the 3426 women included, one‐quarter (25.0%, n=857) were pregnant during follow‐up and 14.4% (n=492) started ART during pregnancy. The rate of LEE was 15/100 person‐years (PY) during pregnancy and 6.1/100 PY outside pregnancy. The risk of LEE was increased during pregnancy (adjusted hazard ratio (aHR) 1.61 [1.26–2.06], p<0.001), including in secondary analysis excluding 493 women pregnant when starting ART. Other factors independently associated with LEE were lower CD4 count (<250 cells/mm3 vs. 251–350 cells/mm3 aHR 1.25 [1.02–1.54], p=0.03), HBV/HCV co‐infection (aHR 1.94 [1.58–2.39], p<0.001), HIV acquired via injecting drug use (aHR 1.61 [1.15–2.24], p=0.01 vs. heterosexually) and calendar year (aHR 1.05 [1.02–1.08], p<0.001 per one year increase). Three ART drugs were associated with increased risk of LEE (efavirenz aHR 1.27 [1.06–1.50], p‐value 0.008; maraviroc 4.19 [1.34–13.1], p=0.01; and nevirapine 1.59 [1.30–1.95], p‐value <0.001). Use of zidovudine was associated with decreased risk of LEE (aHR 0.74 [0.63–0.87], p<0.001) as was increasing time on an NNRTI‐based regimen (aHR 0.91 [0.86–0.96], p<0.001 per additional year).ConclusionsPregnant women were at increased risk of LEE, highlighting the importance of close monitoring of toxicity biomarkers during pregnancy.