Last data update: Jun 17, 2024. (Total: 47034 publications since 2009)
Records 1-21 (of 21 Records) |
Query Trace: Bronson M [original query] |
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Comparison of HIV prevalence, incidence, and viral load suppression in Zambia population-based HIV impact assessments from 2016 and 2021
Mulenga LB , Hines JZ , Stafford KA , Dzekedzeke K , Sivile S , Lindsay B , Chola M , Ussery F , Patel HK , Abimiku A , Birhanu S , Minchella P , Stevens T Jr , Hanunka B , Chisenga T , Shibemba A , Fwoloshi S , Siame M , Mutukwa J , Chirwa L , Siwingwa M , Mulundu G , Agbakwuru C , Mapondera P , Detorio M , Agolory SG , Monze M , Bronson M , Charurat ME . AIDS 2024 BACKGROUND: The Zambian government has implemented a public health response to control the HIV epidemic in the country. Zambia conducted a population-based HIV impact assessment (ZAMPHIA) survey in 2021 to assess the status of the HIV epidemic to guide its public health programs. METHODS: ZAMPHIA 2021 was a cross-sectional two-stage cluster sample household survey among persons aged ≥15 years conducted in Zambia across all 10 provinces. Consenting participants were administered a standardized questionnaire and whole blood was tested for HIV according to national guidelines. HIV-1 viral load (VL), recent HIV infection, and antiretroviral medications were tested for in HIV-seropositive samples. Viral load suppression (VLS) was defined as <1000 copies/ml. ZAMPHIA 2021 results were compared to ZAMPHIA 2016 for persons aged 15-59 years (i.e., the overlapping age ranges). All estimates were weighted to account for nonresponse and survey design. RESULTS: During ZAMPHIA 2021, of 25 483 eligible persons aged ≥15 years, 18 804 (73.8%) were interviewed and tested for HIV. HIV prevalence was 11.0% and VLS prevalence was 86.2% overall, but was <80% among people living with HIV aged 15-24 years and in certain provinces. Among persons aged 15-59 years, from 2016 to 2021, HIV incidence declined from 0.6% to 0.3% (P-value: 0.07) and VLS prevalence increased from 59.2% to 85.7% (P-value: <0.01). DISCUSSION: Zambia has made substantial progress toward controlling the HIV epidemic from 2016 to 2021. Continued implementation of a test-and-treat strategy, with attention to groups with lower VLS in the ZAMPHIA 2021, could support reductions in HIV incidence and improve overall VLS in Zambia. |
Increasing access to quality care for pregnant and postpartum people with opioid use disorder: Coordination of services, provider awareness and training, extended postpartum coverage, and perinatal quality collaboratives
Ellick KL , Kroelinger CD , Chang K , McGown M , McReynolds M , Velonis AJ , Bronson E , Riehle-Colarusso T , Pliska E , Akbarali S , Mueller T , Dronamraju R , Cox S , Barfield WD . J Subst Use Addict Treat 2023 156 209208 INTRODUCTION: Fifteen states participating in the Opioid Use Disorder, Maternal Outcomes, and Neonatal Abstinence Syndrome Initiative Learning Community (OMNI LC) developed action plan goals and activities to address the rise in opioid use disorder (OUD) among birthing persons. In a separate initiative, Perinatal Quality Collaboratives (PQCs) from 12 states participating in Centers for Disease Control and Prevention (CDC)-supported activities hosted trainings to improve the provision of OUD services and implement protocols for screening and treatment in delivery facilities. METHODS: This descriptive study synthesizes qualitative data extracted from 15 OMNI LC state action plans, excerpts from qualitative interviews conducted with OMNI LC state teams, and quantitative data from quarterly project performance monitoring reports from 12 CDC-funded PQCs implementing quality improvement activities to address clinical service gaps for pregnant and postpartum people with OUD. Qualitative data were deidentified, coded as barriers or facilitators, then aggregated into emergent themes. Count data are presented for quantitative results. RESULTS: The OMNI LC states identified a lack of coordinated care among providers, stigma toward people with OUD, discontinued insurance coverage, and inconsistencies in screening and treating birthing people with OUD as barriers to accessing quality care. Facilitators for access to quality care states identified included: 1) improving engagement and communication between providers and other partners to integrate medical and behavioral health services post-discharge, and facilitate improved patient care postpartum; 2) training providers to prescribe medications for OUD, and to address bias and reduce patient stigma; 3) extending Medicaid coverage up to one year postpartum to increase access to and continuity of services; and 4) implementing screening, brief intervention, and referral to treatment (SBIRT) in clinical practice. PQCs demonstrated that increased provider trainings to treat OUD, improvements in implementation of standardized protocols, and use of evidence-based tools can facilitate access to and coordination of services in delivery facilities. CONCLUSION: State-identified facilitators for increasing access to care include coordinating integrated services, extending postpartum coverage, and provider trainings to improve screening and treatment. PQCs provide a platform for identifying emerging areas for quality improvement initiatives and implementing clinical best practices to provide comprehensive, quality perinatal care for birthing populations. |
Gut microbiome perturbation, antibiotic resistance, and Escherichia coli strain dynamics associated with international travel: a metagenomic analysis
Worby CJ , Sridhar S , Turbett SE , Becker MV , Kogut L , Sanchez V , Bronson RA , Rao SR , Oliver E , Walker AT , Walters MS , Kelly P , Leung DT , Knouse MC , Hagmann SHF , Harris JB , Ryan ET , Earl AM , LaRocque RC . Lancet Microbe 2023 4 (10) e790-e799 ![]() ![]() BACKGROUND: Culture-based studies have shown that acquisition of extended-spectrum β-lactamase-producing Enterobacterales is common during international travel; however, little is known about the role of the gut microbiome before and during travel, nor about acquisition of other antimicrobial-resistant organisms. We aimed to identify (1) whether the gut microbiome provided colonisation resistance against antimicrobial-resistant organism acquisition, (2) the effect of travel and travel behaviours on the gut microbiome, and (3) the scale and global heterogeneity of antimicrobial-resistant organism acquisition. METHODS: In this metagenomic analysis, participants were recruited at three US travel clinics (Boston, MA; New York, NY; and Salt Lake City, UT) before international travel. Participants had to travel internationally between Dec 8, 2017, and April 30, 2019, and have DNA extractions for stool samples both before and after travel for inclusion. Participants were excluded if they had at least one low coverage sample (<1 million read pairs). Stool samples were collected at home before and after travel, sent to a clinical microbiology laboratory to be screened for three target antimicrobial-resistant organisms (extended-spectrum β-lactamase-producing Enterobacterales, carbapenem-resistant Enterobacterales, and mcr-mediated colistin-resistant Enterobacterales), and underwent DNA extraction and shotgun metagenomic sequencing. We profiled metagenomes for taxonomic composition, antibiotic-resistant gene content, and characterised the Escherichia coli population at the strain level. We analysed pre-travel samples to identify the gut microbiome risk factors associated with acquisition of the three targeted antimicrobial resistant organisms. Pre-travel and post-travel samples were compared to identify microbiome and resistome perturbation and E coli strain acquisition associated with travel. FINDINGS: A total of 368 individuals travelled between the required dates, and 296 had DNA extractions available for both before and after travel. 29 travellers were excluded as they had at least one low coverage sample, leaving a final group of 267 participants. We observed a perturbation of the gut microbiota, characterised by a significant depletion of microbial diversity and enrichment of the Enterobacteriaceae family. Metagenomic strain tracking confirmed that 67% of travellers acquired new strains of E coli during travel that were phylogenetically distinct from their pre-travel strains. We observed widespread enrichment of antibiotic-resistant genes in the gut, with a median 15% (95% CI 10-20, p<1 × 10(-10)) increase in burden (reads per kilobase per million reads). This increase included antibiotic-resistant genes previously classified as threats to public health, which were 56% (95% CI 36-91, p=2 × 10(-11)) higher in abundance after travel than before. Fluoroquinolone antibiotic-resistant genes were aquired by 97 (54%) of 181 travellers with no detected pre-travel carriage. Although we found that visiting friends or relatives, travel to south Asia, and eating uncooked vegetables were risk factors for acquisition of the three targeted antimicrobial resistant organisms, we did not observe an association between the pre-travel microbiome structure and travel-related antimicrobial-resistant organism acquisition. INTERPRETATION: This work highlights a scale of E coli and antimicrobial-resistant organism acquisition by US travellers not apparent from previous culture-based studies, and suggests that strategies to control antimicrobial-resistant organisms addressing international traveller behaviour, rather than modulating the gut microbiome, could be worthwhile. FUNDING: US Centers for Disease Control and Prevention and National Institute of Allergy and Infectious Diseases. |
HIV, syphilis, and hepatitis B virus infection and male circumcision in five Sub-Saharan African countries: Findings from the Population-based HIV Impact Assessment Surveys, 2015-2019
Peck ME , Bronson M , Djomand G , Basile I , Collins K , Kankindi I , Kayirangwa E , Malamba SS , Mugisha V , Nsanzimana S , Remera E , Kazaura KJ , Amuri M , Mmbando S , Mgomella GS , Simbeye D , Colletar Awor A , Biraro S , Kabuye G , Kirungi W , Chituwo O , Hanunka B , Kamboyi R , Mulenga L , Musonda B , Muyunda B , Nkumbula T , Malaba R , Mandisarisa J , Musuka G , Peterson AE , Toledo C . PLOS Glob Public Health 2023 3 (9) e0002326 Voluntary medical male circumcision (VMMC) has primarily been promoted for HIV prevention. Evidence also supports that male circumcision offers protection against other sexually transmitted infections. This analysis assessed the effect of circumcision on syphilis, hepatitis B virus (HBV) infection and HIV. Data from the 2015 to 2019 Population-based HIV Impact Assessments (PHIAs) surveys from Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe were used for the analysis. The PHIA surveys are cross-sectional, nationally representative household surveys that include biomarking testing for HIV, syphilis and HBV infection. This is a secondary data analysis using publicly available PHIA data. Univariate and multivariable logistic regression models were created using pooled PHIA data across the five countries to assess the effect of male circumcision on HIV, active and ever syphilis, and HBV infection among sexually active males aged 15-59 years. Circumcised men had lower odds of syphilis infection, ever or active infection, and HIV, compared to uncircumcised men, after adjusting for covariates (active syphilis infection = 0.67 adjusted odds ratio (aOR), 95% confidence interval (CI), 0.52-0.87, ever having had a syphilis infection = 0.85 aOR, 95% CI, 0.73-0.98, and HIV = 0.53 aOR, 95% CI, 0.47-0.61). No difference between circumcised and uncircumcised men was identified for HBV infection (P = 0.75). Circumcised men have a reduced likelihood for syphilis and HIV compared to uncircumcised men. However, we found no statistically significant difference between circumcised and uncircumcised men for HBV infection. |
The epidemiology of HIV population viral load in twelve sub-Saharan African countries
Hladik W , Stupp P , McCracken SD , Justman J , Ndongmo C , Shang J , Dokubo EK , Gummerson E , Koui I , Bodika S , Lobognon R , Brou H , Ryan C , Brown K , Nuwagaba-Biribonwoha H , Kingwara L , Young P , Bronson M , Chege D , Malewo O , Mengistu Y , Koen F , Jahn A , Auld A , Jonnalagadda S , Radin E , Hamunime N , Williams DB , Kayirangwa E , Mugisha V , Mdodo R , Delgado S , Kirungi W , Nelson L , West C , Biraro S , Dzekedzeke K , Barradas D , Mugurungi O , Balachandra S , Kilmarx PH , Musuka G , Patel H , Parekh B , Sleeman K , Domaoal RA , Rutherford G , Motsoane T , Bissek AZ , Farahani M , Voetsch AC . PLoS One 2023 18 (6) e0275560 BACKGROUND: We examined the epidemiology and transmission potential of HIV population viral load (VL) in 12 sub-Saharan African countries. METHODS: We analyzed data from Population-based HIV Impact Assessments (PHIAs), large national household-based surveys conducted between 2015 and 2019 in Cameroon, Cote d'Ivoire, Eswatini, Kenya, Lesotho, Malawi, Namibia, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe. Blood-based biomarkers included HIV serology, recency of HIV infection, and VL. We estimated the number of people living with HIV (PLHIV) with suppressed viral load (<1,000 HIV-1 RNA copies/mL) and with unsuppressed viral load (viremic), the prevalence of unsuppressed HIV (population viremia), sex-specific HIV transmission ratios (number female incident HIV-1 infections/number unsuppressed male PLHIV per 100 persons-years [PY] and vice versa) and examined correlations between a variety of VL metrics and incident HIV. Country sample sizes ranged from 10,016 (Eswatini) to 30,637 (Rwanda); estimates were weighted and restricted to participants 15 years and older. RESULTS: The proportion of female PLHIV with viral suppression was higher than that among males in all countries, however, the number of unsuppressed females outnumbered that of unsuppressed males in all countries due to higher overall female HIV prevalence, with ratios ranging from 1.08 to 2.10 (median: 1.43). The spatial distribution of HIV seroprevalence, viremia prevalence, and number of unsuppressed adults often differed substantially within the same countries. The 1% and 5% of PLHIV with the highest VL on average accounted for 34% and 66%, respectively, of countries' total VL. HIV transmission ratios varied widely across countries and were higher for male-to-female (range: 2.3-28.3/100 PY) than for female-to-male transmission (range: 1.5-10.6/100 PY). In all countries mean log10 VL among unsuppressed males was higher than that among females. Correlations between VL measures and incident HIV varied, were weaker for VL metrics among females compared to males and were strongest for the number of unsuppressed PLHIV per 100 HIV-negative adults (R2 = 0.92). CONCLUSIONS: Despite higher proportions of viral suppression, female unsuppressed PLHIV outnumbered males in all countries examined. Unsuppressed male PLHIV have consistently higher VL and a higher risk of transmitting HIV than females. Just 5% of PLHIV account for almost two-thirds of countries' total VL. Population-level VL metrics help monitor the epidemic and highlight key programmatic gaps in these African countries. |
Factors associated with viral suppression among adults living with HIV on antiretroviral therapy in Nigeria: Analysis of a population-based survey, 2018
Abimiku A , Ramadhani HO , Moloney M , Stafford KA , Chang JC , Patel HK , Domaoal RA , Okoye M , Jelpe T , Bronson M , Ibrahim D , Swaminathan M , Gambo A , Charurat ME . HIV Med 2023 24 (7) 827-837 OBJECTIVE: Viral load suppression (VLS) is critical in reducing morbidity and mortality associated with HIV as well as minimizing the likelihood of HIV transmission to uninfected persons. The objective of this study was to identify factors associated with VLS among people living with HIV (PLWH) on antiretroviral (ARV) therapy to inform HIV programme strategies in Nigeria. METHODS: Adult participants, aged 15-64 years, from the 2018 Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS), who self-reported to be a PLWH or had detectable ARVs, were analysed to examine factors associated with VLS defined as HIV RNA <1000 copies/mL. NAIIS measured HIV prevalence, viral load, ARV and hepatitis B in PLWH. Logistic regression models were used and reported weighted prevalence. RESULTS: Of 1322 participants, 949 (68.25%) were women and 1287 (96.82%) had detectable ARVs. The median age was 39.31 [interquartile range (IQR): 31.47-47.63] years. Prevalence of VLS was 80.88%. Compared with participants with detectable ARVs, those with undetectable ARVs in their blood specimens had lower odds of VLS [adjusted odds ratio (aOR) = 0.24, 95% confidence interval (CI): 0.08-0.64). Coinfection with hepatitis B and nonnucleoside reverse transcriptase inhibitor metabolites were also associated with lower odds of VLS. Older people (45-54 vs 15-24 years) had increased odds of VLS (aOR = 2.81, 95% CI: 1.14-6.90). CONCLUSION: Young people and those with undetectable ARVs had lower odds of virological suppression. Targeted interventions focusing on young people and adherence to medication are needed to achieve the UNAIDS 95-95-95 goals for HIV epidemic control. |
A national household survey on HIV prevalence and clinical cascade among children aged 15 years in Kenya (2018)
Mutisya I , Muthoni E , Ondondo RO , Muthusi J , Omoto L , Pahe C , Katana A , Ngugi E , Masamaro K , Kingwara L , Dobbs T , Bronson M , Patel HK , Sewe N , Naitore D , De Cock K , Ngugi C , Nganga L . PLoS One 2022 17 (11) e0277613 We analyzed data from the 2018 Kenya Population-Based HIV Impact Assessment (KENPHIA), a cross-sectional, nationally representative survey, to estimate the burden and prevalence of pediatric HIV infection, identify associated factors, and describe the clinical cascade among children aged < 15 years in Kenya. Interviewers collected information from caregivers or guardians on child's demographics, HIV testing, and treatment history. Blood specimens were collected for HIV serology and if HIV-positive, the samples were tested for viral load and antiretrovirals (ARV). For participants <18 months TNA PCR is performed. We computed weighted proportions with 95% confidence intervals (CI), accounting for the complex survey design. We used bivariable and multivariable logistic regression to assess factors associated with HIV prevalence. Separate survey weights were developed for interview responses and for biomarker testing to account for the survey design and non-response. HIV burden was estimated by multiplying HIV prevalence by the national population projection by age for 2018. Of 9072 survey participants (< 15 years), 87% (7865) had blood drawn with valid HIV test results. KENPHIA identified 57 HIV-positive children, translating to an HIV prevalence of 0.7%, (95% CI: 0.4%-1.0%) and an estimated 138,900 (95% CI: 84,000-193,800) of HIV among children in Kenya. Specifically, children who were orphaned had about 2 times higher odds of HIV-infection compared to those not orphaned, adjusted Odds Ratio (aOR) 2.2 (95% CI:1.0-4.8). Additionally, children whose caregivers had no knowledge of their HIV status also had 2 times higher odds of HIV-infection compared to whose caregivers had knowledge of their HIV status, aOR 2.4 (95% CI: 1.1-5.4)". From the unconditional analysis; population level estimates, 78.9% of HIV-positive children had known HIV status (95% CI: 67.1%-90.2%), 73.6% (95% CI: 60.9%-86.2%) were receiving ART, and 49% (95% CI: 32.1%-66.7%) were virally suppressed. However, in the clinical cascade for HIV infected children, 92% (95% CI: 84.4%-100%) were receiving ART, and of these, 67.1% (95% CI: 45.1%-89.2%) were virally suppressed. The KENPHIA survey confirms a substantial HIV burden among children in Kenya, especially among orphans. |
HIV incidence, recent HIV infection, and associated factors, Kenya, 2007-2018
Young PW , Musingila P , Kingwara L , Voetsch D , Zielinski-Gutierrez E , Bulterys M , Kim AA , Bronson MA , Parekh B , Dobbs T , Patel H , Reid G , Achia T , Keter A , Mwalili S , Ogollah FM , Ondondo R , Longwe H , Chege D , Bowen N , Umuro M , Ngugi C , Justman J , Cherutich P , De Cock KM . AIDS Res Hum Retroviruses 2022 39 (2) 57-67 BACKGROUND: Nationally-representative surveys provide an opportunity to assess trends in recent HIV infection based on assays for recent HIV infection. METHODS: We assessed HIV incidence in Kenya in 2018 and trends in recent HIV infection among adolescents and adults in Kenya using nationally representative household surveys conducted in 2007, 2012 and 2018. To assess trends, we defined a recent HIV infection testing algorithm (RITA) that classified as recently infected (<12 months) those HIV-positive participants that were recent on the HIV-1 limiting antigen (LAg)-avidity assay without evidence of antiretroviral use. We assessed factors associated with recent and long-term (≥12 months) HIV infection versus no infection using a multinomial logit model while accounting for complex survey design. FINDINGS: Of 1,523 HIV-positive participants in 2018, 11 were classified as recent. Annual HIV incidence was 0.14% in 2018 (95% confidence interval [CI] 0.057-0.23), representing 35,900 (95% CI 16,300-55,600) new infections per year in Kenya among persons aged 15-64 years. The percentage of HIV infections that were determined to be recent was similar in 2007 and 2012 but fell significantly from 2012 to 2018 (adjusted odds ratio [aOR]=0.31, p<0.001). Compared to no HIV infection, being aged 25-34 versus 35-64 years (aOR=4.2, 95% CI 1.4-13), having more lifetime sex partners (aOR=5.2, 95% CI 1.6-17 for 2-3 partners and aOR=8.6, 95% CI 2.8-26 for ≥4 partners versus 0-1 partners), and never having tested for HIV (aOR=4.1, 95% CI 1.5-11) were independently associated with recent HIV infection. INTERPRETATION: Though HIV remains a public health priority in Kenya, HIV incidence estimates and trends in recent HIV infection support a significant decrease in new HIV infections from 2012 to 2018, a period of rapid expansion in HIV diagnosis, prevention, and treatment. |
Evaluation of accuracy and performance of self-reported HIV and antiretroviral therapy status in the Nigeria AIDS Indicator and Impact Survey (2018)
Jahun I , Ehoche A , Bamidele M , Yakubu A , Bronson M , Dalhatu I , Greby S , Agbakwuru C , Baffa I , Iwara E , Alagi M , Asaolu O , Mukhtar A , Ikpeazu A , Nzelu C , Tapdiyel J , Bassey O , Abimiku A , Patel H , Parekh B , Aliyu S , Aliyu G , Charurat M , Swaminathan M . PLoS One 2022 17 (8) e0273748 BACKGROUND: Data on awareness of HIV status among people living with HIV (PLHIV) are critical to estimating progress toward epidemic control. To ascertain the accuracy of self-reported HIV status and antiretroviral drug (ARV) use in the Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS), we compared self-reported HIV status with HIV rapid diagnostic test (RDT) results and self-reported ARV use with detectable blood ARV levels. METHODS: On the basis of responses and test results, participants were categorized by HIV status and ARV use. Self-reported HIV status and ARV use performance characteristics were determined by estimating sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Proportions and other analyses were weighted to account for complex survey design. RESULTS: During NAIIS, 186,405 participants consented for interview out of which 58,646 reported knowing their HIV status. Of the 959 (weighted, 1.5%) who self-reported being HIV-positive, 849 (92.1%) tested HIV positive and 64 (7.9%) tested HIV negative via RDT and polymerase chain reaction test for discordant positive results. Of the 849 who tested HIV positive, 743 (89.8%) reported using ARV and 72 (10.2%) reported not using ARV. Of 57,687 who self-reported being HIV negative, 686 (1.2%) tested HIV positive via RDT, with ARV biomarkers detected among 195 (25.1%). ARV was detected among 94.5% of those who self-reported using ARV and among 42.0% of those who self-reported not using ARV. Overall, self-reported HIV status had sensitivity of 52.7% (95% confidence interval [CI]: 49.4%-56.0%) with specificity of 99.9% (95% CI: 99.8%-99.9%). Self-reported ARV use had sensitivity of 95.2% (95% CI: 93.6%-96.7%) and specificity of 54.5% (95% CI: 48.8%-70.7%). CONCLUSIONS: Self-reported HIV status and ARV use screening tests were found to be low-validity measures during NAIIS. Laboratory tests to confirm self-reported information may be necessary to determine accurate HIV and clinical status for HIV studies in Nigeria. |
Performance of HIV rapid testing algorithm in Nigeria: findings from a household-based Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS)
Patel HK , Ikpe S , Bronson M , Birhanu S , Abimiku A , Jahun I , Detorio M , Lupoli K , Yavo D , Bassey OO , Jelpe TD , Kagurusi B , Iriemenam NC , Patel D , Okoye MI , Dalhatu IT , Ohakanu S , Voetsch AC , Aliyu S , Ashefor G , Gambo A , Ikwulono GO , Nzelu C , Adewole IF , Swaminathan M , Parekh B . PLoS Glob Public Health 2022 2 (7) e0000466 Background: The Nigeria AIDS Indicator and Impact Survey (NAIIS), a cross-sectional household survey, was conducted in 2018 with primary objectives to estimate HIV prevalence, HIV-1 incidence, and status of UNAIDS 90-90-90 cascade. We conducted retrospective analysis of the performance of HIV rapid tests and the national HIV testing algorithm used in Nigeria. |
Methods for conducting trends analysis: roadmap for comparing outcomes from three national HIV Population-based household surveys in Kenya (2007, 2012, and 2018)
Achia T , Cervantes IF , Stupp P , Musingila P , Muthusi J , Waruru A , Schmitz M , Bronson M , Chang G , Bore J , Kingwara L , Mwalili S , Muttunga J , Gitonga J , De Cock KM , Young P . BMC Public Health 2022 22 (1) 1337 BACKGROUND: For assessing the HIV epidemic in Kenya, a series of independent HIV indicator household-based surveys of similar design can be used to investigate the trends in key indicators relevant to HIV prevention and control and to describe geographic and sociodemographic disparities, assess the impact of interventions, and develop strategies. We developed methods and tools to facilitate a robust analysis of trends across three national household-based surveys conducted in Kenya in 2007, 2012, and 2018. METHODS: We used data from the 2007 and 2012 Kenya AIDS Indicator surveys (KAIS 2007 and KAIS 2012) and the 2018 Kenya Population-based HIV Impact Assessment (KENPHIA 2018). To assess the design and other variables of interest from each study, variables were recoded to ensure that they had equivalent meanings across the three surveys. After assessing weighting procedures for comparability, we used the KAIS 2012 nonresponse weighting procedure to revise normalized KENPHIA weights. Analyses were restricted to geographic areas covered by all three surveys. The revised analysis files were then merged into a single file for pooled analysis. We assessed distributions of age, sex, household wealth, and urban/rural status to identify unexpected changes between surveys. To demonstrate how a trend analysis can be carried out, we used continuous, binary, and time-to-event variables as examples. Specifically, temporal trends in age at first sex and having received an HIV test in the last 12 months were used to demonstrate the proposed analytical approach. These were assessed with respondent-specific variables (age, sex, level of education, and marital status) and household variables (place of residence and wealth index). All analyses were conducted in SAS 9.4, but analysis files were created in Stata and R format to support additional analyses. RESULTS: This study demonstrates trends in selected indicators to illustrate the approach that can be used in similar settings. The incidence of early sexual debut decreased from 11.63 (95% CI: 10.95-12.34) per 1,000 person-years at risk in 2007 to 10.45 (95% CI: 9.75-11.2) per 1,000 person-years at risk in 2012 and to 9.58 (95% CI: 9.08-10.1) per 1,000 person-years at risk in 2018. HIV-testing rates increased from 12.6% (95% CI: 11.6%-13.6%) in 2007 to 56.1% (95% CI: 54.6%-57.6%) in 2012 but decreased slightly to 55.6% [95% CI: 54.6%-56.6%) in 2018. The decrease in incidence of early sexual debut could be convincingly demonstrated between 2007 and 2012 but not between 2012 and 2018. Similarly, there was virtually no difference between HIV Testing rates in 2012 and 2018. CONCLUSIONS: Our approach can be used to support trend comparisons for variables in HIV surveys in low-income settings. Independent national household surveys can be assessed for comparability, adjusted as appropriate, and used to estimate trends in key indicators. Analyzing trends over time can not only provide insights into Kenya's progress toward HIV epidemic control but also identify gaps. |
Mapping HIV prevalence in Nigeria using small area estimates to develop a targeted HIV intervention strategy
O'Brien-Carelli C , Steuben K , Stafford KA , Aliogo R , Alagi M , Johanns CK , Ibrahim J , Shiraishi R , Ehoche A , Greby S , Dirlikov E , Ibrahim D , Bronson M , Aliyu G , Aliyu S , Dwyer-Lindgren L , Swaminathan M , Duber HC , Charurat M . PLoS One 2022 17 (6) e0268892 OBJECTIVE: Although geographically specific data can help target HIV prevention and treatment strategies, Nigeria relies on national- and state-level estimates for policymaking and intervention planning. We calculated sub-state estimates along the HIV continuum of care in Nigeria. DESIGN: Using data from the Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS) (July-December 2018), we conducted a geospatial analysis estimating three key programmatic indicators: prevalence of HIV infection among adults (aged 15-64 years); antiretroviral therapy (ART) coverage among adults living with HIV; and viral load suppression (VLS) rate among adults living with HIV. METHODS: We used an ensemble modeling method called stacked generalization to analyze available covariates and a geostatistical model to incorporate the output from stacking as well as spatial autocorrelation in the modeled outcomes. Separate models were fitted for each indicator. Finally, we produced raster estimates of each indicator on an approximately 5×5-km grid and estimates at the sub-state/local government area (LGA) and state level. RESULTS: Estimates for all three indicators varied both within and between states. While state-level HIV prevalence ranged from 0.3% (95% uncertainty interval [UI]: 0.3%-0.5%]) to 4.3% (95% UI: 3.7%-4.9%), LGA prevalence ranged from 0.2% (95% UI: 0.1%-0.5%) to 8.5% (95% UI: 5.8%-12.2%). Although the range in ART coverage did not substantially differ at state level (25.6%-76.9%) and LGA level (21.9%-81.9%), the mean absolute difference in ART coverage between LGAs within states was 16.7 percentage points (range, 3.5-38.5 percentage points). States with large differences in ART coverage between LGAs also showed large differences in VLS-regardless of level of effective treatment coverage-indicating that state-level geographic targeting may be insufficient to address coverage gaps. CONCLUSION: Geospatial analysis across the HIV continuum of care can effectively highlight sub-state variation and identify areas that require further attention in order to achieve epidemic control. By generating local estimates, governments, donors, and other implementing partners will be better positioned to conduct targeted interventions and prioritize resource distribution. |
Optimizing community linkage to care and antiretroviral therapy Initiation: Lessons from the Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS) and their adaptation in Nigeria ART Surge
Jahun I , Said I , El-Imam I , Ehoche A , Dalhatu I , Yakubu A , Greby S , Bronson M , Brown K , Bamidele M , Boyd AT , Bachanas P , Dirlikov E , Agbakwuru C , Abutu A , Williams-Sherlock M , Onotu D , Odafe S , Williams DB , Bassey O , Ogbanufe O , Onyenuobi C , Adeola A , Meribe C , Efuntoye T , Fagbamigbe OJ , Fagbemi A , Ene U , Nguhemen T , Mgbakor I , Alagi M , Asaolu O , Oladipo A , Amafah J , Nzelu C , Dakum P , Mensah C , Aliyu A , Okonkwo P , Oyeledun B , Oko J , Ikpeazu A , Gambo A , Charurat M , Ellerbrock T , Aliyu S , Swaminathan M . PLoS One 2021 16 (9) e0257476 BACKGROUND: Ineffective linkage to care (LTC) is a known challenge for community HIV testing. To overcome this challenge, a robust linkage to care strategy was adopted by the 2018 Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS). The NAIIS linkage to care strategy was further adapted to improve Nigeria's programmatic efforts to achieve the 1st 90 as part of the Nigeria Antiretroviral Therapy (ART) Surge initiative, which also included targeted community testing. In this paper we provide an overview of the NAIIS LTC strategy and describe the impact of this strategy on both the NAIIS and the Surge initiatives. METHODS: The NAIIS collaborated with community-based organizations (CBOs) and deployed mobile health (mHealth) technology with real-time dashboards to manage and optimize community LTC for people living with HIV (PLHIV) diagnosed during the survey. In NAIIS, CBOs' role was to facilitate linkage of identified PLHIV in community to facility of their choice. For the ART Surge, we modified the NAIIS LTC strategy by empowering both CBOs and mobile community teams as responsible for not only active LTC but also for community testing, ART initiation, and retention in care. RESULTS: Of the 2,739 PLHIV 15 years and above identified in NAIIS, 1,975 (72.1%) were either unaware of their HIV-positive status (N = 1890) or were aware of their HIV-positive status but not receiving treatment (N = 85). Of these, 1,342 (67.9%) were linked to care, of which 952 (70.9%) were initiated on ART. Among 1,890 newly diagnosed PLHIV, 1,278 (67.6%) were linked to care, 33.7% self-linked and 66.3% were linked by CBOs. Among 85 known PLHIV not on treatment, 64 (75.3%) were linked; 32.8% self-linked and 67.2% were linked by a CBO. In the ART Surge, LTC and treatment initiation rates were 98% and 100%, respectively. Three-month retention for monthly treatment initiation cohorts improved from 76% to 90% over 6 months. CONCLUSIONS: Active LTC strategies by local CBOs and mobile community teams improved LTC and ART initiation in the ART Surge initiative. The use of mHealth technology resulted in timely and accurate documentation of results in NAIIS. By deploying mHealth in addition to active LTC, CBOs and mobile community teams could effectively scale up ART with real-time documentation of client-level outcomes. |
Lessons From Rapid Field Implementation of an HIV Population-Based Survey in Nigeria, 2018
Jahun I , Greby SM , Adesina T , Agbakwuru C , Dalhatu I , Yakubu A , Jelpe T , Okoye M , Ikpe S , Ehoche A , Abimiku A , Aliyu G , Charurat M , Greenwell G , Bronson M , Patel H , McCracken S , Voetsch AC , Parekh B , Swaminathan M , Adewole I , Aliyu S . J Acquir Immune Defic Syndr 2021 87 S36-s42 BACKGROUND: The need for accurate HIV annual program planning data motivated the compressed timeline for the 2018 Nigerian HIV/AIDS Indicator and Impact Survey (NAIIS). The survey team used stakeholder cooperation and responsive design, using survey process and paradata to refine survey implementation, to quickly collect high-quality data. We describe processes that led to generation of data for program and funding decisions, ensuring HIV services were funded in 2019. SETTING: Nigeria is the most populous country in Africa, with approximately 195 million people in 36 states and the Federal Capital Territory. Challenges include multiple security threats, poor infrastructure, seasonal rains, and varied health system capacity. METHODS: Stakeholders worked together to plan and implement NAIIS. Methods from other population-based HIV impact assessments were modified to meet challenges and the compressed timeline. Data collection was conducted in 6 webs. Responsive design included reviewing survey monitoring paradata and laboratory performance. Costs required to correct data errors, for example, staff time and transportation, were tracked. RESULTS: NAIIS data collection was completed in 23 weeks, ahead of the originally scheduled 24 weeks. Responsive design identified and resolved approximately 68,000 interview errors, affecting approximately 62,000 households, saving about US$4.4 million in costs. Biweekly field laboratory test quality control improved from 50% to 100% throughout NAIIS. CONCLUSIONS: Cooperation across stakeholders and responsive design ensured timely release of NAIIS results and informed planning for HIV epidemic control in Nigeria. Based on NAIIS results, funds were provided to place an additional 500,000 HIV-positive Nigerians on antiretroviral therapy by the end of 2020, pushing Nigeria toward epidemic control. |
Unawareness of HIV Infection Among Men Aged 15-59 Years in 13 Sub-Saharan African Countries: Findings From the Population-Based HIV Impact Assessments, 2015-2019
West CA , Chang GC , Currie DW , Bray R , Kinchen S , Behel S , McCullough-Sanden R , Low A , Bissek A , Shang JD , Ndongmo CB , Dokubo EK , Balachandra S , Lobognon LR , Dube L , Nuwagaba-Biribonwoha H , Li M , Pasipamire M , Getaneh Y , Lulseged S , Eshetu F , Kingwara L , Zielinski-Gutierrez E , Tlhomola M , Ramphalla P , Kalua T , Auld AF , Williams DB , Remera E , Rwibasira GN , Mugisha V , Malamba SS , Mushi J , Jalloh MF , Mgomella GS , Kirungi WL , Biraro S , Awor AC , Barradas DT , Mugurungi O , Rogers JH , Bronson M , Bodika SM , Ajiboye A , Gaffga N , Moore C , Patel HK , Voetsch AC . J Acquir Immune Defic Syndr 2021 87 S97-s106 BACKGROUND: Identifying men living with HIV in sub-Saharan Africa (SSA) is critical to end the epidemic. We describe the underlying factors of unawareness among men aged 15-59 years who ever tested for HIV in 13 SSA countries. METHODS: Using pooled data from the nationally representative Population-based HIV Impact Assessments, we fit a log-binomial regression model to identify characteristics related to HIV positivity among HIV-positive unaware and HIV-negative men ever tested for HIV. RESULTS: A total of 114,776 men were interviewed and tested for HIV; 4.4% were HIV-positive. Of those, 33.7% were unaware of their HIV-positive status, (range: 20.2%-58.7%, in Rwanda and Cote d'Ivoire). Most unaware men reported they had ever received an HIV test (63.0%). Age, region, marital status, and education were significantly associated with HIV positivity. Men who had HIV-positive sexual partners (adjusted prevalence ratio [aPR]: 5.73; confidence interval [95% CI]: 4.13 to 7.95) or sexual partners with unknown HIV status (aPR: 2.32; 95% CI: 1.89 to 2.84) were more likely to be HIV-positive unaware, as were men who tested more than 12 months compared with HIV-negative men who tested within 12 months before the interview (aPR: 1.58; 95% CI: 1.31 to 1.91). Tuberculosis diagnosis and not being circumcised were also associated with HIV positivity. CONCLUSION: Targeting subgroups of men at risk for infection who once tested negative could improve yield of testing programs. Interventions include improving partner testing, frequency of testing, outreach and educational strategies, and availability of HIV testing where men are accessing routine health services. |
HIV incidence by male circumcision status from the population-based HIV impact assessment (PHIA) surveys-eight sub-Saharan African countries, 2015-2017
Hines JZ , Sachathep K , Pals S , Davis SM , Toledo C , Bronson M , Parekh B , Carrasco M , Xaba S , Mandisarisa J , Kamobyi R , Chituwo O , Kirungi WL , Alamo S , Kabuye G , Awor AC , Mmbando S , Simbeye D , Aupokolo MA , Zemburuka B , Nyirenda R , Msungama W , Tarumbiswa T , Manda R , Nuwagaba-Biribonwoha H , Kiggundu V , Thomas AG , Watts H , Voetsch AC , Williams DB . J Acquir Immune Defic Syndr 2021 87 S89-S96 BACKGROUND: Male circumcision (MC) offers men lifelong partial protection from heterosexually-acquired HIV infection. The impact of MC on HIV incidence has not been quantified in nationally-representative samples. Data from the Population-based HIV Impact Assessments (PHIAs) were used to compare incidence by MC status in countries implementing voluntary medical MC (VMMC) programs. METHODS: Data were pooled from PHIAs conducted in Eswatini, Lesotho, Malawi, Namibia, Tanzania, Uganda, Zambia and Zimbabwe from 2015-2017. Incidence was measured using a recent infection testing algorithm, and analyzed by self-reported MC status distinguishing between medical and non-medical MC. Country, marital status, urban setting, sexual risk behaviors, and mean population HIV viral load among women as an indicator of treatment scale-up were included in a random effects logistic regression model using pooled survey weights. Analyses were age-stratified (15-34 and 35-59 years). Annualized incidence rates and 95% confidence intervals (CIs) and incidence differences were calculated between medically circumcised and uncircumcised men. RESULTS: Men 15-34 years reporting medical MC had lower HIV incidence than uncircumcised men (0.04% [95% CI: 0.00, 0.10%] versus 0.34% [95% CI: 0.10, 0.57%], respectively; p-value = 0.01); whereas among men 35-59 years, there was no significant incidence difference (1.36% [95% CI: 0.32, 2.39%] versus 0.55% [95% CI: 0.14, 0.67%], respectively; p-value = 0.14). DISCUSSION: Medical MC was associated with lower HIV incidence in men aged 15-34 years in nationally-representative surveys in Africa. These findings are consistent with the expected ongoing VMMC program impact and highlight the importance of VMMC for the HIV response in Africa. |
Ghana's HIV epidemic and PEPFAR's contribution towards epidemic control
Ali H , Amoyaw F , Baden D , Durand L , Bronson M , Kim A , Grant-Greene Y , Imtiaz R , Swaminathan M . Ghana Med J 2019 53 (1) 59-62 Background: The aim of this review was to summarize the data on HIV/AIDS epidemiology and affected populations in Ghana and to describe the United States President's Emergency Plan for Emergency Relief's (PEPFAR) response to the epidemic. Design: We conducted a literature review focusing on PEPFAR's contribution to the HIV response in Ghana. Additionally, we summarized the epidemiology of HIV. We searched both peer-reviewed and grey literature. Setting: Ghana. Results: Overall, HIV prevalence in Ghana is 1.6% with regional variation. Key populations (KPs) are disproportionately affected by HIV in the country. FSW and their clients, and MSM, account for 28% of all new infections. PEPFAR provides technical assistance (TA) to Ghana to maximize the quality, coverage and impact of the national HIV/AIDS response. To ensure adequate supply of antiretrovirals (ARVs), in 2016-2017, PEPFAR invested $23.7 million as a onetime supplemental funding to support Ghana's ARV treatment program. In addition, the National AIDS Control Programme in collaboration with PEPFAR is implementing a scale up of viral load testing. PEPFAR is also implementing a comprehensive package of prevention services in five regions to help reach MSM and FSW and to expand HIV testing services for KPs. Conclusions: Ghana is making changes at both policy and program level in the fight against HIV/AIDS and is working towards achieving the UNAIDS' 90-90-90 targets. PEPFAR is providing TA to ensure these goals can be achieved. Funding: This manuscript has been supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC). |
Integrating community-based verbal autopsy into civil registration and vital statistics (CRVS): system-level considerations
de Savigny D , Riley I , Chandramohan D , Odhiambo F , Nichols E , Notzon S , AbouZahr C , Mitra R , Cobos Munoz D , Firth S , Maire N , Sankoh O , Bronson G , Setel P , Byass P , Jakob R , Boerma T , Lopez AD . Glob Health Action 2017 10 (1) 1272882 BACKGROUND: Reliable and representative cause of death (COD) statistics are essential to inform public health policy, respond to emerging health needs, and document progress towards Sustainable Development Goals. However, less than one-third of deaths worldwide are assigned a cause. Civil registration and vital statistics (CRVS) systems in low- and lower-middle-income countries are failing to provide timely, complete and accurate vital statistics, and it will still be some time before they can provide physician-certified COD for every death. Proposals: Verbal autopsy (VA) is a method to ascertain the probable COD and, although imperfect, it is the best alternative in the absence of medical certification. There is extensive experience with VA in research settings but only a few examples of its use on a large scale. Data collection using electronic questionnaires on mobile devices and computer algorithms to analyse responses and estimate probable COD have increased the potential for VA to be routinely applied in CRVS systems. However, a number of CRVS and health system integration issues should be considered in planning, piloting and implementing a system-wide intervention such as VA. These include addressing the multiplicity of stakeholders and sub-systems involved, integration with existing CRVS work processes and information flows, linking VA results to civil registration records, information technology requirements and data quality assurance. CONCLUSIONS: Integrating VA within CRVS systems is not simply a technical undertaking. It will have profound system-wide effects that should be carefully considered when planning for an effective implementation. This paper identifies and discusses the major system-level issues and emerging practices, provides a planning checklist of system-level considerations and proposes an overview for how VA can be integrated into routine CRVS systems. |
A whole community approach to emergency management: strategies and best practices of seven community programs
Sobelson RK , Wigington CJ , Harp V , Bronson BB . J Emerg Manag 2015 13 (4) 349-357 OBJECTIVE: In 2011, the Federal Emergency Management Agency (FEMA) published the Whole Community Approach to Emergency Management: Principles, Themes, and Pathways for Action, outlining the need for increased individual preparedness and more widespread community engagement to enhance the overall resiliency and security of communities. However, there is limited evidence of how to build a whole community approach to emergency management that provides real-world, practical examples and applications. This article reports on the strategies and best practices gleaned from seven community programs fostering a whole community approach to emergency management. DESIGN: The project team engaged in informal conversations with community stakeholders to learn about their programs during routine monitoring activities, site visits, and during an in-person, facilitated workshop. A total of 88 community members associated with the programs examples contributed. Qualitative analysis was conducted. RESULTS: The findings highlighted best practices gleaned from the seven programs that other communities can leverage to build and maintain their own whole community programs. The findings from the programs also support and validate the three principles and six strategic themes outlined by FEMA. CONCLUSIONS: The findings, like the whole community document, highlight the importance of understanding the community, building relationships, empowering action, and fostering social capital to build a whole community approach. |
Evaluation design of New York City's regulations on nutrition, physical activity, and screen time in early child care centers
Breck A , Goodman K , Dunn L , Stephens RL , Dawkins N , Dixon B , Jernigan J , Kakietek J , Lesesne C , Lessard L , Nonas C , O'Dell SA , Osuji TA , Bronson B , Xu Y , Kettel Khan L . Prev Chronic Dis 2014 11 E184 This article describes the multi-method cross-sectional design used to evaluate New York City Department of Health and Mental Hygiene's regulations of nutrition, physical activity, and screen time for children aged 3 years or older in licensed group child care centers. The Center Evaluation Component collected data from a stratified random sample of 176 licensed group child care centers in New York City. Compliance with the regulations was measured through a review of center records, a facility inventory, and interviews of center directors, lead teachers, and food service staff. The Classroom Evaluation Component included an observational and biometric study of a sample of approximately 1,400 children aged 3 or 4 years attending 110 child care centers and was designed to complement the center component at the classroom and child level. The study methodology detailed in this paper may aid researchers in designing policy evaluation studies that can inform other jurisdictions considering similar policies. |
Prescription histories and dose strengths associated with overdose deaths
Hirsch A , Proescholdbell SK , Bronson W , Dasgupta N . Pain Med 2014 15 (7) 1187-1195 OBJECTIVE: Misuse, abuse, and diversion of prescription drugs are large and growing public health problems that have resulted in an overdose epidemic. We investigated whether short-acting or extended-release opioids were more frequently prescribed to those who died of an overdose and whether there was a linear relationship between dose strength and associated overdose deaths. METHODS: The study population was North Carolina residents in 2010. We conducted a retrospective, population-based, descriptive study of medication histories of overdose decedents using data from vital statistics, medical examiner records, and a prescription drug monitoring program. RESULTS: Unintentional or undetermined drug overdoses were responsible for 892 deaths. Out of 191 deaths involving methadone, only two were patients in opioid treatment programs. Immediate-release oxycodone was involved in the greatest number of opioid-related deaths. Out of 221 oxycodone deaths, 134 (61%) of the decedents filled a prescription for oxycodone in the 60 days prior to death. The most common strength dispensed within 60 days to a decedent who died of an oxycodone overdose was 10mg for immediate-release (72 prescriptions). Immediate-release oxycodone products (rho=1.00, P<0.01) and extended-release fentanyl products (rho=1.00, P<0.01) showed strong increasing linear trends between dose strength and proportion of prescriptions dispensed to decedents. CONCLUSIONS: A significant proportion of overdose decedents had been prescribed the same type of drugs that contributed to their death, especially for decedents who died from overdoses involving oxycodone, hydrocodone, and alprazolam. Higher dose strengths for certain opioids had higher associated mortality, and certain immediate-release opioids may be considered for public health prevention efforts. |
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