The Scale-up of PrEP for HIV Prevention in High-risk Women in Sub-Saharan Africa PDF Download

Author: H. Grant
Publisher:
ISBN:
Category :
Languages : en
Pages :

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Author: Jonathan Crush
Publisher: African Books Collective
ISBN: 1920409491
Category : Medical
Languages : en
Pages : 44

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South Africa's gold mining workforce has the highest prevalence rates of tuberculosis and HIV infection of any industrial sector in the country. The contract migrant labour system, which has long outlived apartheid, is responsible for this unacceptable situation. The spread of HIV to rural communities in Southern Africa is not well understood. The accepted wisdom is that migrants leave for the mines, engage in high-risk behaviour, contract the virus and return to infect their rural partners. This model fails to deal with the phenomenon of rural-rural transmission and cases of HIV discordance (when the female migrant is infected and the male migrant not). Nor does it reveal whether all rural partners are equally at risk of infection. This study examines the vulnerability of rural partners in southern Mozambique and southern Swaziland, which are two major source areas for migrant miners. It presents the results of surveys with miners and partners in these two sending-areas and affords the opportunity to compare two different mine-sending areas. The two areas are not only geographically and culturally different, they have had contrasting experiences with the mine labour system over the last two decades. The spread of HIV in Southern Africa in the 1990s coincided with major downsizing and retrenchment in the gold mining industry which impacted differently on Mozambique and Swaziland. Swaziland has been in decline as a source of mine migrants while Mozambique remained a relatively stable source of mine migrants. The study therefore aims not only to shed light on vulnerability in mine sending areas, but also to draw out any contrasts that might exist between two mine-sending areas that were inserted into the mine migrant labour system in different ways during the expansion of the HIV epidemic.

Author: Valentine Adhiambo Wanga
Publisher:
ISBN:
Category :
Languages : en
Pages : 82

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The rollout of pre-exposure prophylaxis (PrEP) for HIV prevention to priority populations, including young women, is expanding in sub-Saharan Africa. However, existing barriers to PrEP rollout at the individual, community and policy levels could slow progress and impede the success of PrEP implementation programs. In order to achieve success in HIV prevention, it is crucial to address these barriers, particularly among young women, a population especially vulnerable to HIV. In this dissertation, we evaluated the links among risk perception, sexual behavior and PrEP adherence in serodiscordant couples, evaluated the impact of incorporating HIVST in PrEP delivery for young women and assessed the cost of delivering PrEP to young women. In Aim 1, we used data from HIV-negative adults enrolled in a study of PrEP and antiretroviral therapy for HIV-serodiscordant couples in Kenya and Uganda to examine associations between: 1) condom use and risk perception and 2) risk perception and PrEP adherence. In Aim 2, we offered HIV self-testing (HIVST) to young women enrolled in a PrEP implementation study in two family planning clinics and assessed satisfaction with HIV testing and clinic experience, and the impact of HIVST on PrEP delivery procedures. In Aim 3, using the same population as that in Aim 2, we used micro-costing methods to estimate the incremental cost of delivering PrEP to young women. We found that sexual behavior aligned with perceived HIV risk, which can facilitate an HIV-negative individual's decisions about PrEP use. Additionally, we found HIVST to be feasible and acceptable for young women using PrEP, highlighting the need to evaluate its utility to streamline PrEP delivery and provide more testing options for young women on PrEP. Lastly, using practical data from PrEP implementation, we estimated the cost of delivering PrEP to young women, providing valuable data to inform budget impact and cost-effectiveness analyses as well as local resource allocation for scale-up of PrEP delivery to young women. Collectively, these studies addressed some of the barriers to PrEP delivery, proposed solutions to these barriers and drew attention to priority research needs for PrEP delivery to young women.

Author: King K. Holmes
Publisher: World Bank Publications
ISBN: 1464805253
Category : Medical
Languages : en
Pages : 1027

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Infectious diseases are the leading cause of death globally, particularly among children and young adults. The spread of new pathogens and the threat of antimicrobial resistance pose particular challenges in combating these diseases. Major Infectious Diseases identifies feasible, cost-effective packages of interventions and strategies across delivery platforms to prevent and treat HIV/AIDS, other sexually transmitted infections, tuberculosis, malaria, adult febrile illness, viral hepatitis, and neglected tropical diseases. The volume emphasizes the need to effectively address emerging antimicrobial resistance, strengthen health systems, and increase access to care. The attainable goals are to reduce incidence, develop innovative approaches, and optimize existing tools in resource-constrained settings.

Author: David Allen Roberts
Publisher:
ISBN:
Category :
Languages : en
Pages : 0

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Daily oral tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) as HIV pre-exposure prophylaxis (PrEP) is a safe and effective method for HIV prevention and offers potential to substantially reduce HIV incidence in sub-Saharan Africa. Mathematical models are commonly used to project the cost-effectiveness of investments in PrEP in comparison to alternative resource allocation strategies. Predictive modeling can also identify individuals at elevated risk who may benefit most from PrEP. The studies contained in this dissertation address fundamental issues in estimating the cost and potential impact of PrEP implementation in sub-Saharan Africa. First, we estimated the cost of routine PrEP delivery through maternal and child health (MCH) and family planning (FP) clinics in western Kenya (Chapter 1). PrEP delivery through MCH and FP leverages existing service delivery platforms that reach a large fraction of women at elevated HIV risk. Using data from over 20,000 PrEP encounters through 16 clinics, we estimated that the cost per client-month of PrEP dispensed to be $26.52 (2017 USD), with personnel (43%), drugs (25%), and laboratory testing (14%) accounting for the majority of costs. Postponing creatinine testing from PrEP initiation to the first follow-up visit could save 8% of total program costs. Under Ministry of Health implementation, we projected costs would decrease by 38%, but estimates were sensitive to changes in PrEP uptake and retention. Second, we used an individual-based transmission model calibrated to Eswatini to evaluate the sensitivity of model projections of PrEP impact and efficiency to specification HIV exposure heterogeneity (Chapter 2). A common method for introducing HIV exposure heterogeneity into a model is to stratify the population into “risk group” categories with different average sexual behavior parameters, allowing PrEP coverage to vary by risk group without having to explicitly represent individual partnerships. We found that this specification leads to a sharp tradeoff between total impact and efficiency depending on PrEP coverage levels in each risk group. In comparison, PrEP use among the general population is projected to be two times more efficient if PrEP use is prioritized during partnerships and over six times more efficient if use is further prioritized among individuals with HIV-positive partners. In addition, large incidence reductions can be achieved at low levels of PrEP coverage if PrEP use in the general population is concentrated when HIV exposure is more likely, but high levels of PrEP coverage are needed if time-varying individual risk is ignored. Third, we developed and validated HIV risk prediction models incorporating individual-level and geospatial covariates using data from nearly 20,000 individuals in a population-based cohort in rural KwaZulu-Natal, South Africa (Chapter 3). Individual-level predictors included demographic, socioeconomic, and sexual behavior measures, while geospatial covariates included local estimates of community HIV prevalence and viral load. We compared full models to simpler models restricted to only individual-level covariates or only age and geospatial covariates. Models using only age group and geospatial covariates had similar performance (women: area under the receiver operating characteristic curve (AUROC) = 0.65, men: AUROC = 0.71) to the full models (women: AUROC = 0.68, men: AUROC = 0.72). In addition, geospatial models more accurately identified high incidence regions than individual-level models; the 20% of the study area with the highest predicted risk accounted for 60% of the high incidence areas when using geospatial models but only 13% using models with only individual-level covariates. These findings have implications for PrEP policies. Our primary costing study identified service delivery bottlenecks and cost drivers that can inform efforts to streamline PrEP delivery. By ignoring the alignment of PrEP use with time-varying individual HIV exposure, models using a risk group specification may overestimate the cost and underestimate the impact of widespread PrEP availability. Finally, local estimates of HIV prevalence can help identify individuals and areas to prioritize for PrEP services to maximize impact.

Author: S. S. Abdool Karim
Publisher: Cambridge University Press
ISBN: 9781139487931
Category : Medical
Languages : en
Pages : 612

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This second edition of the book provides up-to-date information on new drugs, new proven HIV prevention interventions, a new chapter on positive prevention, and current HIV epidemiology. This definitive text covers all aspects of HIV/AIDS in South Africa, from basic science to medicine, sociology, economics and politics. It has been written by a highly respected team of South African HIV/AIDS experts and provides a thoroughly researched account of the epidemic in the region.

Author: Jillian Pintye
Publisher:
ISBN:
Category :
Languages : en
Pages : 94

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Women in sub-Saharan Africa have substantial risk of acquiring HIV acquisition during and soon after pregnancy. Additionally, acute HIV infection among pregnant and breastfeeding women poses a double burden in that acute maternal HIV accounts for nearly one-third of all mother-to-child transmissions of HIV (MTCT). To reach global targets for elimination of MTCT and HIV prevention for mothers, it is critical to integrate effective primary HIV prevention strategies into maternal and child health (MCH) services. Tenofovir disoproxil fumarate (TDF)-based pre-exposure prophylaxis (PrEP) prevents HIV infection in adherent women. The World Health Organization (WHO) recommends PrEP for all individuals, including pregnant and breastfeeding women, at substantial HIV risk (defined as HIV residence in regions where HIV incidence is >3%). Programmatic delivery of PrEP for pregnant women is currently being considered in high-prevalence regions, though implementation approaches that efficiently optimize the benefit of PrEP during pregnancy have not been defined. Additionally, although WHO guidelines support PrEP use in pregnancy, national committees have differed in their conclusions. For example, PrEP use during pregnancy is supported by Kenyan antiretroviral guidelines but the lack of complete safety data led PrEP to be contraindicated for pregnant women in the current South African PrEP guidelines. As countries expand programmatic delivery of PrEP to pregnant women, it is important to understand motivations and beliefs for using PrEP during pregnancy to address concerns unique to this population. The studies within this dissertation address the implementation science gaps described above for the delivery of PrEP for HIV prevention to pregnant and postpartum in sub-Saharan Africa. To inform efficient PrEP delivery models, we present an empiric risk score for identifying pregnant and postpartum Kenyan women at highest risk for HIV acquisition who would mostly benefit from PrEP while reducing unnecessary exposure among low-risk women. Using data that could be easily collected in standard MCH clinic settings without additional laboratory diagnostics, our risk score identified 56% of pregnant women who acquired HIV among just 16% of women. Using register data from 62 antenatal MCH facilities throughout Kenya, we further estimated the absolute number and proportion of HIV-uninfected pregnant women in Kenya who could be offered PrEP under different public health approaches, including offering PrEP universally or based on either regional HIV prevalence and/or individual-level HIV risk factors. We found that offering PrEP only to pregnant women in the region with highest HIV prevalence (Nyanza) would reduce PrEP use among low-risk women by 74%, but exclude 63% of women with high risk for HIV based on individual-level characteristics nationally. To complement service delivery data, we also assessed experiences of using PrEP during pregnancy among HIV-uninfected Kenyan women in HIV-serodiscordant couples who became pregnant while using PrEP. The personal experiences of women with direct exposure to PrEP during pregnancy offers valuable insights for informing development of effective PrEP messaging strategies and programs. Finally, we evaluate whether adverse perinatal outcomes were more frequent in a cohort of Kenyan and Ugandan HIV-infected women who used TDF-containing antiretroviral therapy (ART) during pregnancy compared to HIV-infected women who used ART during pregnancy that did not contain TDF. Our findings support the growing evidence that prolonged prenatal TDF use is not associated with adverse perinatal outcomes and contribute to the few prospective studies evaluating the safety of TDF use during pregnancy from African cohorts. The studies within this dissertation aim to address these implementation science gaps and inform optimal and effective delivery of PrEP for HIV prevention to pregnant and postpartum in sub-Saharan Africa.

Author: Jennifer Velloza
Publisher:
ISBN:
Category :
Languages : en
Pages : 140

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Daily, oral pre-exposure prophylaxis (PrEP) with emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) is a highly efficacious HIV prevention strategy for key populations at high risk of HIV, including women, in sub-Saharan Africa. However, open-label studies and demonstration projects have reported that young women have difficulty adhering to PrEP over time, which limits its effectiveness as a prevention option. PrEP projects are now exploring modifiable barriers to adherence among women to maximize its public health benefit as it is being rapidly rolled out worldwide. Mental health factors, including depression, traumatic stress symptoms, and stigma, are highly prevalent among women at high risk of HIV acquisition and are barriers to medication use and health promotion behaviors. However, there has been little consideration until now of how such factors might also influence PrEP adherence among women in sub-Saharan Africa. The aims in this dissertation attempt to fill this research gap by: 1) exploring the impact of depressive symptoms on PrEP adherence among women; 2) examining the mechanisms by which depressive symptoms influence PrEP adherence; 3) describing the broader context of HIV-related stigma and empowerment on PrEP use; and 4) integrating depression screening into HIV care delivery to improve mental health and HIV outcomes. Two studies have examined the influence of depression on PrEP adherence and found that depressive symptoms have a negative effect on daily PrEP use for transgender women and men who have sex with men. Ours is the first study to examine links between depression and PrEP adherence among cisgender women in sub-Saharan Africa. We used marginal structural models to estimate the association between depressive symptoms and PrEP adherence while adjusting for time-varying confounding by sexual behavior, stigma, and social support. We found that probable depression was significantly associated with poor PrEP adherence among women, but not men, suggesting that mental health and depression experiences have differential impact on HIV prevention behaviors by gender. This work also led to questions about the mechanism of this association and whether there were important mediators of the relationship between depression and PrEP adherence that could explain at least some of this total effect. We conducted a mediation analysis using marginal structural models to estimate the controlled direct effect of depression on PrEP adherence, after accounting for the potentially mediating influence of HIV-related stigma, social support, and optimism about PrEP effectiveness. We found a significant negative direct influence of depression on PrEP adherence but this relationship was not strongly mediated by other psychosocial factors. Future research is needed to explore additional potential mediators of this relationship and identify areas for intervention. Qualitative research methods allow us to explore narratives around PrEP use, experiences of stigma, and concerns about mental health that are not captured by quantitative data. We analyzed serial in-depth interview data from a cohort of young women using PrEP to understand the broader context around their pill-taking, mental health, and relationships. In this study, we found that women described experiences of HIV-related stigma when they began taking PrEP which influenced their ability to take PrEP and their feelings about themselves. However, over time, women became more empowered to use PrEP and combat HIV-related stigma by becoming "ambassadors" of PrEP in their communities. This work highlights the potential for empowerment-based interventions to improve PrEP adherence and reduce community stigma and the richness of serially collected qualitative data. In Aims 1-3, we found evidence of a strong negative impact of depression on PrEP adherence and high rates of depression among women at risk of HIV. This work suggests that integrated depression screening and treatment with HIV prevention service delivery could improve mental health outcomes and PrEP effectiveness for women. To support the design of future integrated interventions, we conducted cognitive interviews assessing comprehensibility and acceptability of a widely used depression screening tool in the context of a PrEP delivery intervention among pregnant and postpartum women in Thika, Kenya. We found that the tool was largely acceptable and well-understood, but several minor changes to item wording and instructions would improve symptom screening and linkage to mental health care. These changes are part of our recommendations for the future use of this tool. The collective results presented in this dissertation illustrate the negative influence of depression and related psychosocial factors on consistent PrEP use for women, opportunities for stigma-reduction and empowerment-based intervention approaches to improve mental health symptoms and PrEP use in this population, and the potential to administer depression screening within the context of HIV prevention service delivery. This work contributes to a better understanding of the links between mental health and HIV risk for women and highlights the importance of integrating mental health and empowerment-based interventions with PrEP delivery to improve mental health screening and treatment and PrEP effectiveness for women in sub-Saharan Africa.

Author: Maria Pyra
Publisher:
ISBN:
Category :
Languages : en
Pages : 69

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HIV incidence remains disproportionately high for women, particularly young women, in Sub-Saharan Africa; women are also at heightened risk while pregnant, which may account for a substantial portion of their adult lives. Although HIV pre-exposure prophylaxis (PrEP) in pill form is known to be efficacious for women, there remain unanswered questions about adherence in open-label and real-world settings, as well as regarding the effectiveness of PrEP during pregnancy. In the work presented in this dissertation, we first examined how women used PrEP in an open-label demonstration project and particularly, how adherence was related to HIV risk behaviors. Second, to better assess adherence, we evaluated the sensitivity and specificity of a biomarker among East African men and women using PrEP. Finally, we examined the effect of pregnancy on PrEP concentrations. First, we found that women in known serodiscordant relationships were able to take PrEP effectively; more than half took PrEP during their entire risk period, with ≥6 doses for most weeks when on PrEP. HIV incidence was reduced 93% (95% CI 77%-98%) for all women and 91% (95% CI 29%-99%) among women under 25 years old. In further analysis, we found evidence of four adherence trajectories and two risk behavior trajectories over the first six months of PrEP use. Women with a declining risk behavior trajectory were more likely to have a declining adherence trajectory, while women with steady risk were more likely to have high steady adherence; this supports the idea of prevention-effective adherence, which optimizes PrEP use. In the second aim, we found low sensitivities for the adherence biomarker tenofovir-diphosphate, using thresholds established in U.S. populations. Adherence counseling based on biomarkers should carefully consider the trade-offs between sensitivity and specificity. Finally, we found that concentrations of PrEP are significantly lower in pregnant women compared to non-pregnant women, as well as during pregnancy compared to pre-pregnancy, after adjusting for adherence. Additional pharmacology and epidemiology studies are needed to determine if PrEP dosing should be altered to sustain systemic levels of tenofovir during pregnancy.

Author: Ezekiel Kalipeni
Publisher:
ISBN:
Category : Business & Economics
Languages : en
Pages : 580

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HIV/AIDS is holding firm as one of the worst diseases in history and the leading cause of death in sub-Saharan Africa. This collection of essays shares various case studies from sub-Saharan Africa and one from the African Diaspora that demonstrate how multi-faceted women's lives, and thus their HIV risk, are. Notwithstanding women's marginalisation, the essays in this volume maintain that women in Africa are not merely puppets of globalisation, cultural norms, or biological imperatives, but rather agents in their own livelihoods. In each case we see women presented with many challenges that they must navigate in order to mitigate their HIV risk. Some of the most trying challenges are based on economic and political structures that occur at various scales, from the global to the household. While structural factors are indeed important, the authors in this volume also show that traditional norms, cultural beliefs, and gender roles are equally necessary to consider when planning HIV prevention programs. Gender disempowerment is of particular importance, as it is seen in all of these case studies. In order for the HIV epidemic to dissipate in sub-Saharan Africa, prevention programs that truly understand the local circumstances and strive for gender equality must be instituted immediately and broadly. The book is divided into three parts, each concentrating on a different aspect of women and HIV/AIDS in sub-Saharan Africa. The first part provides case studies of the social, political, economic, cultural, and geographic dynamics that play into women's and girls' risk for the virus. The second part transitions into case studies of prevention, concentrating on condom use. The chapters in the final section expand on Part II by highlighting other ways of promoting HIV/AIDS awareness and prevention across the region. In short, the papers in this volume highlight the complicated decision making processes that women in countries of sub-Saharan Africa must make when it comes to HIV risk. In many cases, women find themselves in economically dependent relationships with men whereby they must stay in sexually risky situations to be able to feed themselves and, very often, their children.