Allison Zerbe

Antiretroviral Therapy: A Promising HIV Prevention Strategy?

The use of antiretroviral therapy (ART) has been associated with significant improvement in morbidity and survival of persons living with HIV. In addition, recently, there has also been intense interest in the potential impact of ART on HIV transmission and consequently on the trajectory of the HIV epidemic globally. Evidence from mathematical modeling analyses and observational and ecological studies supports the potential for ART as prevention. However, definitive data from clinical trials are awaited. In the United States, the feasibility and potential of using ART as a prevention strategy presents particular challenges: the large number of individuals with undiagnosed HIV; the predominance of disenfranchised individuals affected by the epidemic; evidence of delay in engagement in HIV care after diagnosis with attendant late initiation of ART; and difficulties with consistent long-term adherence to ART and concerns regarding long-term risk-behavior change. Thus, for this novel effort to succeed, a multidimensional approach is necessary that must include policy changes, social mobilization, and improved access to clinical and supportive services for persons living with HIV, with a particular focus on the unique needs of at-risk populations, combined with engagement of all cadres of health care providers and community constituencies.

‘Men usually say that HIV testing is for women’: gender dynamics and perceptions of HIV testing in Lesotho

In Lesotho, men have lower HIV testing rates, less contact with HIV clinical settings and less knowledge of HIV prevention than women. However, womens HIV prevalence has consistently remained higher than mens. This paper explores gender norms, sexual decision-making and perceptions of HIV among a sample of Basotho men and women in order to understand how these factors influence HIV testing and prevention. A total of 200 women and 30 men were interviewed in Lesotho between April and July 2011. Participants reported reluctance among women to share information about HIV prevention and testing with men, and resistance of men to engage with testing and/or prevention services. Findings demonstrate a critical need for educational initiatives for men, among other strategies, to engage men with HIV testing and prevention. This study highlights how gender issues shape perceptions of HIV and sexual decision-making and underlines the importance of engaging men along with women in HIV prevention efforts. More studies are needed to determine the most effective strategies to inform and engage men.

HIV viraemia and mother-to-child transmission risk after antiretroviral therapy initiation in pregnancy in Cape Town, South Africa.

Maternal HIV viral load (VL) drives mother‐to‐child HIV transmission (MTCT) risk but there are few data from sub‐Saharan Africa, where most MTCT occurs. We investigated VL changes during pregnancy and MTCT following antiretroviral therapy (ART) initiation in Cape Town, South Africa.

Plasma viraemia in HIV-positive pregnant women entering antenatal care in South Africa

Plasma HIV viral load (VL) is the principle determinant of mother‐to‐child HIV transmission (MTCT), yet there are few data on VL in populations of pregnant women in sub‐Saharan Africa. We examined the distribution and determinants of VL in HIV‐positive women seeking antenatal care (ANC) in Cape Town, South Africa.

Intimate partner violence experienced by HIV-infected pregnant women in South Africa: a cross-sectional study

Objectives Intimate partner violence (IPV) during pregnancy may be common in settings where HIV is prevalent but there are few data on IPV in populations of HIV-infected pregnant women in Southern Africa. We examined the prevalence and correlates of IPV among HIV-infected pregnant women. Setting A primary care antenatal clinic in Cape Town, South Africa. Participants 623 consecutive HIV-infected pregnant women initiating lifelong antiretroviral therapy. Measures IPV, depression, substance use and psychological distress were assessed using the 13-item WHO Violence Against Women questionnaire, the Edinburgh Postnatal Depression Scale (EPDS), Alcohol and Drug Use Disorders Identification Tests (AUDIT/DUDIT) and the Kessler 10 (K-10) scale, respectively. Results The median age in the sample was 28 years, 97% of women reported being in a relationship, and 70% of women reported not discussing and/or agreeing on pregnancy intentions before conception. 21% of women (n=132) reported experiencing ≥1 act of IPV in the past 12 months, including emotional (15%), physical (15%) and sexual violence (2%). Of those reporting any IPV (n=132), 48% reported experiencing 2 or more types. Emotional and physical violence was most prevalent among women aged 18–24 years, while sexual violence was most commonly reported among women aged 25–29 years. Reported IPV was less likely among married women, and women who experienced IPV were more likely to score above threshold for substance use, depression and psychological distress. In addition, women who reported not discussing and/or not agreeing on pregnancy intentions with their partner prior to conception were significantly more likely to experience violence. Conclusions HIV-infected pregnant women in the study reported experiencing multiple forms of IPV. While the impact of IPV on maternal and child health outcomes in the context of HIV infection requires further research attention, IPV screening and support services should be considered within the package of routine care for HIV-infected pregnant women. Trial registration number NCT01933477.

Financial Incentives for Linkage to Care and Viral Suppression Among HIV-Positive Patients: A Randomized Clinical Trial (HPTN 065)

Importance Achieving linkage to care and viral suppression in human immunodeficiency virus (HIV)-positive patients improves their well-being and prevents new infections. Current gaps in the HIV care continuum substantially limit such benefits. Objective To evaluate the effectiveness of financial incentives on linkage to care and viral suppression in HIV-positive patients. Design, Setting, and Participants A large community-based clinical trial that randomized 37 HIV test and 39 HIV care sites in the Bronx, New York, and Washington, DC, to financial incentives or standard of care. Interventions Participants at financial incentive test sites who had positive test results for HIV received coupons redeemable for

Implementation and Operational Research: Postpartum Transfer of Care Among HIV-Infected Women Initiating Antiretroviral Therapy During Pregnancy.

125 cash-equivalent gift cards upon linkage to care. HIV-positive patients receiving antiretroviral therapy at financial incentive care sites received

Frequency of Viremic Episodes in HIV-Infected Women Initiating Antiretroviral Therapy During Pregnancy: A Cohort Study

70 gift cards quarterly, if virally suppressed. Main Outcomes and Measures Linkage to care: proportion of HIV-positive persons at the test site who linked to care within 3 months, as indicated by CD4+ and/or viral load test results done at a care site. Viral suppression: proportion of established patients at HIV care sites with suppressed viral load (<400 copies/mL), assessed at each calendar quarter. Outcomes assessed through laboratory test results reported to the National HIV Surveillance System. Results A total of 1061 coupons were dispensed for linkage to care at 18 financial incentive test sites and 39 359 gift cards were dispensed to 9641 HIV-positive patients eligible for gift cards at 17 financial incentive care sites. Financial incentives did not increase linkage to care (adjusted odds ratio, 1.10; 95% CI, 0.73-1.67; P = .65). However, financial incentives significantly increased viral suppression. The overall proportion of patients with viral suppression was 3.8% higher (95% CI, 0.7%-6.8%; P = .01) at financial incentive sites compared with standard of care sites. Among patients not previously consistently virally suppressed, the proportion virally suppressed was 4.9% higher (95% CI, 1.4%-8.5%; P = .007) at financial incentive sites. In addition, continuity in care was 8.7% higher (95% CI, 4.2%-13.2%; P < .001) at financial incentive sites. Conclusions and Relevance Financial incentives, as used in this study (HPTN 065), significantly increased viral suppression and regular clinic attendance among HIV-positive patients in care. No effect was noted on linkage to care. Financial incentives offer promise for improving adherence to treatment and viral suppression among HIV-positive patients. Trial Registration clinicaltrials.gov Identifier: NCT01152918

In Utero Tenofovir Exposure Is Not Associated with Fetal Long Bone Growth

Background:The integration of antiretroviral therapy (ART) services into antenatal care for prevention of mother-to-child transmission has resulted in the need to transfer HIV-infected women to general ART clinics after delivery. Transfer of patients on ART between services may present a challenge to adherence and retention, but there are few data describing this step in the HIV care cascade for women starting ART in pregnancy. Methods:We described postpartum transfer of care in a cohort of women initiating ART during pregnancy and referred from integrated antenatal ART services to general ART clinics. Engagement in ART care at general ART clinics was assessed through routine laboratory records and telephonic interviews. Results:Overall, 279 postpartum women were transferred to ART clinics. By 5 months postreferral, between 74% and 91% of women had evidence of engagement at an ART clinic depending on the outcome definition. In a log-binomial model adjusted for age, CD4 cell count and being diagnosed with HIV in the current pregnancy, additional months on ART before delivery improved the likelihood of engagement in an ART clinic (relative risk: 1.05, 95% confidence interval: 1.00 to 1.09, P = 0.036). Conclusions:Postpartum transfer of ART care is an important and previously neglected step in the HIV care cascade for pregnant women. Even in this cohort of highly adherent women up to 25% did not remain in care after transfer. Retention is required across all steps of the cascade, including transfer of ART care after delivery, to maximize the benefits of ART for both maternal and child health.

‘There’s no place like home’: perceptions of home-based HIV testing in Lesotho

Background The numbers of human immunodeficiency virus (HIV)-infected women initiating antiretroviral therapy (ART) in pregnancy are increasing rapidly with global policy changes. There are widespread concerns about ART adherence during pregnancy and postpartum but few data on viral suppression (VS) over time in these populations. Methods We followed a cohort of 523 women in Cape Town, South Africa, initiating ART in pregnancy (once-daily tenofovir 300 mg, emtricitabine 200 mg, and efavirenz 600 mg) and achieving VS (<50 copies/mL). Participants provided specimens through 12 months postpartum for batched viral load (VL) testing separate from routine care. Analyses described the incidence of major (>1000 copies/mL) and minor (50-1000 copies/mL) viremic episodes (VEs) and factors associated with major VEs. Results In the cohort (median age, 28 years; median pre-ART VL, 3.99 copies/mL; 3% previously defaulted ART; 24% with previous exposure to short-course antiretrovirals), the median time of follow-up from VS was 322 days. Overall, 70% maintained VS throughout follow-up, 8% experienced minor VEs only, and at least 1 major VE was documented in 22% of women. In women with VEs, peak viremia (median, 3.79 log10 copies/mL) was linearly related to pre-ART VL. The incidence of major VEs after initial VS was independently associated with younger age, ART initiation during the third trimester, previous defaulting on ART, and postpartum follow-up. Conclusions Viremia appears to occur frequently, particularly postpartum, among HIV-infected women after initial VS in this setting. More intensive VL monitoring is warranted in this population; the immediate causes and long-term implications of VE require investigation.