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The Lancet | 2013

Extra-couple HIV transmission in sub-Saharan Africa: a mathematical modelling study of survey data

Steve E. Bellan; Kathryn J. Fiorella; Dessalegn Y. Melesse; Wayne M. Getz; Brian Williams; Jonathan Dushoff

BACKGROUND The proportion of heterosexual HIV transmission in sub-Saharan Africa that occurs within cohabiting partnerships, compared with that in single people or extra-couple relationships, is widely debated. We estimated the proportional contribution of different routes of transmission to new HIV infections. As plans to use antiretroviral drugs as a strategy for population-level prevention progress, understanding the importance of different transmission routes is crucial to target intervention efforts. METHODS We built a mechanistic model of HIV transmission with data from Demographic and Health Surveys (DHS) for 2003-2011, of 27,201 cohabiting couples (men aged 15-59 years and women aged 15-49 years) from 18 sub-Saharan African countries with information about relationship duration, age at sexual debut, and HIV serostatus. We combined this model with estimates of HIV survival times and country-specific estimates of HIV prevalence and coverage of antiretroviral therapy (ART). We then estimated the proportion of recorded infections in surveyed cohabiting couples that occurred before couple formation, between couple members, and because of extra-couple intercourse. FINDINGS In surveyed couples, we estimated that extra-couple transmission accounted for 27-61% of all HIV infections in men and 21-51% of all those in women, with ranges showing intercountry variation. We estimated that in 2011, extra-couple transmission accounted for 32-65% of new incident HIV infections in men in cohabiting couples, and 10-47% of new infections in women in such couples. Our findings suggest that transmission within couples occurs largely from men to women; however, the latter sex have a very high-risk period before couple formation. INTERPRETATION Because of the large contribution of extra-couple transmission to new HIV infections, interventions for HIV prevention should target the general sexually active population and not only serodiscordant couples. FUNDING US National Institutes of Health, US National Science Foundation, and J S McDonnell Foundation.


Multiple sclerosis and related disorders | 2016

Adherence and persistence to drug therapies for multiple sclerosis: A population-based study

Charity Evans; Ruth Ann Marrie; Feng Zhu; Stella Leung; Xinya Lu; Dessalegn Y. Melesse; Elaine Kingwell; Yinshan Zhao; Helen Tremlett

OBJECTIVE We aimed to estimate the prevalence and predictors of optimal adherence and persistence to the disease-modifying therapies (DMT) for multiple sclerosis (MS) in 3 Canadian provinces. METHODS We used population-based administrative databases in British Columbia (BC), Saskatchewan, and Manitoba. All individuals receiving DMT (interferon-B-1b, interferon-B-1a, and glatiramer acetate) between 1-January-1996 and 31-December-2011 (BC), 31-March-2014 (Saskatchewan), or 31-March-2012 (Manitoba) were included. One-year adherence was estimated using the proportion of days covered (PDC). Persistence was defined as time to DMT discontinuation. Regression models were used to assess predictors of adherence and persistence; results were pooled using random effects meta-analysis. RESULTS 4830 individuals were included. When results were combined, an estimated 76.4% (95% CI: 69.1-82.4%) of subjects exhibited optimal adherence (PDC ≥80%). Median time to discontinuation of the initial DMT was 1.9 years (95% CI: 1.6-2.1) in Manitoba, 2.8 years (95% CI: 2.5-3.0) in BC, and 4.0 years (95% CI: 3.5-4.6) in Saskatchewan. Age, sex and socioeconomic status were not associated with adherence or persistence. Individuals who had ≥4 physician visits during the year prior to the first DMT dispensation were more likely to exhibit optimal adherence compared to those with fewer (0-3) physician visits. CONCLUSIONS We observed adherence that is higher than what has been reported for other chronic diseases, and other non-population-based MS cohorts. Closer examination as to why adherence appears to be relatively better in MS and how adherence influences disease outcomes could contribute to our understanding of MS, and prove useful in the management of other chronic diseases.


Sexually Transmitted Infections | 2013

Patterns and trends in Pakistan's heterogeneous HIV epidemic

Tahira Reza; Dessalegn Y. Melesse; Leigh Anne Shafer; Momina Salim; Arshad Altaf; Altaf Sonia; Gayatri C. Jayaraman; Faran Emmanuel; Laura H. Thompson; James F. Blanchard

Background Considerable HIV transmission occurs among injection drug users (IDUs) in Pakistan and recently the HIV prevalence has been increasing among male (MSW), hijra (transgender; HSW) and female (FSW) sex workers. We describe past and estimate future patterns of HIV emergence among these populations in several cities in Pakistan. Methods The density of these key populations per 1000 adult men was calculated using 2011 mapping data from Karachi, Lahore, Faisalabad, Larkana, Peshawar and Quetta, and surveillance data were used to assess bridging between these key populations. We used the UNAIDS Estimation and Projection Package model to estimate and project HIV epidemics among these key populations in Karachi, Lahore, Faisalabad and Larkana. Results The density and bridging of key populations varied across cities. Lahore had the largest FSW population (11.5/1000 adult men) and the smallest IDU population (1.7/1000 adult men). Quetta had the most sexual and drug injection bridging between sex workers and IDUs (6.7%, 7.0% and 3.8% of FSW, MSW and HSW, respectively, reported injecting drugs). Model evidence suggests that by 2015 HIV prevalence is likely to reach 17–22% among MSWs/HSWs in Karachi, 44–49% among IDUs in Lahore and 46–66% among IDUs in Karachi. Projection suggests the prevalence may reach as high as 65–75% among IDUs in Faisalabad by 2025. HIV prevalence is also estimated to increase among FSWs, particularly in Karachi and Larkana. Conclusions There is a need to closely monitor regional and subpopulation epidemic patterns and implement prevention programmes customised to local epidemics.


Inflammatory Bowel Diseases | 2015

Patterns and Predictors of Long-term Nonuse of Medical Therapy Among Persons with Inflammatory Bowel Disease.

Dessalegn Y. Melesse; Laura E. Targownik; Harminder Singh; James F. Blanchard; Charles N. Bernstein

Background:To evaluate patterns and predictors of long-term nonuse of inflammatory bowel disease (IBD)–specific medications among patients with IBD. Methods:All incident cases of IBD diagnosed between 1987 and 2012 were identified from the population-based University of Manitoba IBD Epidemiology Database. Point prevalence of long-term medication nonuse (defined as no receipt of IBD-specific medications for a year or longer) was determined over calendar time and the course of disease. Cox proportional hazard regression analysis was performed to identify factors associated with delayed initiation and with becoming a long-term nonuser. Results:Among 6451 persons with IBD followed since 1987 (46.8% male, 47.8% with Crohns disease), 11.7% were not dispensed an IBD-specific medication within the first year and 6.2% within 5 years after diagnosis. Factors associated with delayed initiation included having Crohns disease (hazard ratio [HR] = 0.78, 95% confidence interval [CI], 0.73–0.83), lower socioeconomic status (HR = 0.91, 95% CI, 0.84–0.98), age more than 65 years (HR = 0.76, 95% CI, 0.67–0.86), and having any medical comorbidity. The prevalence of long-term nonuse consistently remained between 40% and 50% of persons with IBD across the study years. Patients with Crohns disease (HR = 1.14, 95% CI, 1.04–1.25), lower socioeconomic status (HR = 1.14, 95% CI, 1.02–1.27), patients with IBD-associated surgery (HR = 1.72, 95% CI, 1.51–1.96), or delayed initiation of first IBD medication were more likely to become long-term nonusers after initiation. Conclusions:At any given time, roughly half of all patients with IBD have not used IBD-specific medications in the previous year. Further work is required to evaluate the clinical implications of long-term medication nonuse in IBD.


The Lancet | 2018

Global epidemiology of use of and disparities in caesarean sections

Ties Boerma; Carine Ronsmans; Dessalegn Y. Melesse; Aluísio J. D. Barros; Fernando C. Barros; Liang Juan; Ann-Beth Moller; Lale Say; Ahmad Reza Hosseinpoor; Mu Yi; Dácio de Lyra Rabello Neto; Marleen Temmerman

In this Series paper, we describe the frequency of, trends in, determinants of, and inequalities in caesarean section (CS) use, globally, regionally, and in selected countries. On the basis of data from 169 countries that include 98·4% of the worlds births, we estimate that 29·7 million (21·1%, 95% uncertainty interval 19·9-22·4) births occurred through CS in 2015, which was almost double the number of births by this method in 2000 (16·0 million [12·1%, 10·9-13·3] births). CS use in 2015 was up to ten times more frequent in the Latin America and Caribbean region, where it was used in 44·3% (41·3-47·4) of births, than in the west and central Africa region, where it was used in 4·1% (3·6-4·6) of births. The global and regional increases in CS use were driven both by an increasing proportion of births occurring in health facilities (accounting for 66·5% of the global increase) and increases in CS use within health facilities (33·5%), with considerable variation between regions. Based on the most recent data available for each country, 15% of births in 106 (63%) of 169 countries were by CS, whereas 47 (28%) countries showed CS use in less than 10% of births. National CS use varied from 0·6% in South Sudan to 58·1% in the Dominican Republic. Within-country disparities in CS use were also very large: CS use was almost five times more frequent in births in the richest versus the poorest quintiles in low-income and middle-income countries; markedly high CS use was observed among low obstetric risk births, especially among more educated women in, for example, Brazil and China; and CS use was 1·6 times more frequent in private facilities than in public facilities.


Medicine | 2016

Heterogeneity Among Sex Workers in Overlapping HIV Risk Interactions With People Who Inject Drugs: A Cross-Sectional Study From 8 Major Cities in Pakistan.

Dessalegn Y. Melesse; Leigh Anne Shafer; Souradet Y. Shaw; Laura H. Thompson; Baser K. Achakzai; Sofia Furqan; Tahira Reza; Faran Emmanuel; James F. Blanchard

AbstractConcerns remain regarding the heterogeneity in overlapping human immunodeficiency virus (HIV) risk behaviors among sex workers (SWs) in Pakistan; specifically, the degree to which SWs interact with people who inject drugs (PWID) through sex and/or needle sharing.Following an in-depth mapping performed in 2011 to determine the size and distribution of key populations at highest risk of HIV acquisition in Pakistan, a cross-sectional biological and behavioral survey was conducted among PWID, female (FSWs), male (MSWs), and hijra/transgender (HSWs) sex workers, and data from 8 major cities were used for analyses. Logistic regression was used to identify factors, including city of residence and mode of SW-client solicitation, contributing to the overlapping risks of drug injection and sexual interaction with PWID.The study comprised 8483 SWs (34.5% FSWs, 32.4% HSWs, and 33.1% MSWs). Among SWs who had sex with PWID, HSWs were 2.61 (95% confidence interval [CI], 1.19–5.74) and 1.99 (95% CI, 0.94–4.22) times more likely to inject drugs than MSWs and FSWs, respectively. There was up to a 3-fold difference in drug injecting probability, dependent on where and/or how the SW solicited clients. Compared with SWs in Larkana, the highest likelihood of drug injection use was among SWs in Multan (OR = 4.52; 95% CI: 3.27–6.26), followed by those in Lahore, Quetta, and Faisalabad.Heterogeneity exists in the overlapping patterns of HIV risk behaviors of SWs. The risk of drug injection among SWs also varies by city. Some means of sexual client solicitation may be along the pathway to overlapping HIV risk vulnerability due to increased likelihood of drug injection among SWs. There is a need to closely to monitor the mixing patterns between SWs and PWID and underlying structural factors, such as means of sexual client solicitation, that mediate HIV risk, and implement prevention programs customized to local subepidemics.


Journal of Crohns & Colitis | 2016

Estimates of Disease Course in Inflammatory Bowel Disease Using Administrative Data: A Population-level Study.

Dessalegn Y. Melesse; Lisa M. Lix; Zoann Nugent; Laura E. Targownik; Harminder Singh; James F. Blanchard; Charles N. Bernstein

Background and Aims We sought develop a predictive model of disease course in inflammatory bowel disease [IBD] using health care utilization measures from administrative health data, and to apply this model to estimate disease course at a population level over time. Methods Study participants were IBD patients who were prospectively followed for a 1-year period between 2009 and 2010 in a Canadian clinic setting to assess their IBD disease course [i.e. remission, mild, moderate, severe]. Clinic data were linked with population-based administrative health data. A multivariable partial proportional odds model tested health care utilization measures that discriminated disease course groups. The model was applied to project the distribution of disease course for the Manitoba IBD population for 1995-2013. Results There were 407 participants (54.3% females, 64.4% Crohns disease [CD]) with mean age at diagnosis of 29.8 years [SD 14.9]. Forty-one per cent of participants were clinically in remission, while 14.0% had severe IBD. Mild, moderate or severe disease was associated with three or more gastroenterologist visits (odds ratio [OR] = 3.33, 95% confidence interval [CI]: 2.03-5.54) or three or more general practitioner visits [OR = 2.97, 95% CI: 1.44-6.37] with an IBD diagnosis and ≥1 radiology test [OR = 2.22, 95% CI: 1.31-3.80]. The percentages of the Manitoba IBD population in remission rose steadily from 1995 to 2013 [43.6 to 59.9%], while the percentages of individuals with mild, moderate or severe disease declined. Conclusion This study demonstrated that health care utilization measures from administrative data can be used to predict disease course in the IBD population.


Patient Preference and Adherence | 2017

Persistence to disease-modifying therapies for multiple sclerosis in a Canadian cohort

Dessalegn Y. Melesse; Ruth Ann Marrie; James F. Blanchard; Bo Nancy Yu; Charity Evans

Purpose To examine the long-term persistence to the first-line injectable disease-modifying therapies (DMTs) for multiple sclerosis (MS) and to identify the factors associated with nonpersistence. Patients and methods We used population-based administrative data from Manitoba, Canada. All adult subjects who were diagnosed with MS and dispensed a first-line injectable DMT (beta-interferon-1b, beta-interferon-1a, and glatiramer acetate) between 1996 and 2011 and had a minimum of 1 year of follow-up were included. The primary outcome was the median time to discontinuation of any DMT. The associations between potential predictors and persistence were estimated using multivariable Cox-proportional hazard models. Results Overall, 721 subjects were followed for a median of 7.8 years (interquartile range 6.1). The median time to discontinuation of all first-line DMTs was 4.2 years (25th and 75th percentile: 1.7, 10.6 years). Of the 451 (62.6%) subjects who discontinued their DMT during the study period, 259 (57.4%) eventually resumed or restarted a DMT. Subjects who were younger when starting a DMT, had prior MS-related hospitalizations, were more recently diagnosed with MS, or had a greater lag time between their MS diagnosis and DMT initiation were more likely to discontinue therapy. Conclusion Over half of the individuals receiving a DMT for MS in Manitoba remained on therapy for at least 4 years. DMT discontinuation occurred in 60% of the cohort, but most restarted a DMT within 1 year. While not all of the factors identified with discontinuing DMT are modifiable, they may help practitioners enhance MS care by identifying individuals who may be at particular risk for DMT discontinuation.


Journal of Global Health | 2018

Heterogeneity in geographical trends of HIV epidemics among key populations in Pakistan: a mathematical modeling study of survey data

Dessalegn Y. Melesse; Leigh Anne Shafer; Faran Emmanuel; Tahira Reza; Baseer K Achakzai; Sofia Furqan; James F. Blanchard

Background Assessing patterns and trends in new infections is key to better understanding of HIV epidemics, and is best done through monitoring changes in incidence over time. In this study, we examined disparities in geographical trends of HIV epidemics among people who inject drugs (PWIDs), female sex workers (FSWs) and hijra/transgender/male sex workers (H/MSWs), in Pakistan. Methods The UNAIDS Estimation and Projection Package (EPP) mathematical model was used to explore geographical trends in HIV epidemics. Four rounds of mapping and surveillance data collected among key populations (KPs) across 20 cities in Pakistan between 2005-2011 was used for modeling. Empirical estimates of HIV prevalence of each KP in each city were used to fit the model to estimate prevalence and incidence over time. Results HIV incidence among PWIDs in Pakistan reached its peak in 2011, estimated at 45.3 per 1000 person-years. Incidence was projected to continue to rise from 18.9 in 2015 to 24.3 in 2020 among H/MSWs and from 3.2 in 2015 to 6.3 in 2020 among FSWs. The number of people living with HIV in Pakistan was estimated to steadily increase through at least 2020. HIV incidence peak among PWIDs ranged from 16.2 in 1997 in Quetta to 71.0 in 2010 in Faisalabad (per 1000 person-years). Incidence among H/MSWs may continue to rise through 2020 in all the cities, except in Larkana where it peaked in the early 2000s. In 2015, model estimated incidence among FSWs was 8.1 in Karachi, 6.6 in Larkana, 2.0 in Sukkur and 1.2 in Lahore (per 1000 person-years). Conclusions There exists significant geographical heterogeneity in patterns and trends of HIV sub-epidemics in Pakistan. Focused interventions and service delivery approaches, different by KP and city, are recommended.


Global Public Health | 2016

Programmatic and ethical challenges in the implementation of treatment-as-prevention in the context of HIV and drug-resistant tuberculosis co-infection in sub-Saharan Africa

Dessalegn Y. Melesse; Marissa Becker; Leigh M. McClarty; Kellee Hodge; Laura H. Thompson; James F. Blanchard; Joseph M. Kaufert

There is limited literature on programmatic challenges in the implementation of a treatment-as-prevention (TasP) strategy among human immunodeficiency virus (HIV) and drug-resistant tuberculosis (DR-TB) co-infected individuals in sub-Saharan Africa (SSA). This paper highlights specific programmatic challenges surrounding the implementation of this strategy among HIV and DR-TB co-infected populations in SSA. In SSA, limitations in administrative, human and financial resources and poor health infrastructure, as well as increased duration and complexity of providing long-term treatment for HIV individuals co-infected with DR-TB, pose substantial challenges to the implementation of a TasP strategy and warrant further investigation. A comprehensive approach must be devised to implement TasP strategy, with special attention paid to the sizable HIV and DR-TB co-infected populations. We suggest that evidence-informed and human rights–based guidelines for participant protection and strategies for programme delivery must be developed and tailored to maximise the benefits to those most at risk of developing HIV and DR-TB co-infection. Assessing regional circumstances is crucial, and TasP programmes in the region should be complemented by combined prevention strategies to achieve the intended goals.

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Bo Nancy Yu

University of Manitoba

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Charity Evans

University of Saskatchewan

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