Examining the effects of HIV self‐testing compared to standard HIV testing services: a systematic review and meta‐analysis

Introduction : HIV self‐testing (HIVST) is a discreet and convenient way to reach people with HIV who do not know their status, including many who may not otherwise test. To inform World Health Organization (WHO) guidance, we assessed the effect of HIVST on uptake and frequency of testing, as well as identification of HIV‐positive persons, linkage to care, social harm, and risk behaviour. Methods : We systematically searched for studies comparing HIVST to standard HIV testing until 1 June 2016. Meta‐analyses of studies reporting comparable outcomes were conducted using a random‐effects model for relative risks (RR) and 95% confidence intervals. The quality of evidence was evaluated using GRADE. Results : After screening 638 citations, we identified five randomized controlled trials (RCTs) comparing HIVST to standard HIV testing services among 4,145 total participants from four countries. All offered free oral‐fluid rapid tests for HIVST and were among men. Meta‐analysis of three RCTs showed HIVST doubled uptake of testing among men (RR = 2.12; 95% CI: 1.51, 2.98). Meta‐analysis of two RCTs among men who have sex with men showed frequency of testing nearly doubled (Rate ratio = 1.88; 95% CI: 1.17; 3.01), resulting in two more tests in a 12–15‐month period (Mean difference = 2.13; 95% CI: 1.59, 2.66). Meta‐analysis of two RCTs showed HIVST also doubled the likelihood of an HIV‐positive diagnosis (RR = 2.02; 95% CI: 0.37, 10.76, 5.32). Across all RCTs, there was no indication of harm attributable to HIVST and potential increases in risk‐taking behaviour appeared to be minimal. Conclusions : HIVST is associated with increased uptake and frequency of testing in RCTs. Such increases, particularly among those at risk who may not otherwise test, will likely identify more HIV‐positive individuals as compared to standard testing services alone. However, further research on how to support linkage to confirmatory testing, prevention, treatment and care services is needed. WHO now recommends HIVST as an additional HIV testing approach.     

The HIV Modes of Transmission model: a systematic review of its findings and adherence to guidelines

Introduction

The HIV Modes of Transmission (MOT) model estimates the annual fraction of new HIV infections (FNI) acquired by different risk groups. It was designed to guide country-specific HIV prevention policies. To determine if the MOT produced context-specific recommendations, we analyzed MOT results by region and epidemic type, and explored the factors (e.g. data used to estimate parameter inputs, adherence to guidelines) influencing the differences.

Methods

We systematically searched MEDLINE, EMBASE and UNAIDS reports, and contacted UNAIDS country directors for published MOT results from MOT inception (2003) to 25 September 2012.

Results

We retrieved four journal articles and 20 UNAIDS reports covering 29 countries. In 13 countries, the largest FNI (range 26 to 63%) was acquired by the low-risk group and increased with low-risk population size. The FNI among female sex workers (FSWs) remained low (median 1.3%, range 0.04 to 14.4%), with little variability by region and epidemic type despite variability in sexual behaviour. In India and Thailand, where FSWs play an important role in transmission, the FNI among FSWs was 2 and 4%, respectively. In contrast, the FNI among men who have sex with men (MSM) varied across regions (range 0.1 to 89%) and increased with MSM population size. The FNI among people who inject drugs (PWID, range 0 to 82%) was largest in early-phase epidemics with low overall HIV prevalence. Most MOT studies were conducted and reported as per guidelines but data quality remains an issue.

Conclusions

Although countries are generally performing the MOT as per guidelines, there is little variation in the FNI (except among MSM and PWID) by region and epidemic type. Homogeneity in MOT FNI for FSWs, clients and low-risk groups may limit the utility of MOT for guiding country-specific interventions in heterosexual HIV epidemics.     

HIV testing and linkage to ART following secondary distribution of HIV self‐test kits to male partners of women living with HIV: a pilot randomized control trial in Mpumalanga,South Africa

IntroductionSouth African men are underrepresented in HIV testing and treatment services. Secondary distribution of oral HIV self‐test (HIVST) kits by women living with HIV (WLHIV) to their male partners (i.e. index partner HIVST) may increase men''s testing and treatment but has been understudied.MethodsBetween March and July 2021, we evaluated the effectiveness of index partner HIVST versus the standard of care (SOC) (invitations for men''s facility‐based testing) on men''s testing in a 1:1 randomized control trial. Eligibility criteria included: WLHIV; ≥18 years of age; attending one of four high‐density rural clinics; have a working cell phone; and self‐reported having a primary male partner of unknown serostatus. The primary outcome was the proportion of WLHIV reporting that her partner tested for HIV within 3 months after enrolment.ResultsWe enrolled 180 WLHIV and 176 completed an endline survey (mean age = 35 years, 15% pregnant, 47% unmarried or non‐cohabiting). In the HIVST arm, 78% of male partners were reported to have tested for HIV versus 55% in SOC (RR = 1.41; 95% CI = 1.14–1.76). In the HIVST arm, nine men were reactive with HIVST (14% positivity), six were confirmed HIV positive with standard testing (67%) and all of those started antiretroviral therapy (ART), and four HIV‐negative men started pre‐exposure prophylaxis (PrEP) (5%). In SOC, six men were diagnosed with HIV (12% positivity), 100% started ART and seven HIV‐negative men started PrEP (16%). One case of verbal intimate partner violence was reported in the HIVST arm.ConclusionsSecondary distribution of HIVST to partners of WLHIV was acceptable and effective for improving HIV testing among men in rural South Africa in our pilot study. Interventions are needed to link reactive HIVST users to confirmatory testing and ART.     

Barriers to HIV remission research in low‐ and middle‐income countries

Introduction : HIV eradication and remission research has largely taken place in high‐income countries. In low‐ and middle‐income countries (LMIC), there may be factors that have a substantial impact on the size of the latent HIV reservoir and the immunological response to infection. If a curative strategy is to be available to all HIV‐infected individuals, these factors must be understood. Methods : We use a scoping review to examine the literature on biological factors that may have an impact on HIV persistence in LMIC. Three databases were searched without date restrictions. Results : Uncontrolled viral replication and higher coinfection prevalence may alter the immunological milieu of individuals in LMIC and increase the size of the HIV reservoir. Differences in HIV subtype could also influence the measurement and size of the HIV reservoir. Immune activation may differ due to late presentation to care, presence of chronic infections, increased gut translocation of bacterial products and poor nutrition. Conclusions : Research on HIV remission is urgently needed in LMIC. Research into chronic immune activation in resource poor environments, the immune response to infection, the mechanisms of HIV persistence and latency in different viral clades and the effect of the microbiological milieu must be performed. Geographic differences, which may be substantial and may delay access to curative strategies, should be identified.     

A qualitative exploration to understand barriers and facilitators to daily oral PrEP uptake and sustained adherence among HIV‐negative women planning for or with pregnancy in rural Southwestern Uganda

IntroductionAntiretroviral pre‐exposure prophylaxis (PrEP) may reduce periconception and pregnancy HIV incidence among women in settings, where gender power imbalances limit HIV testing, engagement in care and HIV viral suppression. We conducted qualitative interviews to understand factors influencing periconception and pregnancy PrEP uptake and use in a cohort of women (Trial registration: {"type":"clinical-trial","attrs":{"text":"NCT03832530","term_id":"NCT03832530"}}NCT03832530) offered safer conception counselling in rural Southwestern Uganda, where PrEP uptake was high.MethodsBetween March 2018 and January 2019, in‐depth interviews informed by conceptual frameworks for periconception risk reduction and PrEP adherence were conducted with 37 women including those with ≥80% and <80% adherence to PrEP doses measured by electronic pill cap, those who never initiated PrEP, and seven of their male partners. Content and dyadic analyses were conducted to identify emergent challenges and facilitators of PrEP use within individual and couple narratives.ResultsThe median age for women was 33 years (IQR 28, 35), 97% felt likely to acquire HIV and 89% initiated PrEP. Individual‐level barriers included unwillingness to take daily pills while healthy, side effects and alcohol use. Women overcame these barriers through personal desires to have control over their HIV serostatus, produce HIV‐negative children and prevent HIV transmission within partnerships. Couple‐level barriers included nondisclosure, mistrust and gender‐based violence; facilitators included shared goals and perceived HIV protection, which improved communication, sexual intimacy and emotional support within partnerships through a self‐controlled method. Community‐level barriers included multi‐level stigma related to HIV, ARVs/PrEP and serodifference; facilitators included active peer, family or healthcare provider support as women aspired to safely meet socio‐cultural expectations to conceive and preserve serodifferent relationships. Confidence in PrEP effectiveness was promoted by positive peer experiences with PrEP and ongoing HIV testing.ConclusionsMulti‐level forms of HIV‐, serodifference‐ and disclosure‐related stigma, side effects, pill burden, alcohol use, relationship dynamics, social, professional and partnership support towards adaptation and HIV risk reduction influence PrEP uptake and adherence among HIV‐negative women with plans for pregnancy in rural Southwestern Uganda. Confidence in PrEP, individually controlled HIV prevention and improved partnership communication and intimacy promoted PrEP adherence. Supporting individuals to overcome context‐specific barriers to PrEP use may be an important approach to improving uptake and prolonged use.     

Reasons for late presentation to HIV care in Switzerland

Introduction

Late presentation to HIV care leads to increased morbidity and mortality. We explored risk factors and reasons for late HIV testing and presentation to care in the nationally representative Swiss HIV Cohort Study (SHCS).

Methods

Adult patients enrolled in the SHCS between July 2009 and June 2012 were included. An initial CD4 count <350 cells/µl or an AIDS-defining illness defined late presentation. Demographic and behavioural characteristics of late presenters (LPs) were compared with those of non-late presenters (NLPs). Information on self-reported, individual barriers to HIV testing and care were obtained during face-to-face interviews.

Results

Of 1366 patients included, 680 (49.8%) were LPs. Seventy-two percent of eligible patients took part in the survey. LPs were more likely to be female (p<0.001) or from sub-Saharan Africa (p<0.001) and less likely to be highly educated (p=0.002) or men who have sex with men (p<0.001). LPs were more likely to have their first HIV test following a doctor''s suggestion (p=0.01), and NLPs in the context of a regular check-up (p=0.02) or after a specific risk situation (p<0.001). The main reasons for late HIV testing were “did not feel at risk” (72%), “did not feel ill” (65%) and “did not know the symptoms of HIV” (51%). Seventy-one percent of the participants were symptomatic during the year preceding HIV diagnosis and the majority consulted a physician for these symptoms.

Conclusions

In Switzerland, late presentation to care is driven by late HIV testing due to low risk perception and lack of awareness about HIV. Tailored HIV testing strategies and enhanced provider-initiated testing are urgently needed.     

HIV prevention metrics: lessons to be learned from contraception

IntroductionAs the range of effective HIV prevention options, including multiple biomedical tools, increases, there are many challenges to measuring HIV prevention efforts. In part, there is the challenge of varying prevention needs, between individuals as well as within individuals over time. The field of contraception faces many similar challenges, such as the range of prevention methods and changing contraceptive needs, and has developed many metrics for assessing contraceptive use at the program level, using frameworks that move beyond the HIV prevention cascade. We explore these similarities and differences between these two prevention fields and then discuss how each of these contraceptive metrics could be adapted to assessing HIV prevention.DiscussionWe examined measures of initiation, coverage and persistence. Among measures of initiation, HIV Prevention–Post Testing would be a useful corollary to Contraceptive Use–Post Partum for a subset of the population. As a measure of coverage, both Net Prevention Coverage and HIV Protection Index (modelled off the Contraception Protection Index) may be useful. Finally, as a measure of persistence, Person‐Years of HIV Protection could be adapted from Couple‐Years Protection. As in contraception, most programs will not reach 100% on HIV prevention metrics but these metrics are highly useful for making comparisons.ConclusionsWhile we may not be able to perfectly capture the true population of who would benefit from HIV prevention, by building off the work of the contraceptive field to use and refine these metrics, we can assess and compare HIV prevention over time and across programs. Furthermore, these metrics can help us reach global targets, such as the 2025 UNAIDS Goals, and reduce HIV incidence.     

Sexual risk behaviour among people living with HIV according to the biomedical risk of transmission: results from the ANRS-VESPA2 survey

Introduction

People living with HIV (PLHIV) on antiretroviral therapy (ART), with sustained undetectable viral load (sUVL) and no history of sexually transmitted infections for at least six months, are considered to have a low risk of HIV transmission (LRT). We aimed to characterize, in a representative sample of French PLHIV, the sexual behaviour of LRT PLHIV compared with non-LRT PLHIV.

Methods

The cross-sectional ANRS-VESPA2 survey was conducted on adult PLHIV attending French hospitals in 2011. The LRT PLHIV group included participants with sUVL and no sexually transmitted infection for at least 12 months. Socio-behavioural and medical data were collected. Chi-square tests helped compare sexual risk indicators between LRT and non-LRT PLHIV. The survey''s retrospective nature allowed us to perform complementary category-based analyses of LRT PLHIV according to whether they had sUVL for at least 18, 24 or 36 months in three socio-epidemiological groups: men who have sex with men (MSM), other men and women.

Results

Analysis included 2638 PLHIV diagnosed >12 months with available viral load data. The proportion of LRT PLHIV varied from 58% (≥12 months sUVL) to 38% (≥36 months sUVL). Irrespective of sUVL duration, we found the following: 1) LRT men (MSM and other men) were more likely to report having no sexual partner than their non-LRT counterparts. Among men having sexual partners in the previous 12 months, no significant difference was seen between LRT and non-LRT men in the number of sexual partners. LRT women were less likely to report having more than one sexual partner than non-LRT women; 2) LRT MSM were more likely to report being in sexually inactive couples than their non-LRT counterparts; 3) among sexually active participants, no difference was observed between LRT and non-LRT PLHIV concerning condom use with their serodiscordant steady partner or with their most recent casual sexual partners.

Conclusions

LRT PLHIV with sUVL ≥12 months did not report more sexual risk behaviours than their non-LRT counterparts. Because the same result was obtained for those having a sUVL ≥36 months, the hypothesis of increased sexual risk behaviour over time in PLHIV meeting non-transmission biomedical criteria is not supported.     

Acceptability of woman‐delivered HIV self‐testing to the male partner,and additional interventions: a qualitative study of antenatal care participants in Malawi

Introduction : In the era of ambitious HIV targets, novel HIV testing models are required for hard‐to‐reach groups such as men, who remain underserved by existing services. Pregnancy presents a unique opportunity for partners to test for HIV, as many pregnant women will attend antenatal care (ANC). We describe the views of pregnant women and their male partners on HIV self‐test kits that are woman‐delivered, alone or with an additional intervention. Methods : A formative qualitative study to inform the design of a multi‐arm multi‐stage cluster‐randomized trial, comprised of six focus group discussions and 20 in‐depth interviews, was conducted. ANC attendees were purposively sampled on the day of initial clinic visit, while men were recruited after obtaining their contact information from their female partners. Data were analysed using content analysis, and our interpretation is hypothetical as participants were not offered self‐test kits. Results : Providing HIV self‐test kits to pregnant women to deliver to their male partners was highly acceptable to both women and men. Men preferred this approach compared with standard facility‐based testing, as self‐testing fits into their lifestyles which were characterized by extreme day‐to‐day economic pressures, including the need to raise money for food for their household daily. Men and women emphasized the need for careful communication before and after collection of the self‐test kits in order to minimize the potential for intimate partner violence although physical violence was perceived as less likely to occur. Most men stated a preference to first self‐test alone, followed by testing as a couple. Regarding interventions for optimizing linkage following self‐testing, both men and women felt that a fixed financial incentive of approximately USD$2 would increase linkage. However, there were concerns that financial incentives of greater value may lead to multiple pregnancies and lack of child spacing. In this low‐income setting, a lottery incentive was considered overly disappointing for those who receive nothing. Phone call reminders were preferred to short messaging service. Conclusions : Woman‐delivered HIV self‐testing through ANC was acceptable to pregnant women and their male partners. Feedback on additional linkage enablers will be used to alter pre‐planned trial arms.     

Long-Term Follow-up of a Heart Transplant Recipient with Documented Seroconversion to HIV-Positive Status 1 Year After Transplant

Whether human immunodeficiency virus (HIV) should be an absolute contraindication to heart transplantation has been a topic of recent discussion. There is a paucity of data regarding the expected outcome of heart transplantation in a recipient who is HIV positive. Herein, we report the case and long-term follow-up of a woman who was found to have seroconverted to HIV positive status 1 year after transplant.     

Revealing geographical and population heterogeneity in HIV incidence,undiagnosed HIV prevalence and time to diagnosis to improve prevention and care: estimates for France

Introduction

To close gaps in HIV prevention and care, knowledge about locations and populations most affected by HIV is essential. Here, we provide subnational and sub‐population estimates of three key HIV epidemiological indicators, which have been unavailable for most settings.

Methods

We used surveillance data on newly diagnosed HIV cases from 2004 to 2014 and back‐calculation modelling to estimate in France, at national and subnational levels, by exposure group and country of birth: the numbers of new HIV infections, the times to diagnosis, the numbers of undiagnosed HIV infections. The denominators used for rate calculations at national and subnational levels were based on population size (aged 18 to 64) estimates produced by the French National Institute of Statistics and Economic Studies and the latest national surveys on sexual behaviour and drug use.

Results

We estimated that, in 2014, national HIV incidence was 0.17‰ (95% confidence intervals (CI): 0.16 to 0.18) or 6607 (95% CI: 6057 to 7196) adults, undiagnosed HIV prevalence was 0.64‰ (95% CI: 0.57 to 0.70) or 24,197 (95% CI: 22,296 to 25,944) adults and median time to diagnosis over the 2011 to 2014 period was 3.3 years (interquartile range: 1.2 to 5.7). Three mainland regions, including the Paris region, out of the 27 French regions accounted for 56% of the total number of new and undiagnosed infections. Incidence and undiagnosed prevalence rates were 2‐ to 10‐fold higher than the national rates in three overseas regions and in the Paris region (p‐values < 0.001). Rates of incidence and undiagnosed prevalence were higher than the national rates for the following populations (p‐values < 0.001): born‐abroad men who have sex with men (MSM) (respectively, 108‐ and 78‐fold), French‐born MSM (62‐ and 44‐fold), born‐abroad persons who inject drugs (14‐ and 18‐fold), sub‐Saharan African‐born heterosexuals (women 15‐ and 15‐fold, men 11‐ and 13‐fold). Importantly, affected populations varied from one region to another, and in regions apparently less impacted by HIV, some populations could be as impacted as those living in most impacted regions.

Conclusions

In France, some regions and populations have been most impacted by HIV. Subnational and sub‐population estimates of key indicators are not only essential to adapt, design implement and evaluate tailored HIV interventions in France, but also elsewhere where similar heterogeneity is likely to exist.

     

Community action to end paediatric HIV infections

Virtual prevention of HIV transmission from parents to children is possible. This is cause for hope and renewed energy for prevention in general. The Global Plan is the most concerted and ambitious plan to date to protect children and to promote their care. But the inspiring and much appreciated global targets cannot be achieved, nor will they be realized in spirit in addition to form, without joint action between health services, affected women, their partners, families and communities and the wider society. In turn, this engagement is only possible under enabling political, legal, material and social conditions. Much has already been achieved, and community engagement can everywhere be seen in efforts to increase demand, to supply services and to create and improve enabling environments. Some of these initiatives are highly organized and expansive, with demonstrated success. Others are local but essential adjuncts to health services. The nature of this engagement varies because the challenges are different across countries and parts of countries. To be sustained and effective, community action must simultaneously be inclusive and supportive for those people who are affected, it must be appreciated and assigned a place within the broad systemic response, and it must promote and defend social justice.     

Timing of HIV diagnosis relative to pregnancy and postpartum HIV care continuum outcomes among Latin American women, 2000 to 2017

BackgroundHIV incidence among women of reproductive age and vertical HIV transmission rates remain high in Latin America. We, therefore, quantified HIV care continuum barriers and outcomes among pregnant women living with HIV (WLWH) in Latin America.MethodsWLWH (aged ≥16 years) enrolling at Caribbean, Central and South America network for HIV epidemiology (CCASAnet) sites from 2000 to 2017 who had HIV diagnosis, pregnancy and delivery dates contributed. Logistic regression produced adjusted odds ratios (aOR) and 95% confidence intervals (CI) for retention in care (≥2 visits ≥3 months apart) and virological suppression (viral load <200 copies/mL) 12 months after pregnancy outcome. Cumulative incidences of loss to follow‐up (LTFU) postpartum were estimated using Cox regression. Evidence of HIV status at pregnancy confirmation was the exposure. Covariates included pregnancy outcome (born alive vs. others); AIDS diagnosis prior to delivery; CD4, age, HIV‐1 RNA and cART regimen at first delivery and CCASAnet country.ResultsAmong 579 WLWH, median postpartum follow‐up was 4.34 years (IQR 1.91, 7.35); 459 (79%) were HIV‐diagnosed before pregnancy confirmation, 445 (77%) retained in care and 259 (45%) virologically suppressed at 12 months of postpartum. Cumulative incidence of LTFU was 21% by 12 months and 40% by five years postpartum. Those HIV‐diagnosed during pregnancy had lower odds of retention (aOR = 0.58, 95% CI: 0.35 to 0.97) and virological suppression (aOR = 0.50, 95% CI: 0.31 to 0.82) versus those HIV‐diagnosed before.ConclusionHIV diagnosis during pregnancy was associated with poorer 12‐month retention and virological suppression. Young women should be tested and linked to HIV care earlier to narrow these disparities.