Characterizing street-connected children and youths' social and health inequities in Kenya: a qualitative study.

BACKGROUND: Street-connected children and youth (SCY) in Kenya disproportionately experience preventable morbidities and premature mortality. We theorize these health inequities are socially produced and result from systemic discrimination and a lack of human rights attainment. Therefore, we sought to identify and understand how SCY's social and health inequities in Kenya are produced, maintained, and shaped by structural and social determinants of health using the WHO conceptual framework on social determinants of health (SDH) and the Convention on the Rights of the Child (CRC) General Comment no. 17. METHODS: This qualitative study was conducted from May 2017 to September 2018 using multiple methods including focus group discussions, in-depth interviews, archival review of newspaper articles, and analysis of a government policy document. We purposively sampled 100 participants including community leaders, government officials, vendors, police officers, general community residents, parents of SCY, and stakeholders in 5 counties across Kenya to participate in focus group discussions and in-depth interviews. We conducted a thematic analysis situated in the conceptual framework on SDH and the CRC. RESULTS: Our findings indicate that SCY's social and health disparities arise as a result of structural and social determinants stemming from a socioeconomic and political environment that produces systemic discrimination, breaches human rights, and influences their unequal socioeconomic position in society. These social determinants influence SCY's intermediary determinants of health resulting in a lack of basic material needs, being precariously housed or homeless, engaging in substance use and misuse, and experiencing several psychosocial stressors, all of which shape health outcomes and equity for this population. CONCLUSIONS: SCY in Kenya experience social and health inequities that are avoidable and unjust. These social and health disparities arise as a result of structural and social determinants of health inequities stemming from the socioeconomic and political context in Kenya that produces systemic discrimination and influences SCYs' unequal socioeconomic position in society. Remedial action to reverse human rights contraventions and to advance health equity through action on SDH for SCY in Kenya is urgently needed.

Piloting an evidence-based intervention for HIV prevention among street youth in Eldoret, Kenya.

OBJECTIVES: This study presents findings from piloting an adapted evidence-based intervention, Stepping Stones and Creating Futures, to change street-connected young people's HIV knowledge, condom-use self-efficacy, and sexual practices. METHODS: Eighty street-connected young people participated in a pre- and post-test mixed methods design in Eldoret, Kenya. The primary outcome of interest was HIV knowledge. Secondary outcomes included condom-use self-efficacy and sexual practices. Multiple linear regression models for change scores with adjustment for socio-demographic variables were fitted. Qualitative and quantitative findings are presented together, where integration confirms, expands on, or uncovers discordant findings. RESULTS: Participants had a significant increase in HIV knowledge from pre- to post-intervention. The median HIV knowledge score pre-intervention was 11 (IQR 8-13) and post-intervention 14 (IQR 12-16). Attendance was significantly associated with HIV knowledge change scores. Qualitatively participants reported increased HIV and condom-use knowledge and improved condom-use self-efficacy and health-seeking practices. CONCLUSIONS: Our findings support the potential for further testing with a rigorous study design to investigate how best to tailor the intervention, particularly by gender, and increase the overall effectiveness of the program.

Cost and cost-effectiveness of voluntary medical male circumcision in street-connected youth: findings from an education-based pilot intervention in Eldoret, Kenya.

BACKGROUND: Voluntary medical male circumcision (VMMC) is a critical component of HIV prevention. VMMC policies have achieved initial targets in adult men yet continue to fall short in reaching younger men and adolescents. SETTING: We present the cost and scale-up implications of an education-based, VMMC intervention for adolescent street-connected males, for whom the street has become their home and/or source of livelihood. The intervention was piloted as part of the Engaging Street Youth in HIV Interventions Project in Eldoret, Kenya. METHODS: We used a micro-costing approach to estimate the average cost of a VMMC intervention in 116 street-connected youth. Average cost was estimated per individual and per cohort by dividing total cost per intervention by number of clients accessing the intervention over a 30-day period. Total average costs included direct and support procedure costs, educational costs, and direct research costs. Cost-effectiveness was measured in cost per DALYs averted over a 5 and 10-year period. RESULTS: The total cost of the intervention was $12,526 over the 30-day period, with an average cost per individual of $108. The direct VMMC procedure cost was approximately $9 per individual. Personnel costs contributed the greatest percentage to the total intervention cost (38.2%), with mentors and social workers representing the highest wage earners. Retreat-related and education costs contributed 51% and 13% respectively to the total average cost, with surgical equipment costs contributing less than 1%. At a cost of $108 per individual, the intervention averted 60166 DALYs in 5 years resulting in a cost per DALY averted of $267. CONCLUSION: The VMMC intervention was highly cost-effective in Kenya, despite the additional costs incurred to reach SCY. Further scale-up may be warranted to effectively apply this intervention in comparable populations.

Implementing intensified tuberculosis case-finding among street-connected youth and young adults in Kenya.

BACKGROUND: Street-connected youth and young adults (SCY) suffer a myriad of health problems. In Kenya, SCY are at high risk for tuberculosis (TB) due to their congregate living situations. TB screening is not routinely implemented in SCY and there has been no published literature on the burden of TB in SCY in western Kenya. PROGRAM DESCRIPTION: In 2011, the AMPATH TB Program, an experienced TB screening program, partnered with the Tumaini Center, a trusted street youth organization, to conduct intensified case finding (ICF) for pulmonary TB among SCY. Our program aimed to investigate the numbers of SCY who reported symptoms and those diagnosed with smear-positive pulmonary TB, and link SCY with TB to treatment. RESULTS: Of 116 SCY who were screened, 114 (98%) had a positive questionnaire; 104 (90%) provided a spot sputum sample, 39 (34%) provided a morning sputum sample, and 111 (97%) reported cough of >2 weeks. One street youth tested smear-positive for TB and was treated through to cure. CONCLUSIONS: Implementing TB ICF is feasible in low-resource settings through unique collaborations between health care programs and community-based organizations. In addition to identifying smear-positive TB, our program uncovered a high burden of respiratory symptoms among SCY in Eldoret, Kenya.

Contexte : Les jeunes et les adultes vivant dans la rue (SCY) souffrent d'une myriade de problèmes de santé. Au Kenya, les SCY ont un risque élevé de tuberculose (TB) à cause de la promiscuité de leur habitat. Le dépistage de la TB n'est pas mis en œuvre en routine parmi les SCY et il n'y a eu aucune littérature publiée sur le poids de la TB chez les SCY de l'ouest du Kenya.Description du programme : En 2011, le programme TB AMPATH, un programme de dépistage de TB expérimenté, a établi un partenariat avec le Tumaini Center, une organisation fiable de jeunes de la rue, afin de réaliser une recherche de cas intensifiée (ICF) de la TB pulmonaire parmi les SCY. Notre programme a eu pour but de rechercher le nombre de SCY qui présentaient des symptômes et ceux qui ont eu un diagnostic de TB pulmonaire à frottis positif, et enfin de mettre en contact les SCY avec un site de traitement de la TB.Résultats : De 116 SCY qui ont été dépistés, 114 (98%) ont remis un questionnaire positif, 104 (90%) ont fourni un échantillon de crachats, 39 (34%) un échantillon matinal et 111 (97%) ont fait état d'une toux de >2 semaines. Un jeune de la rue a eu un frottis positif pour la TB et a été traité avec succès.Conclusions: La mise en œuvre de l'ICF de TB est faisable dans un contexte de faibles ressources à travers une unique collaboration entre les programmes de soins de santé et les organisations communautaires. En plus d'identifier la TB à frottis positif, notre programme a révélé un lourd fardeau de symptômes respiratoires parmi les SCY d'Eldoret, au Kenya.

Marco de referencia: Los jóvenes y los adultos jóvenes en situación de calle (SCY) sufren de una miríada de problemas de salud. En Kenia, los SCY tienen un alto riesgo de contraer la tuberculosis (TB), dada la situación de su convivencia. La detección de la TB no se practica de manera sistemática en esta población y no existen publicaciones científicas sobre la carga de morbilidad por TB en los SCY en el oeste de Kenia.Descripción del programa: En el 2011, el Programa TB AMPATH, un programa con experiencia en la detección sistemática de la TB, creó una alianza con el Tumaini Center, que es una organización reconocida que se ocupa de los SCY; su objetivo fue realizar una búsqueda intensiva de casos de TB pulmonar en esta población de jóvenes. El presente estudio tuvo por objeto investigar el número de SCY que refirieron síntomas y la cantidad de casos de TB pulmonar con baciloscopia positiva que se diagnosticaron, y vincular los SCY diagnosticados con los centros de tratamiento.Resultados: Se practicó la detección sistemática en 116 SCY, de los cuales 114 tuvieron un cuestionario positivo (98%), 104 aportaron una muestra inmediata de esputo (90%) y 39 una muestra de esputo matinal (34%). De los SCY, 111 refirieron tos de >2 semanas de duración (97%). Un joven tuvo una baciloscopia de esputo positiva y recibió tratamiento hasta su curación.Conclusión: La ejecución de una búsqueda intensiva de casos de TB es factible en los entornos de bajos recursos, por conducto de colaboraciones especiales entre los programas de atención de salud y las organizaciones comunitarias. Además de detectar los casos de TB bacilífera, el programa reveló una alta carga de morbilidad por síntomas respiratorios en los SCY en la ciudad de Eldoret, en Kenia.

Adapting ethical guidelines for adolescent health research to street-connected children and youth in low- and middle-income countries: a case study from western Kenya.

BACKGROUND: Street-connected children and youth (SCCY) in low- and middle-income countries (LMIC) have multiple vulnerabilities in relation to participation in research. These require additional considerations that are responsive to their needs and the social, cultural, and economic context, while upholding core ethical principles of respect for persons, beneficence, and justice. The objective of this paper is to describe processes and outcomes of adapting ethical guidelines for SCCY's specific vulnerabilities in LMIC. METHODS: As part of three interrelated research projects in western Kenya, we created procedures to address SCCY's vulnerabilities related to research participation within the local context. These consisted of identifying ethical considerations and solutions in relation to community engagement, equitable recruitment, informed consent, vulnerability to coercion, and responsibility to report. RESULTS: Substantial community engagement provided input on SCCY's participation in research, recruitment, and consent processes. We designed an assent process to support SCCY to make an informed decision regarding their participation in the research that respected their autonomy and their right to dissent, while safeguarding them in situations where their capacity to make an informed decision was diminished. To address issues related to coercion and access to care, we worked to reduce the unequal power dynamic through street outreach, and provided access to care regardless of research participation. CONCLUSIONS: Although a vulnerable population, the specific vulnerabilities of SCCY can to some extent be managed using innovative procedures. Engaging SCCY in ethical research is a matter of justice and will assist in reducing inequities and advancing their health and human dignity.

Physical and sexual abuse in orphaned compared to non-orphaned children in sub-Saharan Africa: a systematic review and meta-analysis.

This systematic review assessed the quantitative literature to determine whether orphans are more likely to experience physical and/or sexual abuse compared to non-orphans in sub-Saharan Africa (SSA). It also evaluated the quality of evidence and identified research gaps. Our search identified 10 studies, all published after 2005, from Zimbabwe, South Africa, Kenya and Uganda. The studies consisted of a total 17,336 participants (51% female and 58% non-orphans). Of those classified as orphans (n=7,315), 73% were single orphans, and 27% were double orphans. The majority of single orphans were paternal orphans (74%). Quality assessment revealed significant variability in the quality of the studies, although most scored higher for general design than dimensions specific to the domain of orphans and abuse. Combined estimates of data suggested that, compared to non-orphans, orphans are not more likely to experience physical abuse (combined OR=0.96, 95% CI [0.79, 1.16]) or sexual abuse (combined OR=1.25, 95% CI [0.88, 1.78]). These data suggest that orphans are not systematically at higher risk of experiencing physical or sexual abuse compared to non-orphans in sub-Saharan Africa. However, because of inconsistent quality of data and reporting, these findings should be interpreted with caution. Several recommendations are made for improving data quality and reporting consistency on this important issue.

Factors Underlying Taking a Child to HIV Care: Implications for Reducing Loss to Follow-up among HIV-Infected and Exposed Children

Objective: With the aim of reducing pediatric loss to follow-up (LTFU) from HIV clinical care programs in sub-Saharan Africa; we sought to understand the personal and socio-cultural factors associated with the behavior of caregivers taking HIV-infected and -exposed children for care in western Kenya.Methods: Between Mayand August; 2010; in-depth interviews were conducted with 26 purposively sampled caregivers caring for HIVinfected(7); HIV-exposed (17) and HIV-unknown status (2) children; documented as LTFU from an urban and rural HIV care clinic. All were women with a majority (77) being biological parents. Interviews were audio-recorded; transcribed and content analyzed.Results: Thematic content analysis of the women's perceptions revealed that their decision about routinely taking their children to HIV care involved multiple levels of factors including: (1) intrapersonal: transport costs; food availability; time constraints due to work commitment; disclosure of HIV status for both mother and child; perception that child is healthy and religious beliefs; (2) interpersonal: unsupportive male partner; stigma by the family and family conflicts; (3) community: cultural norms; changing community dynamics and perceived stigma; (4) health care system: clinic location; lack of patient-centered care; delays at the clinic and different appointment schedules (mother and child). Furthermore; the factors across these different levels interacted with each other in a complex way; illustrating the challenges women face in taking their children to HIV care.Conclusion: The complexity and interconnectedness of the factors underlying retention of children in HIV care perceived by these women caregivers suggests that interventions to reduce pediatric LTFU need to be holistic and address multiple socio-ecological levels. Patient-centered care that integrates a family-centered approach to HIV pediatric care is recommended

Tuberculosis in HIV programmes in lower-income countries: practices and risk factors.

BACKGROUND: Tuberculosis (TB) is a common diagnosis in human immunodeficiency virus (HIV) infected patients on antiretroviral treatment (ART). OBJECTIVE: To describe TB-related practices in ART programmes in lower-income countries and identify risk factors for TB in the first year of ART. METHODS: Programme characteristics were assessed using standardised electronic questionnaire. Patient data from 2003 to 2008 were analysed and incidence rate ratios (IRRs) calculated using Poisson regression models. RESULTS: Fifteen ART programmes in 12 countries in Africa, South America and Asia were included. Chest X-ray, sputum microscopy and culture were available free of charge in respectively 13 (86.7%), 14 (93.3%) and eight (53.3%) programmes. Eight sites (53.3%) used directly observed treatment and five (33.3%) routinely administered isoniazid preventive treatment (IPT). A total of 19 413 patients aged ≥ 16 years contributed 13,227 person-years of follow-up; 1081 new TB events were diagnosed. Risk factors included CD4 cell count (>350 cells/µl vs. <25 cells/µl, adjusted IRR 0.46, 95%CI 0.33-0.64, P < 0.0001), sex (women vs. men, adjusted IRR 0.77, 95%CI 0.68-0.88, P = 0.0001) and use of IPT (IRR 0.24, 95%CI 0.19-0.31, P < 0.0001). CONCLUSIONS: Diagnostic capacity and practices vary widely across ART programmes. IPT prevented TB, but was used in few programmes. More efforts are needed to reduce the burden of TB in HIV co-infected patients in lower income countries.

Task shifting in HIV clinics, Western Kenya.

BACKGROUND: United states Agency for International development-Academic Model for Providing Accesses to Healthcare (USAID-AMPATH) cares for over 80,000 HIV-infected patients. Express care (EC) model addresses challenges of: clinically stable patient's adherent to combined-antiretroviral-therapy with minimal need for clinician intervention and high risk patients newly initiated on cART with CD4 counts < or = 100 cells/mm3 with frequent need for clinician intervention. OBJECTIVE: To improve patient outcomes without increasing clinic resources. DESIGN: A descriptive study of a clinician supervised shared nurse model. SETTING: USAID-AMPATH clinics, Western Kenya. RESULTS: Four thousand eight hundred and twenty four patients were seen during the pilot period, 90.4% were eligible for EC of whom 34.6% were enrolled. Nurses performed all traditional roles and attended to two thirds and three quarters of stable and high risk patient visits respectively. Clinicians attended to one third and one quarter of stable and high risk patient visits respectively and all visits ineligible for express care. CONCLUSION: The EC model is feasible. Task shifting allowed stable patients to receive visits with nurses, while clinicians had more time to concentrate on patients that were new as well as more acutely ill patients.

Home-based HIV counselling and testing in western Kenya.

BACKGROUND: The World Health Organisation (WHO) estimates that only 12% of men and 10% of women in sub-Saharan Africa have been tested for HIV and know their test results. Home-based counselling and testing (HBCT) offers a novel approach to complement facility-based provider initiated testing and counselling (PITC) and voluntary counselling and testing (VCT) and could greatly increase HIV prevention opportunities. However, there is almost no evidence that large-scale, door-to-door testing is even feasible in settings with both limited resources and significant stigma around HIV and AIDS. OBJECTIVE: To describe our experience with the feasibility and acceptance of home-based HIV counselling and testing (HBCT) in two large, rural, administrative divisions of western Kenya. DESIGN: The USAID-AMPATH Partnership conducted population-based, house-to-house HIV counselling and testing in western Kenya between June 2007 and June 2009. All individuals aged > or = 13 years and all eligible children were offered HBCT. Children were eligible if they were above 13 years of age, and their mother was either HIV-positive or had unknown HIV serostatus, or if their mother was deceased or whose vital status was unknown. SETTING: Kosirai and Turbo Divisions, Rift Valley Province, Kenya. RESULTS: There were 47,066 households approached in 294 villages: 97% of households allowed entry. Of the 138,026 individuals captured, 101,167 individuals were eligible for testing: 89% of adults and 58% of children consented to HIV testing. The prevalence of HIVin these communities was 3.0%: 2.7% in adults and 3.7% among children. Prevalence was highest in the 36-45 year age group and was almost always higher among women and girls. All persons testing HIV-positive were referred to Academic Model Providing Access to Healthcare (AMPATH) for further assessment and care; all consenting persons were counselled on HIV risk-lowering behaviours. CONCLUSION: Home-based HIV counselling and testing was feasible among this rural population in western Kenya, with a majority of the population accepting to get tested. These data suggest that scaling-up of HBCT is possible and may enable large numbers of individuals to know their HIV serostatus in sub-Saharan Africa. More research is needed to describe the cost-effectiveness and clinical impact of this approach.

Assessment of knowledge, attitudes and practices of infant feeding in the context of HIV: a case study from western Kenya.

Guidelines for infant feeding options among HIV-positive mothers are changing with informative research. Cultural factors, socialisation processes, gender dimensions and socio-economic status within communities should be considered in recommending feasible and sustainable options. The objective of this study was to assess the knowledge, attitudes and practices with regards to infant feeding in the context of HIV. A cross-sectional study was conducted between November 2003 and January 2004. The study was carried out in Kosirai Division, Nandi-North District, in western Kenya. The target population was community members aged 18 - 45 years and key informants aged 18 years and above. Structured questionnaires and in-depth interviews were used to collect data. Multistage and snowball sampling methods were used to identify study participants. Quantitative data were analysed using the SPSS statistical package for social scientists (Version 12). Cross-tabulations were calculated and Pearson's chi-square test used to test significance of relationships between categorical variables. Recorded qualitative data were transcribed and coded. Themes were developed and integrated. A generation of concepts was used to organise the presentation into summaries, interpretations and text. A total of 385 individuals participated in the survey, 50% of whom were women. There were 30 key informants. Farming was the main source of income but half of the women (49.7% ) had no income. Most of the respondents (85.5% ) knew of breastfeeding as a route of HIV transmission with sex (p=0.003) and age (p=0.000) being highly associated with this knowledge. Breastfeeding was the norm although exclusive breastfeeding was not practised. Cow's milk, the main breast milk substitute, was reported as being given to infants as early as two weeks. It was the most popular (93.5% ) infant feeding option in the context of HIV/AIDS. Heating expressed milk, wet nursing and milk banks were least preferred. Thus, the social, cultural and psychological complexity of infant feeding practices should be taken into account when advocating appropriate infant feeding options. Further research is required to determine the safety of using cow's milk as an infant feeding option. Community engagement, including education and awareness strategies, specific to the benefits of exclusive breastfeeding as a mechanism to reduce the risk of HIV transmission is urgently needed.

Differences in access to care among injection drug users infected either with HIV and hepatitis C or hepatitis C alone.

Access to HCV (Hepatitis C virus) care for HIV/HCV-co-infected patients is an urgent public health concern. The objective of the present study was to describe the self-reported health status of HIV/HCV-co-infected and HCV-mono-infected injection drug users and to describe their access to HCV-related care. Beginning in May 1996, persons who had injected illicit drugs in the previous month were recruited into the Vancouver Injection Drug User Study (VIDUS). At baseline and then semi-annually, participants complete an interviewer-administered questionnaire. Blood is drawn at each semi-annual interview and tested for HIV and Hepatitis C infection. Data for this descriptive, cross-sectional study were drawn from the most recent of either the July 2003 or December 2003 nurse-administered questionnaire. Statistics used were the chi-square, Wilcoxon Rank Sum and Student's t-test. Logistic regression was used to examine factors independently associated with accessing HCV care. There were 707 individuals eligible for this analysis, including 240 HIV/HCV-co-infected and 467 HCV-mono-infected persons. Co-infected individuals were more likely to be female, younger, of Aboriginal ethnicity and less likely to use heroin daily. The HCV-mono-infected group tended to report higher rates of HCV-related symptoms, including fatigue, liver pain, nausea, night-sweats and stomach pain. However, it was the HIV/HCV-co-infected group who were more likely to report that they believed their hepatitis C was affecting them. The HIV/HCV-co-infected group were also more likely to report having received any hepatitis-related follow-up care, including blood work, liver biopsies and referrals to specialists. In logistic regression analysis, factors independently associated with ever receiving any hepatitis C related follow-up were HIV/HCV-co-infection (AOR 3.1; 95% CI: 2-4.7), being older (AOR 1.04; 95% CI: 1.02-1.06 per year older), using heroin daily (AOR 0.54; 95% CI: 0.36-0.82) and believing that hepatitis C was affecting one's health (AOR 1.4; 95% CI: 1.0-2.1). In conclusion, our data indicate more HCV healthcare utilization among those HIV/HCV-co-infected.

Quality of life, depression and fatigue among persons co-infected with HIV and hepatitis C: outcomes from a population-based cohort.

The objective of the study was to describe the additional burden generated by hepatitis C (HCV) infection among HIV-infected individuals as measured by self-reported quality of life, depression and fatigue. The provincial HIV/AIDS Drug Treatment Program (DTP) distributes all antiretroviral medication in the province of British Columbia. Eligibility for accessing antiretrovirals is based on published guidelines commensurate with the International AIDS Society. Each participant is asked to complete a self-administered mailed questionnaire that includes patient sociodemographic information, quality of life measures (Medical Outcomes Study-Short Form (MOS-SF), mental health issues (Centre for Epidemiological Studies Depression scale (CESD) and fatigue information. HIV-HCV co-infected individuals were compared to HIV mono-infected individuals using parametric and nonparametric methods. Multivariate logistic regression was used to examine the impact of hepatitis C on quality of life, depression and fatigue, after controlling for sociodemographics and HIV-specific clinical characteristics. Of the 4,134 individuals who were sent a HIV/AIDS DTP survey in 1999, 2000 or 2001, 484 participants both returned one and had an HCV-antibody test result on file. Of the 484 participants eligible for this analysis, 105 (22%) were HCV-positive. In comparison to the 379 (78%) patients testing negative for HCV, a larger proportion of co-infected patients were female (18% versus 3%, p<0.001), aboriginal (20% versus 3%, p<0.001), had ever injected drugs (79% versus 5%, p<0.001), were unemployed (91% versus 49%, p<0.001) and lived in unstable housing (19% versus 1%, p<0.001) at the time they completed the survey. Co-infected patients reported more symptoms consistent with depression, increased fatigue and poorer quality of life. However, using multivariate modeling, it was determined that the impact of HCV on quality of life, depression and fatigue was better explained by the sociodemographic factors related to poverty and injection drug use, than by HCV itself. In conclusion, individuals co-infected with HIV and HCV represent a patient population with significant physical and mental health challenges. Although these patients experience poorer quality of life, increased depression and fatigue, this experience appears to be primarily related to socio-economic issues rather than HCV infection.

Use of antiretroviral therapy among HIV positive individuals living in British Columbia.

The objective of this study was to examine the level of antiretroviral use and characterize individuals accessing antiretroviral therapy in British Columbia. The study was conducted by the British Columbia Persons with AIDS Society and the British Columbia Centre for Excellence in HIV/AIDS. Self-administered questionnaires were mailed out to HIV-positive members from May to September of 2002. Comparisons of sociodemographic characteristics and disease status were made using Pearson's Chi2 and the Kruskal-Wallis test for continuous variables. A total of 764 (51%) HIV-positive participants returned the questionnaire. Of these, 80% reported ever using antiretroviral therapy and 64.5% indicated current use. Reasons for never taking antiretroviral therapy were high CD4 or doctor's advice (74/126; 59%), feeling healthy (50/126; 40%) and being afraid of side-effects (35/126; 28%). Those reporting current antiretroviral use were more likely to be older (p<0.001), white (p=0.01), male (p<0.001), gay or bisexual (p<0.001), graduated from high school (p=0.001), non-injecting drug user (IDU) (p<0.001) and earning a household income greater than CAN$10,000/year (p=0.003). IDU status and length of time since diagnosis remained significantly associated with antiretroviral use in multivariate models. The differences in current antiretroviral use by sociodemographic characteristics such as IDU suggest that the need remains to target marginalized populations in order to maximize the health benefits from antiretroviral therapy.

Extent to which low-level use of antiretroviral treatment could curb the AIDS epidemic in sub-Saharan Africa.

BACKGROUND: Despite growing international pressure to provide HIV-1 treatment to less-developed countries, potential demographic and epidemiological impacts have yet to be characterised. We modelled the future impact of antiretroviral use in South Africa from 2000 to 2005. METHODS: We produced a population projection model that assumed zero antiretroviral use to estimate the future demographic impacts of the HIV-1 epidemic. We also constructed four antiretroviral-adjusted scenarios to estimate the potential effect of antiretroviral use. We modelled total drug cost, cost per life-year gained, and the proportion of per-person health-care expenditure required to finance antiretroviral treatment in each scenario. FINDINGS: With no antiretroviral use between 2000 and 2005, there will be about 276,000 cumulative HIV-1-positive births, 2,302,000 cumulative new AIDS cases, and the life expectancy at birth will be 46.6 years by 2005. By contrast, 110,000 HIV-1-positive births could be prevented by short-course antiretroviral prophylaxis, as well as a decline of up to 1 year of life expectancy. The direct drug costs of universal coverage for this intervention would be US$54 million--less than 0.001% of the per-person health-care expenditure. In comparison, triple-combination treatment for 25% of the HIV-1-positive population could prevent a 3.1-year decline in life expectancy and more than 430,000 incident AIDS cases. The drug costs of this intervention would, however, be more than $19 billion at present prices, and would require 12.5% of the country's per-person health-care expenditure. INTERPRETATION: Although there are barriers to widespread HIV-1 treatment, limited use of antiretrovirals could have an immediate and substantial impact on South Africa's AIDS epidemic.