Implants for HIV prevention in young women: Provider perceptions and lessons learned from contraceptive implant provision.

Preventing new HIV infections, especially amongst young women, is key to ending the HIV epidemic especially in sub-Saharan Africa. Potent antiretroviral (ARV) drugs used as pre-exposure prophylaxis (PrEP) are currently being formulated as long-acting implantable devices, or nanosuspension injectables that release drug at a sustained rate providing protection from acquiring HIV. PrEP as implants (PrEP Implants) offers an innovative and novel approach, expanding the HIV prevention toolbox. Feedback from providers and future users in the early clinical product development stages may identify modifiable characteristics which can improve acceptability and uptake of new technologies. Healthcare workers (HCWs) perspectives and lessons learned during the rollout of contraceptive implants will allow us to understand what factors may impact the roll-out of PrEP implants. We conducted eighteen interviews with HCWs (9 Nurses and 9 Community Healthcare Workers) in rural KwaZulu-Natal, South Africa. HCWs listed the long-acting nature of the contraceptive implant as a key benefit, helping to overcome healthcare system barriers like heavy workloads and understaffing. However, challenges like side effects, migration of the implant, stakeholder buy-in and inconsistent training on insertion and removal hampered the roll-out of the contraceptive implant. For PrEP implants, HCWs preferred long-acting products that were palpable and biodegradable. Our findings highlighted that the characteristics of PrEP implants that are perceived to be beneficial by HCWs may not align with that of potential users, potentially impacting the acceptability and uptake of PrEP implants. Further our data highlight the need for sustained and multi-pronged approaches to training HCWs and introducing new health technologies into communities. Finding a balance between the needs of HCWs that accommodate their heavy workloads, limited resources at points of delivery of care and the needs and preferences of potential users need to be carefully considered in the development of PrEP implants.

Household Transmission of Seasonal Influenza From HIV-Infected and HIV-Uninfected Individuals in South Africa, 2013-2014.

BACKGROUND: We estimated the household secondary infection risk (SIR) and serial interval (SI) for influenza transmission from HIV-infected and HIV-uninfected index cases. METHODS: Index cases were the first symptomatic person in a household with influenza-like illness, testing influenza positive on real-time reverse transcription polymerase chain reaction (rRT-PCR). Nasopharyngeal swabs collected from household contacts every 4 days were tested by rRT-PCR. Factors associated with SIR were evaluated using logistic regression. RESULTS: We enrolled 28 HIV-infected and 57 HIV-uninfected index cases. On multivariable analysis, HIV-infected index cases were less likely to transmit influenza to household contacts (odds ratio [OR] 0.2; 95% confidence interval [CI], 0.1-0.6; SIR 16%, 18/113 vs 27%, 59/220). Factors associated with increased SIR included index age group 1-4 years (OR 3.6; 95% CI, 1.2-11.3) and 25-44 years (OR 8.0; 95% CI, 1.8-36.7), and contact age group 1-4 years (OR 3.5; 95% CI, 1.2-10.3) compared to 5-14 years, and sleeping with index case (OR 2.7; 95% CI, 1.3-5.5). HIV infection of index case was not associated with SI. CONCLUSIONS: HIV-infection was not associated with SI. Increased infectiousness of HIV-infected individuals is likely not an important driver of community influenza transmission.

Influenza Viral Shedding in a Prospective Cohort of HIV-Infected and Uninfected Children and Adults in 2 Provinces of South Africa, 2012-2014.

Background: Prolonged shedding of influenza viruses may be associated with increased transmissibility and resistance mutation acquisition due to therapy. We compared duration and magnitude of influenza shedding between human immunodeficiency virus (HIV)-infected and -uninfected individuals. Methods: A prospective cohort study during 3 influenza seasons enrolled patients with influenza-like illness and a positive influenza rapid test. Influenza viruses were detected by real-time reverse transcription polymerase chain reaction. Weibull accelerated failure time regression models were used to describe influenza virus shedding. Mann-Whitney U tests explored initial influenza viral loads (VL). Results: Influenza virus shedding duration was similar in 65 HIV-infected (6 days; interquartile range [IQR] 3-10) and 176 HIV-uninfected individuals (7 days; IQR 4-11; P = .97), as was initial influenza VL (HIV-uninfected 5.28 ± 1.33 log10 copies/mL, HIV-infected 4.73 ± 1.68 log10 copies/mL; P = .08). Adjusted for age, HIV-infected individuals with low CD4 counts shed influenza virus for longer than those with higher counts (adjusted hazard ratio 3.55; 95% confidence interval, 1.05-12.08). Discussion: A longer duration of influenza virus shedding in HIV-infected individuals with low CD4 counts may suggest a possible increased risk for transmission or viral evolution in severely immunocompromised individuals. HIV-infected individuals should be prioritized for annual influenza immunization.

Trends in HIV Prevalence in Pregnant Women in Rural South Africa.

BACKGROUND: Despite substantial progress in the delivery of HIV prevention programs, some communities continue to experience high rates of HIV infection. We report on temporal trends in HIV prevalence in pregnant women in a community in rural KwaZulu-Natal in South Africa. METHODS: Annual, anonymous cross-sectional HIV sero-prevalence surveys were conducted between 2001 and 2013 among first visit prenatal clinic attendees. The time periods 2001 to 2003 were defined as pre-antiretroviral therapy (ART), 2004 to 2008 as early ART, and 2009 to 2013 as contemporary ART roll-out, to correspond with the substantial scale-up of ART program. RESULTS: Overall, HIV prevalence rose from 35.3% [95% confidence interval (CI): 32.3 to 38.3] pre-ART (2001-2003) to 39.0% (95% CI: 36.8 to 41.1) in the early ART (2004-2008) to 39.3% (95% CI: 37.2 to 41.4) in the contemporary ART (2009-2013) roll-out periods. In teenage women (<20 years), HIV prevalence declined from 22.5% (95% CI: 17.5 to 27.5) to 20.7% (95% CI: 17.5 to 23.8) and to 17.2% (95% CI: 14.3 to 20.2) over the similar ART roll-out periods (P = 0.046). Prevalence increased significantly in women 30 years and older (P < 0.001) over the same time period largely because of survival after ART scale up. Teenage girls with male partners of age 20-24 and ≥ 25 years had a 1.7-fold (95% CI: 1.3-2.4; P = 0.001) and 3-fold (95% CI: 2.1 to 4.3; P < 0.001) higher HIV prevalence respectively. CONCLUSIONS: Notwithstanding the encouraging decline in teenagers, the ongoing high HIV prevalence in pregnant women in this rural community, despite prevention and treatment programs, is deeply concerning. Targeted interventions for teenagers, especially for those in age-disparate relationships, are needed to impact this HIV epidemic trajectory.

Meeting the sexual and reproductive health needs of high-school students in South Africa: experiences from rural KwaZulu-Natal.

BACKGROUND: Adolescents in South Africa (SA) have a huge unmet need for sexual and reproductive health (SRH) services. Integrating such services into schools may overcome many of the current barriers to access. OBJECTIVES: We describe an SRH service model developed for high-school students and its implementation in 14 high schools in rural SA. METHODS: Following consultation with community and other key stakeholders about the demand for and acceptability of adolescent-targeted SRH services, a three-tier school-based model was developed that included: (i) in-school group SRH information and awareness sessions; (ii) in-school individual SRH counselling and customised HIV counselling and testing (CCT); and (iii) referrals to in-school fixed, in-school mobile or public sector primary SRH clinics. RESULTS: From October 2011 to June 2012, 70 consultative meetings were held. There was overwhelming support for the pilot founded on concerns about the high HIV prevalence and teenage pregnancy rates among adolescents in the community. SRH information was provided to 8 867 high-school students, 4 171 (47.0%) of whom accessed on-site CCT services for HIV. The gender-specific prevalence of HIV in these students was 3.3% (64/1 962) and 1.1% (24/2 209) for females and males, respectively. Two hundred and thirty-nine students (5.7%) were referred for clinical services at in-school fixed, in-school mobile or public sector primary SRH clinics. CONCLUSIONS: The SRH service provision pilot was acceptable in the community and seems feasible for scale-up. Further work is required to understand inter-school variability in uptake, identify additional service needs of students, and characterise SRH demand dynamics.

HIV infection in high school students in rural South Africa: role of transmissions among students.

In South Africa, adolescents constitute a key population at high risk of HIV acquisition. However, little is known about HIV transmission among students within schools. This study was undertaken to assess the risk factors for HIV infection and the extent of transmission among rural high school students. Between February and May 2012, consenting students from five randomly selected public sector high schools in rural KwaZulu-Natal participated in an anonymous cross-sectional survey. Dried blood spot samples were collected and tested for HIV. ß-Human chorionic gonadotropin (ßHCG) levels were measured in females for pregnancy. Family circumstances as well as sociodemographic and behavioral factors were assessed as potential risk factors. A subset (106/148, 72%) of HIV-positive samples underwent gag p17p24 sequencing for phylogenetic analysis. A total of 3,242 students (81.7% of enrolled students) participated. HIV prevalence was 6.8% [95% confidence interval (CI) 3.9-9.8%] in girls and 2.7% (CI 1.6-3.8%) in boys [adjusted odds ratio (aOR)=3.0, CI 2.4-3.8; p<0.001]. HIV prevalence increased from 4.6% (95% CI 1.9-7.3) in the 12- to 15-year-old girls to 23.1% (95% CI 7.7-38.5) in girls over 20 years, while in boys HIV prevalence increased from 2.7% (95% CI 0.6-4.9) in the 12- to15-year-old boys to 11.1% (95% CI 2.7-19.4) in those over 20 years. Sequencing of samples obtained from students revealed only two clusters, suggesting within-school transmission and three interschool clusters, while the remainder was most likely acquired from sources other than those currently found in students attending the school concerned. HIV prevalence in both girls (aOR=3.6, CI 2.9-4.5; p<0.001) and boys (aOR=2.8, CI 1.2-6.2; p=0.01) was higher in those without a living biological mother. The high burden of HIV infection among students was not associated with intraschool transmission in this rural setting. Lack of a living parent is an important factor defining high risk in this group of adolescents.

Implementation of adolescent-friendly voluntary medical male circumcision using a school based recruitment program in rural KwaZulu-Natal, South Africa.

BACKGROUND: Epidemiological data from South Africa demonstrate that risk of human immunodeficiency virus (HIV) infection in males increases dramatically after adolescence. Targeting adolescent HIV-negative males may be an efficient and cost-effective means of maximising the established HIV prevention benefits of voluntary medical male circumcision (VMMC) in high HIV prevalence-, low circumcision practice-settings. This study assessed the feasibility of recruiting male high school students for VMMC in such a setting in rural KwaZulu-Natal. METHODS AND FINDINGS: Following community and key stakeholder consultations on the acceptability of VMMC recruitment through schools, information and awareness raising sessions were held in 42 high schools in Vulindlela. A three-phase VMMC demand-creation strategy was implemented in partnership with a local non-governmental organization, ZimnadiZonke, that involved: (i) community consultation and engagement; (ii) in-school VMMC awareness sessions and centralized HIV counselling and testing (HCT) service access; and (iii) peer recruitment and decentralized HCT service access. Transport was provided for volunteers to the Centre for the AIDS Programme of Research in South Africa (CAPRISA) clinic where the forceps-guided VMMC procedure was performed on consenting HIV-negative males. HIV infected volunteers were referred to further care either at the CAPRISA clinic or at public sector clinics. Between March 2011 and February 2013, a total of 5165 circumcisions were performed, the majority (71%) in males aged between 15 and 19 years. Demand-creation strategies were associated with an over five-fold increase in VMMC uptake from an average of 58 procedures/month in initial community engagement phases, to an average of 308 procedures/month on initiation of the peer recruitment-decentralized service phase. Post-operative adverse events were rare (1.2%), mostly minor and self-resolving. CONCLUSIONS: Optimizing a high volume, adolescent-targeted VMMC program was feasible, acceptable and safe in this setting. Adaptive demand-creation strategies are required to sustain high uptake.

HIV transmission risk behavior among HIV-positive patients receiving antiretroviral therapy in KwaZulu-Natal, South Africa.

The aim of this investigation was to identify factors associated with HIV transmission risk behavior among HIV-positive women and men receiving antiretroviral therapy (ART) in KwaZulu-Natal, South Africa. Across 16 clinics, 1,890 HIV+ patients on ART completed a risk-focused audio computer-assisted self-interview upon enrolling in a prevention-with-positives intervention trial. Results demonstrated that 62 % of HIV-positive patients' recent unprotected sexual acts involved HIV-negative or HIV status unknown partners. For HIV-positive women, multivariable correlates of unprotected sex with HIV-negative or HIV status unknown partners were indicative of poor HIV prevention-related information and of sexual partnership-associated behavioral skills barriers. For HIV-positive men, multivariable correlates represented motivational barriers, characterized by negative condom attitudes and the experience of depressive symptomatology, as well as possible underlying information deficits. Findings suggest that interventions addressing gender-specific and culturally-relevant information, motivation, and behavioral skills barriers could help reduce HIV transmission risk behavior among HIV-positive South Africans.

Understanding HIV transmission risk behavior among HIV-infected South Africans receiving antiretroviral therapy: an information--motivation--behavioral skills model analysis.

OBJECTIVE: The current study applied the Information-Motivation-Behavioral Skills (IMB) model (Fisher & Fisher, 1992; Fisher & Fisher, 1993) to identify factors associated with human immunodeficiency virus (HIV) transmission risk behavior among HIV-infected South Africans receiving antiretroviral therapy (ART), a population of considerable significance for curtailing, or maintaining, South Africa's generalized HIV epidemic. METHODS: HIV prevention information, HIV prevention motivation, HIV prevention behavioral skills, and HIV transmission risk behavior were assessed in a sample of 1,388 South Africans infected with HIV and receiving ART in 16 clinics in KwaZulu-Natal, South Africa. RESULTS: Findings confirmed the assumptions of the IMB model and demonstrated that HIV prevention information and HIV prevention motivation work through HIV prevention behavioral skills to affect HIV transmission risk behavior in this population. Subanalyses confirmed these relationships for HIV transmission risk behavior overall and for HIV transmission risk behavior with partners perceived to be HIV-negative or HIV-status unknown. A consistent pattern of gender differences showed that for men, HIV prevention information and HIV prevention motivation may have direct links with HIV preventive behavior, whereas for women, the effect of HIV prevention motivation works through HIV prevention behavioral skills to affect HIV preventive behavior. CONCLUSION: These IMB model-based findings suggest directions for HIV prevention interventions with South African men and women living with HIV and on ART as an important component of overall strategies to contain South Africa's generalized HIV epidemic.

Counsellor-delivered HIV risk reduction intervention addresses safer sex barriers of people living with HIV in KwaZulu-Natal, South Africa.

This study developed an HIV risk reduction intervention for people living with HIV (PLWH) obtaining care at primary healthcare clinics in KwaZulu-Natal, South Africa by (1) conducting elicitation research to understand the dynamics of risk behaviour among PLWH, (2) modifying an existing HIV risk reduction intervention based on research findings and (3) conducting a pilot study to evaluate feasibility, acceptability and fidelity of the modified intervention implemented by trained lay counsellors at a rural clinic in KwaZulu-Natal. A total of 61 healthcare providers and 77 HIV+ patients from four primary healthcare clinics participated in 14 focus groups and 20 individual interviews to identify informational, motivational and behavioural skills (IMB) factors contributing to PLWH's sexual risk behaviour. Elicitation research findings were incorporated into a revised version of Options for Health, an evidence-based risk reduction intervention for PLWH in clinical care. In a 5-day training, lay counsellors learned strategies to address IMB barriers to safer sex identified in elicitation research. The revised intervention, which was implemented by six counsellors with 39 patients, was feasible to implement, acceptable to patients and counsellors, and implemented with good fidelity. This study makes an important contribution towards development of a theory-based HIV risk reduction intervention for PLWH linking prevention with treatment in South Africa.