HIV transmission and retention in care among HIV‐exposed children enrolled in Malawi's prevention of mother‐to‐child transmission programme

Introduction : In Malawi, HIV‐infected pregnant and breastfeeding women are offered lifelong antiretroviral therapy (ART) regardless of CD4 count or clinical stage (Option B+). Their HIV‐exposed children are enrolled in the national prevention of mother‐to‐child transmission (PMTCT) programme, but many are lost to follow‐up. We estimated the cumulative incidence of vertical HIV transmission, taking loss to follow‐up into account. Methods : We abstracted data from HIV‐exposed children enrolled into care between September 2011 and June 2014 from patient records at 21 health facilities in central and southern Malawi. We used competing risk models to estimate the probability of loss to follow‐up, death, ART initiation and discharge, and used pooled logistic regression and inverse probability of censoring weighting to estimate the vertical HIV transmission risk. Results : A total of 11,285 children were included; 9285 (82%) were born to women who initiated ART during pregnancy. At age 30 months, an estimated 57.9% (95% CI 56.6–59.2) of children were lost to follow‐up, 0.8% (0.6–1.0) had died, 2.6% (2.3–3.0) initiated ART, 36.5% (35.2–37.9) were discharged HIV‐negative and 2.2% (1.5–2.8) continued follow‐up. We estimated that 5.3% (95% CI 4.7–5.9) of the children who enrolled were HIV‐infected by the age of 30 months, but only about half of these children (2.6%; 95% CI 2.3–2.9) were diagnosed. Conclusions : Confirmed mother‐to‐child transmission rates were low, but due to poor retention only about half of HIV‐infected children were diagnosed. Tracing of children lost to follow‐up and HIV testing in outpatient clinics should be scaled up to ensure that all HIV‐positive children have access to early ART.     

Targeted HIV testing at birth supported by low and predictable mother‐to‐child transmission risk in Botswana

Introduction

Most African countries perform infant HIV testing at 6 weeks or later. The addition of targeted testing at birth may improve retention in care, treatment outcomes and survival for HIV‐infected infants.

Methods

HIV‐exposed infants were screened as part of the Early Infant Treatment (EIT) study in Botswana. Screened infants were ≥35 weeks gestational age and ≥2000 g at birth. Risk factors for mother‐to‐child transmission (MTCT) were assessed by maternal obstetric card or verbally. Risk factors included <8 weeks ART in pregnancy, last known CD4 <250 cells/mm³, last known HIV RNA >400 copies/mL, poor maternal ART adherence, lack of maternal zidovudine (ZDV) in labour, or lack of infant post‐exposure prophylaxis. Infants underwent dried blood spot testing by Roche Cobas Ampliprep/Cobas Taqman HIV‐1 qualitative PCR.

Results

From April 2015 to April 2016, 2303 HIV‐exposed infants were tested for HIV in the EIT study. Of these, 369 (16%) were identified as high risk for HIV infection by information available at birth, and 12 (0.5% overall, 3.25% of high risk) were identified as HIV positive at birth. All 12 positive infants were identified as high risk at the time of screening, and only 2 risk factors were required to identify all positive infants: either <8 weeks of maternal ART in pregnancy (75%) or lack of maternal HIV suppression at last test (25%).

Conclusions

In utero MTCT occurred only among infants identified as high risk at delivery, using information available from the mother or obstetric record. Birth testing that targets high‐risk infants based on maternal ART receipt is likely to identify the majority of in utero HIV transmissions, and allows early ART initiation for these infants.

     

HIV misdiagnosis in sub‐Saharan Africa: performance of diagnostic algorithms at six testing sites

Introduction : We evaluated the diagnostic accuracy of HIV testing algorithms at six programmes in five sub‐Saharan African countries. Methods : In this prospective multisite diagnostic evaluation study (Conakry, Guinea; Kitgum, Uganda; Arua, Uganda; Homa Bay, Kenya; Doula, Cameroun and Baraka, Democratic Republic of Congo), samples from clients (greater than equal to five years of age) testing for HIV were collected and compared to a state‐of‐the‐art algorithm from the AIDS reference laboratory at the Institute of Tropical Medicine, Belgium. The reference algorithm consisted of an enzyme‐linked immuno‐sorbent assay, a line‐immunoassay, a single antigen‐enzyme immunoassay and a DNA polymerase chain reaction test. Results : Between August 2011 and January 2015, over 14,000 clients were tested for HIV at 6 HIV counselling and testing sites. Of those, 2786 (median age: 30; 38.1% males) were included in the study. Sensitivity of the testing algorithms ranged from 89.5% in Arua to 100% in Douala and Conakry, while specificity ranged from 98.3% in Doula to 100% in Conakry. Overall, 24 (0.9%) clients, and as many as 8 per site (1.7%), were misdiagnosed, with 16 false‐positive and 8 false‐negative results. Six false‐negative specimens were retested with the on‐site algorithm on the same sample and were found to be positive. Conversely, 13 false‐positive specimens were retested: 8 remained false‐positive with the on‐site algorithm. Conclusions : The performance of algorithms at several sites failed to meet expectations and thresholds set by the World Health Organization, with unacceptably high rates of false results. Alongside the careful selection of rapid diagnostic tests and the validation of algorithms, strictly observing correct procedures can reduce the risk of false results. In the meantime, to identify false‐positive diagnoses at initial testing, patients should be retested upon initiating antiretroviral therapy.     

Performance of self‐reported HIV status in determining true HIV status among older adults in rural South Africa: a validation study

Introduction : In South Africa, older adults make up a growing proportion of people living with HIV. HIV programmes are likely to reach older South Africans in home‐based interventions where testing is not always feasible. We evaluate the accuracy of self‐reported HIV status, which may provide useful information for targeting interventions or offer an alternative to biomarker testing. Methods : Data were taken from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) baseline survey, which was conducted in rural Mpumalanga province, South Africa. A total of 5059 participants aged ≥40 years were interviewed from 2014 to 2015. Self‐reported HIV status and dried bloodspots for HIV biomarker testing were obtained during at‐home interviews. We calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for self‐reported status compared to “gold standard” biomarker results. Log‐binomial regression explored associations between demographic characteristics, antiretroviral therapy (ART) status and sensitivity of self‐report. Results : Most participants (93%) consented to biomarker testing. Of those with biomarker results, 50.9% reported knowing their HIV status and accurately reported it. PPV of self‐report was 94.1% (95% confidence interval (CI): 92.0–96.0), NPV was 87.2% (95% CI: 86.2–88.2), sensitivity was 51.2% (95% CI: 48.2–54.3) and specificity was 99.0% (95% CI: 98.7–99.4). Participants on ART were more likely to report their HIV‐positive status, and participants reporting false‐negatives were more likely to have older HIV tests. Conclusions : The majority of participants were willing to share their HIV status. False‐negative reports were largely explained by lack of testing, suggesting HIV stigma is retreating in this setting, and that expansion of HIV testing and retesting is still needed in this population. In HIV interventions where testing is not possible, self‐reported status should be considered as a routine first step to establish HIV status.     

Identification of HIV patients with active pulmonary tuberculosis using urine based polymerase chain reaction assay

BACKGROUND: Despite the increased dissemination of tuberculosis among HIV infected patients, the diagnosis is difficult to establish. Traditional microbiological methods lack satisfactory sensitivity. We have developed a highly sensitive and specific nested polymerase chain reaction (PCR) capable of detecting Mycobacterium tuberculosis DNA in urine specimens and have used this test to examine urine specimens from HIV patients with active pulmonary tuberculosis. METHODS: Urine specimens from 13 HIV infected patients with microbiologically proven active pulmonary tuberculosis, 10 AIDS patients with non-tuberculous mycobacterial infection (documented by blood culture), 53 AIDS patients with no evidence of mycobacterial disease, and 80 healthy subjects (25 with positive skin test to purified protein derivative) were tested for M tuberculosis using PCR, acid fast staining (AFS), and culture. RESULTS: Of the urine specimens from patients with active tuberculosis, all tested positive by PCR, two by culture, and none by AFS. No reactivity was observed in urine specimens from patients with non-tuberculous mycobacterial infection. Of the 53 AIDS patients without mycobacterial infection, one had a positive urine PCR. Normal subjects were all negative. CONCLUSIONS: Urine based nested PCR for M tuberculosis may be a useful test for identifying HIV patients with pulmonary tuberculosis.     

HCV antigen instead of RNA testing to diagnose acute HCV in patients treated in the Dutch Acute HCV in HIV Study

Introduction : Affordable and sensitive screening methods for acute hepatitis C (HCV) are necessary to successfully intervene in the current HCV epidemic among HIV‐positive men having sex with men. HCV core antigen (Ag) testing has been proven effective in diagnosing chronic HCV‐infected patients at low costs. We studied the characteristics of HCV Ag testing in acute HCV‐infected HIV‐positive patients. Methods : Plasma samples were selected from acutely HCV genotype 1‐infected patients treated with peginterferon, ribavirin and boceprevir in the Dutch Acute HCV in HIV Study. The control group consisted of HIV‐positive patients with a newly raised alanine aminotransferase (ALT) (>41 U/L) in whom HCV RNA was undetectable and who were tested for HCV Ag. Spearman correlation coefficient between HCV RNA and HCV Ag was calculated together with the sensitivity and specificity of HCV Ag testing at acute HCV diagnosis. Results and discussion : Upon acute HCV diagnosis, HCV Ag was identified in 39 out of 44 patients with detectable HCV RNA levels. In all 23 control patients without detectable HCV RNA in plasma, HCV Ag was undetectable as well. This resulted in a sensitivity and specificity of HCV Ag of respectively 89% (95% CI 75–96) and 100% (95% CI 82–100). The correlation between HCV Ag and HCV RNA was 0.97 (p < 0.001) upon diagnosis. Conclusion : The data presented in this study suggest that HCV Ag testing is a sensitive and specific method that can be used in diagnosing AHCV in HIV‐infected patients.     

Timing of HIV testing among pregnant and breastfeeding women and risk of mother‐to‐child HIV transmission in Malawi: a sampling‐based cohort study

IntroductionPregnant women living with HIV can achieve viral suppression and prevent HIV mother‐to‐child transmission (MTCT) with timely HIV testing and early ART initiation and maintenance. Although it is recommended that pregnant women undergo HIV testing early in antenatal care in Malawi, many women test positive during breastfeeding because they did not have their HIV status ascertained during pregnancy, or they tested negative during pregnancy but seroconverted postpartum. We sought to estimate the association between the timing of last positive HIV test (during pregnancy vs. breastfeeding) and outcomes of maternal viral suppression and MTCT in Malawi’s PMTCT programme.MethodsWe conducted a two‐stage cohort study among mother–infant pairs in 30 randomly selected high‐volume health facilities across five nationally representative districts of Malawi between 1 July 2016 and 30 June 2017. Log‐binomial regression was used to estimate prevalence ratios (PR) and risk ratios (RR) for associations between timing of last positive HIV test (i.e. breastfeeding vs. pregnancy) and maternal viral suppression and MTCT, controlling for confounding using inverse probability weighting.ResultsOf 822 mother–infant pairs who had available information on the timing of the last positive HIV test, 102 mothers (12.4%) had their last positive test during breastfeeding. Women who lived one to two hours (PR = 2.15; 95% CI: 1.29 to 3.58) or >2 hours (PR = 2.36; 95% CI: 1.37 to 4.10) travel time to the nearest health facility were more likely to have had their last positive HIV test during breastfeeding compared to women living <1 hour travel time to the nearest health facility. The risk of unsuppressed VL did not differ between women who had their last positive HIV test during breastfeeding versus pregnancy (adjusted RR [aRR] = 0.87; 95% CI: 0.48 to 1.57). MTCT risk was higher among women who had their last positive HIV test during breastfeeding compared to women who had it during pregnancy (aRR = 6.57; 95% CI: 3.37 to 12.81).ConclusionsMTCT in Malawi occurred disproportionately among women with a last positive HIV test during breastfeeding. Testing delayed until the postpartum period may lead to higher MTCT. To optimize maternal and child health outcomes, PMTCT programmes should focus on early ART initiation and providing targeted testing, prevention, treatment and support to breastfeeding women.     

Liver Retransplantation in HIV‐Infected Patients: A Prospective Cohort Study

Information regarding liver retransplantation in HIV‐infected patients is scant. Data from 14 HIV‐infected patients retransplanted between 2002 and 2011 in Spain (6% retransplantation rate) were analyzed and compared with those from 157 matched HIV‐negative retransplanted patients. In HIV‐infected patients, early (≤30 days) retransplantation was more frequently indicated (57% vs. 29%; p = 0.057), and retransplantation for HCV recurrence was less frequently indicated (7% vs. 37%; p = 0.036). Survival probability after retransplantation in HIV‐positive patients was lower than in HIV‐negative patients, 42% versus 64% at 3 years, although not significantly (p = 0.160). Among HIV‐infected patients, those with undetectable HCV RNA at retransplantation and those with late (>30 days) retransplantation showed better 3‐year survival probability (80% and 67%, respectively), similar to that in their respective HIV‐negative counterparts (72% and 70%). In HIV‐infected and HIV‐negative patients, 3‐year survival probability in those with positive HCV RNA at retransplantation was 22% versus 65% (p = 0.008); in those with early retransplantation, 3‐year survival probability was 25% versus 56% (p = 0.282). HIV infection was controlled with antiretroviral therapy after retransplantation. In conclusion, HIV‐infected patients taken as a whole have unsatisfactory survival after liver retransplantation, although patients with undetectable HCV RNA at retransplantation or undergoing late retransplantation show a more favorable outcome.     

Prevention of mother-to-child transmission of HIV programme: low vertical transmission in KwaZulu-Natal, South Africa

OBJECTIVE: To describe the operational effectiveness of the prevention of mother-to-child transmission (PMTCT) of HIV programme at McCord Hospital during the period 1 March 2004 - 31 August 2005. DESIGN: Observational cohort study. SETTING: McCord Hospital, Durban, South Africa. SUBJECTS: Antenatal patients attending the PMTCT clinic. MEASUREMENTS AND RESULTS: During the 18 months all 2 624 women (100%) attending the antenatal clinic received HIV counselling, resulting in 91% (2 388) being tested for HIV. The prevalence of HIV in the total cohort was 13% (95% confidence interval (CI) 11.6 - 14.2). Of the HIV-positive mothers 302 (89%) completed their pregnancy at the hospital, and in this group there were 3 intrauterine deaths, 1 miscarriage, 1 maternal death (with the baby in utero) and 297 live births with 1 early neonatal death. Only 11% (36 out of 338) were lost to follow-up. A quarter (668) of the partners of all women attending the antenatal clinic were tested for HIV. Delivery in 70% (209) of live births was by caesarean section. Nevirapine was administered to 98% (290) of live babies and 75% (224) received zidovudine (AZT) as well. The 6-week polymerase chain reaction (PCR) baby test uptake was 81% (239 out of 296 live babies). Of those tested, 2.9% (95% CI 1.3 - 6.2) tested HIV positive. CONCLUSION: Despite challenges faced by PMTCT providers in a resource-constrained setting, this state-aided hospital provides a comprehensive and integrated service and has achieved outcomes that compare favourably with those in the developed world.     

Evaluating the feasibility and uptake of a community‐led HIV testing and multi‐disease health campaign in rural Uganda

Introduction: Multi‐disease community health campaigns can be effective for population‐wide HIV testing in a research setting (SEARCH: NCT01864603). We sought to evaluate feasibility and uptake of a community‐led health campaign (CLHC) planned and implemented by village leaders and local clinic workers in Uganda. Methods: Over five months in 2014, locally elected village leaders and Ministry of Health (MoH) clinic staff in a rural parish in Uganda planned a census followed by a CLHC, after training by two SEARCH trial consultants and by leaders from a neighbouring parish that had previously participated in a SEARCH health campaign. We defined feasibility as: (1) elected leaders’ participation in training and implementation of pre‐campaign census and mobilization activities; (2) implementation of all campaign activities by MoH‐funded, local clinic staff; and (3) community participation in the campaign, including point‐of‐care screening for HIV, malaria, hypertension and diabetes, and same‐day referral for male circumcision and family planning (FP). Costing of all salaries and supplies was conducted. Results: Elected leaders from all eight villages in the parish participated in CLHC training. They and local clinic staff met monthly to select and plan CLHC services. Village leaders then leveraged existing volunteer health teams to perform a door‐to‐door census, enumerating 5,202 parish residents over 2 weeks. 2,753 (53%) residents participated in the 6‐day CLHC. Of 1,584 adult participants, 1,474 (93%) tested for HIV: 105/1,474 (7.1%) tested HIV positive. 27% (751/2,753) of participants reported fever and underwent malaria rapid diagnostic testing: 5.3% (40/751) tested positive. Among adults screened, 19% (271/1,452) were hypertensive, and 3% (18/637) had a random blood sugar >11.1 mmol/L. Of 805 men and boys (>10 years), 91 (11%) accepted same‐day clinic referral and underwent medical circumcision. Of 900 women offered same‐day long‐term FP referrals, 25 accepted. The CLHC cost, including census, mobilization and testing services, was $23,597 ($8.57/participant). C onclusions: Elected village leaders successfully planned and conducted a 6‐day multi‐disease health campaign with service provision by local clinic staff that reached over half of a rural Ugandan community. These data suggest it is feasible for local leaders and clinics to adopt a multi‐disease health campaign approach to scale‐up HIV testing in rural Africa.     

24‐Month HIV‐free survival among HIV‐exposed Infants in Lesotho: the PEAWIL cohort study

IntroductionFollowing the implementation of the provision of lifelong antiretroviral therapy to all HIV‐positive pregnant or breastfeeding women for prevention of mother‐to‐child transmission (PMTCT) of HIV by the Kingdom of Lesotho in 2013, we assessed the effectiveness of this approach by evaluating 24‐month HIV‐free survival among HIV‐exposed infants (HEIs).MethodsWe conducted a prospective observational cohort study that enrolled HIV‐positive and HIV‐negative pregnant women, with follow‐up of women and their infants for 24 months after delivery. Participant recruitment started in June 2014 and follow‐up ended in September 2018. Trained nurses collected study information through patient interviews and chart abstraction at enrolment and every three to six months thereafter. Maternal HIV testing, infant mortality, HIV transmission and HIV‐free survival rates were computed using Kaplan–Meier estimation. Cox regression hazard models were used to identify factors associated with infant HIV infection and death.ResultsBetween June 2014 and February 2016, we enrolled 653 HIV‐positive and 941 HIV‐negative pregnant women. Twenty‐seven HIV‐negative women acquired HIV during follow‐up. Ultimately, 634 liveborn HEI (382 (52%) male, 303 (48%) female, 3 missing) and 839 who remained HIV‐unexposed (HUIs) (409 (49.0%) male, 426 (51.0%) female, 4 missing) were followed; 550 HEIs and 701 HUIs completed the 24‐month follow‐up period. Of 607 (95.7%) HEIs who were tested for HIV at least once during follow‐up, 17 were found to be HIV‐positive. Two (9.5%) of 21 infants born to mothers who acquired HIV infection during follow‐up were HIV‐positive compared to 15 (2.4%) of 613 HEI born to women with known HIV infection. The risk of HIV transmission from HIV‐positive mothers to their infants by 24 months of age was 2.9% (95% CI: 1.8 to 4.7). The estimated 24‐month mortality rate among HEIs was 6.0% (95% CI: 4.4 to 8.2) compared to 3.8% (95% CI: 2.6 to 5.3) among HUIs (Log‐rank p = 0.065). HIV‐free survival at 24 months was 91.8% (95% CI: 89.2 to 93.7). Lower maternal age and birth weight were independently associated with increased HIV infection or death of infants.ConclusionsThe implementation of lifelong ART for PMTCT in the Lesotho public health system resulted in low HIV transmission, but survival of HEI remains lower than their HIV uninfected counterparts.     

Acceptability and utilisation of voluntary HIV testing and nevirapine to reduce mother-to-child transmission of HIV-1 integrated into routine clinical care.

OBJECTIVES: Use of nevirapine for prevention of mother-to-child transmission (PMTCT) of HIV-1 has been routine clinical care at Coronation Women and Children's Hospital since April 2000. We assessed the effect of regular audit and targeted interventions on the utilisation of the PMTCT programme. METHODS: Review of antenatal cards and hospital records of women discharged following delivery, in three time periods between October 2000 and February 2002. Following the initial audit an intervention was implemented to eliminate weaknesses in our PMTCT service. Following the second audit the hospital became a pilot site for the Gauteng PMTCT programme. RESULTS: In the initial audit 53.2% of women (159/299) were tested for HIV and received their results, while 56% (14/25) of identified HIV-infected women, and 16% (4/25) of their infants, received nevirapine. By the third audit 74.3% of women (266/358) received their results, and 86% (43/50) of HIV-positive women and 74% (37/50) of newborns were documented to have received nevirapine. In all three audits over 90% of women initiating antenatal care at the hospital were tested for HIV, while women who initiated care at district community clinics were less likely to receive testing. CONCLUSIONS: Ongoing audit has been important for targeting obstacles to detection of HIV-infected women and documented nevirapine uptake by women and infants. Rates of HIV testing and nevirapine use have increased significantly. Voluntary counselling and testing for HIV and use of nevirapine are acceptable to pregnant women in our setting. Roll-out of the pilot programme to district community clinics is essential for further improvement.     

A Prospective Longitudinal Study Evaluating the Usefulness of a T‐Cell‐Based Assay for Latent Tuberculosis Infection in Kidney Transplant Recipients

We evaluated whether ELISPOT assay can predict tuberculosis (TB) development in kidney‐transplantation (KT) recipients with a negative tuberculin skin test (TST). All adult patients admitted to a KT institute between June 2008 and December 2009 were enrolled; TB development after KT was observed between June 2008 and December 2010. Isoniazid (INH) was given to those patients with positive TST or clinical risk factors for latent TB infection (LTBI). ELISPOT assay was performed on all patients, and TB development after KT was observed by a researcher blinded to the results of ELISPOT. A total of 312 KT recipients including 242 (78%) living‐donor KT were enrolled. Of the 312 patients, 40 (13%) had positive TST or clinical risk factors for LTBI and received INH; none developed TB after KT. Of the remaining 272 patients, 4 (6%) of 71 with positive ELISPOT assay developed TB after KT, whereas none of the 201 patients with negative (n = 171) or indeterminate ELISPOTs (n = 30) developed TB after KT (rate difference between positive and negative/indeterminate ELISPOT, 3.3 per 100 person‐years [95% CI 1.4–5.1, p<0.001]). Positive ELISPOT results predict subsequent development of TB in KT recipients in whom LTBI cannot be detected by TST or who lack clinical risk factors for LTBI.     

Distinction Between Persistent and Transient Infection in a Bovine Viral Diarrhoea (BVD) Control Programme: Appropriate Interpretation of Real‐Time RT‐PCR and Antigen‐ELISA Test Results

Control of bovine viral diarrhoea (BVD) in Belgium is currently implemented on a voluntary basis at herd level and mainly relies on detection and culling of persistently infected (PI) animals. The present field study was conducted during the winter of 2010/2011 to assess the performances of diagnostic assays used in the testing scheme for BVD as proposed by the two Belgian regional laboratories. Individual blood samples were collected from 4972 animals, and individual samples from the same herd were pooled (maximum of 30 individual samples per pool) and screened for the presence of Bovine Viral Diarrhoea Virus (BVDV)‐specific RNA using a commercial real‐time RT‐PCR test (ADIAGENE). Individual samples from positive pools were then tested in parallel with the same RT‐PCR test and with an antigen‐capture ELISA test (IDEXX) to detect viremic animals. This study demonstrated that individual results differed according to the type of assay used (P < 0.001): 140 animals (2.8%) were positive by RT‐PCR and 72 (1.4%) by antigen‐ELISA. A second blood sample was taken 40 days later from 74 PCR positive animals to detect persistent viremia: 17 (23%) of these were still PCR positive and considered to be PI and the 57 that no longer tested positive were assumed to be transiently infected (TI) animals. All PI animals were positive also by antigen‐ELISA at both time points. Among TI animals, 10 (16%) were positive by antigen‐ELISA at the first but none at the second sampling. A highly significant difference in cycle threshold (C_t) values obtained by RT‐PCR was observed between PI and TI animals. ROC analysis was performed to establish thresholds to confirm with high probability that an animal is PI, based on the result of RT‐PCR test performed on a single individual blood sample.     

Twelve‐year mortality in adults initiating antiretroviral therapy in South Africa

Introduction : South Africa has the largest number of individuals living with HIV and the largest antiretroviral therapy (ART) programme worldwide. In September 2016, ART eligibility was extended to all 7.1 million HIV‐positive South Africans. To ensure that further expansion of services does not compromise quality of care, long‐term outcomes must be monitored. Few studies have reported long‐term mortality in resource‐constrained settings, where mortality ascertainment is challenging. Combining site records with data linked to the national vital registration system, sites in the International Epidemiology Databases to Evaluate AIDS Southern Africa collaboration can identify >95% of deaths in patients with civil identification numbers (IDs). This study used linked data to explore long‐term mortality and viral suppression among adults starting ART in South Africa. Methods : The study was a cohort analysis of routine data on adults with IDs starting ART 2004–2015 in five large ART cohorts. Mortality was estimated overall and by gender using the Kaplan‐Meier estimator and Cox's proportional hazards regression. Standardized mortality ratios (SMRs) were calculated by dividing observed numbers of deaths by numbers expected if patients had been HIV‐negative. Viral suppression in patients with viral loads (VLs) in their last year of follow‐up was the secondary outcome. Results : Among 72,812 adults followed for 350,376 person years (pyrs), the crude mortality rate was 3.08 (95% CI 3.02–3.14)/100 pyrs. Patients were predominantly female (67%) and the percentage of men initiating ART did not increase. Cumulative mortality 12 years after ART initiation was 23.9% (33.4% male and 19.4% female). Mortality peaked in patients enrolling in 2007–2009 and was higher in men than women at all durations. Observed mortality rates were higher than HIV‐negative mortality, decreasing with duration. By 48 months, observed mortality was close to that in the HIV‐negative population, and SMRs were similar for all baseline CD4 strata. Three‐quarters of patients had VLs in their last year, and 86% of these were virally suppressed. Conclusions : The South African ART programme has shown a remarkable ability to initiate and manage patients successfully over 12 years, despite rapid expansion. With further scale‐up, testing and initiating men on ART must be a national priority.     

Antenatal care and uptake of HIV testing among pregnant women in sub-Saharan Africa: a cross-sectional study

Introduction

Current guidelines recommend inclusion of HIV testing in routine screening tests for all pregnant women. For this reason, antenatal care (ANC) represents a vital component of efforts to prevent mother-to-child transmission (PMTCT) of HIV. To elucidate the relationship between ANC services and HIV testing among pregnant women in sub-Saharan Africa, we undertook an analysis of data from four countries.

Methods

Four countries (Congo, Mozambique, Nigeria and Uganda) were purposively selected to represent unique geographical regions of sub-Saharan Africa. Using Demographic and Health Survey datasets, weighted crude and adjusted logistic regression models were used to explore factors that influenced HIV testing as part of ANC services. The study was approved by the Institutional Review Board of the University of Arizona.

Results

Pooled results showed that 60.7% of women received HIV testing as part of ANC. Ugandan women had the highest rate of HIV testing as part of ANC (81.5%) compared with women in Mozambique (69.4%), Nigeria (54.4%) and Congo (45.4%). Difficulty reaching a health facility was a barrier in Congo and Mozambique but not Nigeria or Uganda. HIV testing rates were lower in rural areas, among the poorest women, the least educated and those with limited knowledge of HIV. In every country, crude regression analyses showed higher odds of being tested for HIV if women received their ANC services from a skilled attendant compared with an unskilled attendant. After adjusting for confounders, women in the total sample had 1.78 (99% CI: 1.45–2.18) times the odds of having an HIV test as part of their ANC if they went to a skilled attendant compared with an unskilled attendant.

Conclusions

There is a need for integration of HIV testing into routine ANC service to increase opportunities for PMTCT programmes to reach HIV-positive pregnant women. Attention should be paid to the expansion of outreach services for women in rural settings, and to the training, supervision and integration of unskilled attendants into formal maternal and child health programmes. Education of pregnant women and their communities is needed to increase HIV knowledge and reduce HIV stigma.     

Changes in Bone Mineral Density,Body Composition,Vitamin D Status,and Mineral Metabolism in Urban HIV‐Positive South African Women Over 12 Months

Human immunodeficiency virus (HIV) infection and antiretroviral therapy (ART) are associated with bone loss and poor vitamin D status in white populations, though their relative roles are not known. No previous studies have examined longitudinal changes in areal bone mineral density (aBMD), measured by dual‐energy X‐ray absorptiometry (DXA), or in vitamin D status in HIV‐positive African women. Of 247 premenopausal, urban, black African women from Soweto, South Africa, initially recruited, 187 underwent anthropometry, DXA scanning and blood and urine collections at both baseline and 12 months. Of these, 67 were HIV‐negative throughout (Nref), 60 were HIV‐positive with preserved CD4 counts at baseline (Ppres), and 60 were HIV‐positive with low CD4 counts at baseline, eligible for ART by South African standards of care at the time (Plow). No participant had been exposed to ART at baseline. By 12 months, 51 Plow women had initiated ART, >85% of whom took combined tenofovir disoproxil fumarate (TDF), lamivudine, and efavirenz. By 12 months, Plow and Nref, but not Ppres, increased in body weight and fat mass (group‐by‐timepoint p ≤ 0.001, p = 0.002, respectively). Plow had significant decreases in aBMD of 2% to 3%, before and after size adjustment, at the femoral neck (p ≤ 0.002) and lumbar spine (p ≤ 0.001), despite significant weight gain. These decreases were associated with increased bone turnover but there were no significant differences or changes over time in vitamin D status, serum phosphate concentrations, or renal phosphate handling. Excluding data from nine Plow women unexposed to ART and 11 Ppres women who had initiated ART accentuated these findings, suggesting the bone loss in Plow was related to ART exposure. This is the first study describing DXA‐defined bone loss in HIV‐positive Sub‐Saharan African women in association with ART. Further work is required to establish if bone loss continues with ongoing ART and, if so, whether this results in increased fracture rates. © 2017 American Society for Bone and Mineral Research.     

Barriers and facilitators to HIV testing among young men who have sex with men and transgender women in Kingston,Jamaica: a qualitative study

Introduction : Young men who have sex with men (MSM) in Jamaica have the highest HIV prevalence in the Caribbean. There is little information about HIV among transgender women in Jamaica, who are also overrepresented in the Caribbean epidemic. HIV‐related stigma is a barrier to HIV testing among Jamaica's general population, yet little is known of MSM and transgender women's HIV testing experiences in Jamaica. We explored perceived barriers and facilitators to HIV testing among young MSM and transgender women in Kingston, Jamaica. Methods : We implemented a community‐based research project in collaboration with HIV and lesbian, gay, bisexual and transgender (LGBT) agencies in Kingston. We held two focus groups, one with young (aged 18–30 years) transgender women (n = 8) and one with young MSM (n = 10). We conducted 53 in‐depth individual semi‐structured interviews focused on HIV testing experiences with young MSM (n = 20), transgender women (n = 20), and community‐based key informants (n = 13). We conducted thematic analysis to identify, analyze, and report themes. Results : Participant narratives revealed social‐ecological barriers and facilitators to HIV testing. Barriers included healthcare provider mistreatment, confidentiality breaches, and HIV‐related stigma: these spanned interpersonal, community and structural levels. Healthcare provider discrimination and judgment in HIV testing provision presented barriers to accessing HIV services (e.g. treatment), and resulted in participants hiding their sexual orientation and/or gender identity. Confidentiality concerns included: clinic physical arrangements that segregated HIV testing from other health services, fear that healthcare providers would publicly disclose their status, and concerns at LGBT‐friendly clinics that peers would discover they were getting tested. HIV‐related stigma contributed to fear of testing HIV‐positive; this intersected with the stigma of HIV as a “gay” disease. Participants also anticipated healthcare provider mistreatment if they tested HIV positive. Participants identified individual (belief in benefits of knowing one's HIV status), social (social support) and structural (accessible testing) factors that can increase HIV testing uptake. Conclusions : Findings suggest the need for policy and practice changes to enhance confidentiality and reduce discrimination in Jamaica. Interventions to challenge HIV‐related and LGBT stigma in community and healthcare settings can enhance access to the HIV prevention cascade among MSM and transgender youth in Jamaica.