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Overcoming resistance to HIV testing in sub-Saharan Africa
Comment
Overcoming resistance to HIV testing in sub-Saharan Africa Published Online January 25, 2016 http://dx.doi.org/10.1016/ S2352-3018(16)00004-7 See Articles page e111
e106
Personal awareness of HIV serostatus is an essential requirement for effective prevention and treatment, but despite decades of concerted efforts to promote HIV testing, less than 45% of people with HIV in sub-Saharan Africa know their status.1 Major barriers to testing include stigma and discrimination, inaccessibility of services, and low awareness of the benefits of testing and early treatment. Strategies to increase HIV testing have moved beyond fixed clinics to include community-based services, including mobile and home-based HIV testing, and selftesting. These strategies have increased the proportion of people being tested, reduced risk behaviour,2 and increased linkage to care; however, many people remain unreached and unaware of their HIV status. In The Lancet HIV, Gabriel Chamie and colleagues3 report findings from their assessment of a new HIV testing strategy in Kenya and Uganda designed to overcome barriers to HIV testing and quickly increase uptake. They used a hybrid, multistage approach, which first involved a census with enumeration and fingerprinting of all household members. Next, they initiated community health campaigns for multiple diseases, supported by mobilisation efforts. The campaigns offered screening for HIV and various other health services, including screening for diabetes and hypertension. Patients diagnosed with HIV infection were provided immediate CD4 testing for staging and referrals for care. Those opting for HIV testing had their fingerprints taken, and these scans were matched against biometric data from the census to identify those not tested for HIV. Non-testers were then approached at their home and offered on-site HIV testing. The results were impressive, with 131 307 (89%) of the 149 906 residents tested for HIV over a period of 1 year, with 104 635 (80%) of those tested for HIV in the initial multiple-disease campaigns. The integration of HIV testing with other health screening probably helped destigmatise the service while addressing health problems of importance to communities. The enthusiasm for the multiple-disease campaign is striking. In our community-based HIV testing services in rural Tanzania (NCT02018978), we identified similar large increases in HIV testing when integrated with non-communicable disease screening. Combination HIV prevention has received a lot of attention in the past 5 years,4 but the prevailing notion is to offer a combination
of HIV prevention services, typically dominated by biomedical interventions supported by behavioural initiatives that generate demand.5 The work by Chamie and colleagues3 shows that demand is probably improved substantially when combining HIV interventions with non-HIV health interventions. Moreover, their work suggests that combination HIV prevention strategies could be most cost-effective if they integrate HIV with non-HIV services and provide services in a sequence such that more intensive efforts are targeted to people who were resistant to other approaches. Additionally, because HIV has essentially become a chronic disorder, linking screening and care with that for other chronic disorders is logical and has been advocated for previously.6 Ethical concerns are raised by diagnosing large numbers of people with illnesses such as diabetes and hypertension in countries where health systems are not well resourced to treat these diseases,7,8 especially when large numbers of clients are diagnosed in a short timeframe. These concerns recall earlier times in the battle against HIV in sub-Saharan Africa, when provision of HIV testing in the context of no treatment was questioned. We feel strongly that diagnosis of some diseases, even when there is limited access to medical care, is both ethical and useful in public health promotion, especially when the diseases can be mitigated by behavioural change, including diet and exercise modifications. Such screening programmes allow people to know that they have a serious disease and provide access to valuable health information, which is a human right irrespective of treatment access.9,10 They also create groups of people who advocate for their right to care. In 2003, when we initiated large-scale communitybased mobile HIV testing in Tanzania as part of the National Institute of Mental Health Project Accept,11 we received resistance from the donor community about the value of testing people for HIV when treatment was not available. However, we learned that people did engage in HIV testing if the service was confidential and convenient. Access to HIV treatment eventually became a reality in our study setting, in no small part because of demand from communities affected by HIV who were motivated by the awareness of their infection. That Chamie and colleagues were able to test 89% of their study site populations in east Africa is impressive, and their strategy provides insights to others who are www.thelancet.com/hiv Vol 3 March 2016
Comment
designing combination HIV prevention interventions on the value of integration of non-HIV services. The challenge now is to replicate their success more broadly and to empower health systems in the region to provide the comprehensive care needed. *Michael Sweat, Virginia Fonner Center for Global and Community Health Research, Department of Psychiatry and Behavioral Sciences, The Medical University of South Carolina, SC 29401, USA [email protected]
4
5
6
7
8 9
We declare no competing interests. 1
2
3
Staveteig S, Wang S, Head S, Bradley S, Nybro E. Demographic patterns of HIV testing uptake in sub-Saharan Africa. Calverton, Maryland, USA: ICF International, 2013. Fonner VA, Denison J, Kennedy CE, O’Reilly K, Sweat M. Voluntary counseling and testing (VCT) for changing HIV-related risk behavior in developing countries. Cochrane Database Syst Rev 2012; 9: CD001224. Chamie G, Clark TD, Kabami J, et al. A hybrid mobile approach for populationwide HIV testing in rural east Africa: an observational study. Lancet HIV 2016; published online Jan 25. http://dx.doi.org/10.1016/S2352-3018(15)00251-9.
10 11
Padian NS, McCoy SI, Manian S, Wilson D, Schwartlander B, Bertozzi SM. Evaluation of large-scale combination HIV prevention programs: essential issues. J Acquir Immune Defic Syndr 2011; 58: e23–28. Vermund SH, Fidler SJ, Ayles H, Beyers N, Hayes RJ. Can combination prevention strategies reduce HIV transmission in generalized epidemic settings in Africa? The HPTN 071 (PopART) study plan in South Africa and Zambia. J Acquir Immune Defic Syndr 2013; 63 (suppl 2): S221–27. Rabkin M, El-Sadr WM. Why reinvent the wheel? Leveraging the lessons of HIV scale-up to confront non-communicable diseases. Glob Public Health 2011; 6: 247–56. Kupitz DG, Fenwick E, Kollmann KH, Holz FG, Finger RP. Diabetes and diabetic retinopathy management in east Africa: knowledge, attitudes, and practices of hospital staff in Kenya. Asia Pac J Ophthalmol (Phila) 2014; 3: 271–76. Wasswa H. Uganda struggles to cope with rise in diabetes incidence. BMJ 2006; 333: 672. UN Committee on Economic Social and Cultural Rights (CESCR). General comment no. 14: the right to the highest attainable standard of health (art. 12 of the covenant). Geneva: United Nations High Commissioner for Human Rights, 2000. UN General Assembly. International covenant on economic, social, and cultural rights (ICESCR). New York: United Nations General Assembly, 1966. Sweat M, Morin S, Celentano D, et al, for the Project Accept study team. Community-based intervention to increase HIV testing and case detection in people aged 16–32 years in Tanzania, Zimbabwe, and Thailand (NIMH Project Accept, HPTN 043): a randomised study. Lancet Infect Dis 2011; 11: 525–32.
The tuberculosis emergency in eastern Europe
www.thelancet.com/hiv Vol 3 March 2016
routine tuberculosis practice, similar to those described in a recent Lancet Series on eliminating the disease.5 Yet there has been great hesitation on the part of a tuberculosis community more comfortable with tradition than innovation to demand these interventions be implemented worldwide and urgently, even though similar outbreaks are also being reported in places as disparate as Papua New Guinea6 and India.7 Because most drug-resistant tuberculosis comes from primary transmission,8 treatment as prevention must become the prevailing strategy to stop the spread of drugresistant tuberculosis, as is the case for HIV.9 This means
Published Online February 1, 2016 http://dx.doi.org/10.1016/ S2352-3018(16)00002-3 See Articles page e120
Zephyr/Science Photo Library
Recently, when it comes to tuberculosis, there has been no shortage of bad news. WHO announced in November that, once again, the disease has earned the dubious distinction of being the leading infectious killer of adults.1 And, now, in The Lancet HIV, Daria Podlekareva and colleagues2 show that almost one in every three people living with HIV in eastern Europe who is diagnosed with tuberculosis is dead within a year. Although unsettling, there is nothing surprising about the results of this study. Once again, we are presented with evidence that two familiar stumbling blocks are killing people with tuberculosis at unprecedented rates: HIV coinfection and drug-resistant forms of the disease.3 The noxious synergy4 between tuberculosis and HIV has been well described, with many different solutions proposed for halting this mortality. However, this paper presents clear evidence that straightforward interventions—such as drug-susceptibility testing for tuberculosis and the prompt initiation of antiretroviral therapy in all patients with tuberculosis—are still not being implemented. Drug resistance continues to be a formidable foe, with this study documenting a death rate three-times higher in those with drug-resistant tuberculosis than in those with fully susceptible disease. In western Europe, however, no such excess mortality was recorded, probably because effective interventions are part of
e107
Overcoming resistance to HIV testing in sub-Saharan Africa Published Online January 25, 2016 http://dx.doi.org/10.1016/ S2352-3018(16)00004-7 See Articles page e111
e106
Personal awareness of HIV serostatus is an essential requirement for effective prevention and treatment, but despite decades of concerted efforts to promote HIV testing, less than 45% of people with HIV in sub-Saharan Africa know their status.1 Major barriers to testing include stigma and discrimination, inaccessibility of services, and low awareness of the benefits of testing and early treatment. Strategies to increase HIV testing have moved beyond fixed clinics to include community-based services, including mobile and home-based HIV testing, and selftesting. These strategies have increased the proportion of people being tested, reduced risk behaviour,2 and increased linkage to care; however, many people remain unreached and unaware of their HIV status. In The Lancet HIV, Gabriel Chamie and colleagues3 report findings from their assessment of a new HIV testing strategy in Kenya and Uganda designed to overcome barriers to HIV testing and quickly increase uptake. They used a hybrid, multistage approach, which first involved a census with enumeration and fingerprinting of all household members. Next, they initiated community health campaigns for multiple diseases, supported by mobilisation efforts. The campaigns offered screening for HIV and various other health services, including screening for diabetes and hypertension. Patients diagnosed with HIV infection were provided immediate CD4 testing for staging and referrals for care. Those opting for HIV testing had their fingerprints taken, and these scans were matched against biometric data from the census to identify those not tested for HIV. Non-testers were then approached at their home and offered on-site HIV testing. The results were impressive, with 131 307 (89%) of the 149 906 residents tested for HIV over a period of 1 year, with 104 635 (80%) of those tested for HIV in the initial multiple-disease campaigns. The integration of HIV testing with other health screening probably helped destigmatise the service while addressing health problems of importance to communities. The enthusiasm for the multiple-disease campaign is striking. In our community-based HIV testing services in rural Tanzania (NCT02018978), we identified similar large increases in HIV testing when integrated with non-communicable disease screening. Combination HIV prevention has received a lot of attention in the past 5 years,4 but the prevailing notion is to offer a combination
of HIV prevention services, typically dominated by biomedical interventions supported by behavioural initiatives that generate demand.5 The work by Chamie and colleagues3 shows that demand is probably improved substantially when combining HIV interventions with non-HIV health interventions. Moreover, their work suggests that combination HIV prevention strategies could be most cost-effective if they integrate HIV with non-HIV services and provide services in a sequence such that more intensive efforts are targeted to people who were resistant to other approaches. Additionally, because HIV has essentially become a chronic disorder, linking screening and care with that for other chronic disorders is logical and has been advocated for previously.6 Ethical concerns are raised by diagnosing large numbers of people with illnesses such as diabetes and hypertension in countries where health systems are not well resourced to treat these diseases,7,8 especially when large numbers of clients are diagnosed in a short timeframe. These concerns recall earlier times in the battle against HIV in sub-Saharan Africa, when provision of HIV testing in the context of no treatment was questioned. We feel strongly that diagnosis of some diseases, even when there is limited access to medical care, is both ethical and useful in public health promotion, especially when the diseases can be mitigated by behavioural change, including diet and exercise modifications. Such screening programmes allow people to know that they have a serious disease and provide access to valuable health information, which is a human right irrespective of treatment access.9,10 They also create groups of people who advocate for their right to care. In 2003, when we initiated large-scale communitybased mobile HIV testing in Tanzania as part of the National Institute of Mental Health Project Accept,11 we received resistance from the donor community about the value of testing people for HIV when treatment was not available. However, we learned that people did engage in HIV testing if the service was confidential and convenient. Access to HIV treatment eventually became a reality in our study setting, in no small part because of demand from communities affected by HIV who were motivated by the awareness of their infection. That Chamie and colleagues were able to test 89% of their study site populations in east Africa is impressive, and their strategy provides insights to others who are www.thelancet.com/hiv Vol 3 March 2016
Comment
designing combination HIV prevention interventions on the value of integration of non-HIV services. The challenge now is to replicate their success more broadly and to empower health systems in the region to provide the comprehensive care needed. *Michael Sweat, Virginia Fonner Center for Global and Community Health Research, Department of Psychiatry and Behavioral Sciences, The Medical University of South Carolina, SC 29401, USA [email protected]
4
5
6
7
8 9
We declare no competing interests. 1
2
3
Staveteig S, Wang S, Head S, Bradley S, Nybro E. Demographic patterns of HIV testing uptake in sub-Saharan Africa. Calverton, Maryland, USA: ICF International, 2013. Fonner VA, Denison J, Kennedy CE, O’Reilly K, Sweat M. Voluntary counseling and testing (VCT) for changing HIV-related risk behavior in developing countries. Cochrane Database Syst Rev 2012; 9: CD001224. Chamie G, Clark TD, Kabami J, et al. A hybrid mobile approach for populationwide HIV testing in rural east Africa: an observational study. Lancet HIV 2016; published online Jan 25. http://dx.doi.org/10.1016/S2352-3018(15)00251-9.
10 11
Padian NS, McCoy SI, Manian S, Wilson D, Schwartlander B, Bertozzi SM. Evaluation of large-scale combination HIV prevention programs: essential issues. J Acquir Immune Defic Syndr 2011; 58: e23–28. Vermund SH, Fidler SJ, Ayles H, Beyers N, Hayes RJ. Can combination prevention strategies reduce HIV transmission in generalized epidemic settings in Africa? The HPTN 071 (PopART) study plan in South Africa and Zambia. J Acquir Immune Defic Syndr 2013; 63 (suppl 2): S221–27. Rabkin M, El-Sadr WM. Why reinvent the wheel? Leveraging the lessons of HIV scale-up to confront non-communicable diseases. Glob Public Health 2011; 6: 247–56. Kupitz DG, Fenwick E, Kollmann KH, Holz FG, Finger RP. Diabetes and diabetic retinopathy management in east Africa: knowledge, attitudes, and practices of hospital staff in Kenya. Asia Pac J Ophthalmol (Phila) 2014; 3: 271–76. Wasswa H. Uganda struggles to cope with rise in diabetes incidence. BMJ 2006; 333: 672. UN Committee on Economic Social and Cultural Rights (CESCR). General comment no. 14: the right to the highest attainable standard of health (art. 12 of the covenant). Geneva: United Nations High Commissioner for Human Rights, 2000. UN General Assembly. International covenant on economic, social, and cultural rights (ICESCR). New York: United Nations General Assembly, 1966. Sweat M, Morin S, Celentano D, et al, for the Project Accept study team. Community-based intervention to increase HIV testing and case detection in people aged 16–32 years in Tanzania, Zimbabwe, and Thailand (NIMH Project Accept, HPTN 043): a randomised study. Lancet Infect Dis 2011; 11: 525–32.
The tuberculosis emergency in eastern Europe
www.thelancet.com/hiv Vol 3 March 2016
routine tuberculosis practice, similar to those described in a recent Lancet Series on eliminating the disease.5 Yet there has been great hesitation on the part of a tuberculosis community more comfortable with tradition than innovation to demand these interventions be implemented worldwide and urgently, even though similar outbreaks are also being reported in places as disparate as Papua New Guinea6 and India.7 Because most drug-resistant tuberculosis comes from primary transmission,8 treatment as prevention must become the prevailing strategy to stop the spread of drugresistant tuberculosis, as is the case for HIV.9 This means
Published Online February 1, 2016 http://dx.doi.org/10.1016/ S2352-3018(16)00002-3 See Articles page e120
Zephyr/Science Photo Library
Recently, when it comes to tuberculosis, there has been no shortage of bad news. WHO announced in November that, once again, the disease has earned the dubious distinction of being the leading infectious killer of adults.1 And, now, in The Lancet HIV, Daria Podlekareva and colleagues2 show that almost one in every three people living with HIV in eastern Europe who is diagnosed with tuberculosis is dead within a year. Although unsettling, there is nothing surprising about the results of this study. Once again, we are presented with evidence that two familiar stumbling blocks are killing people with tuberculosis at unprecedented rates: HIV coinfection and drug-resistant forms of the disease.3 The noxious synergy4 between tuberculosis and HIV has been well described, with many different solutions proposed for halting this mortality. However, this paper presents clear evidence that straightforward interventions—such as drug-susceptibility testing for tuberculosis and the prompt initiation of antiretroviral therapy in all patients with tuberculosis—are still not being implemented. Drug resistance continues to be a formidable foe, with this study documenting a death rate three-times higher in those with drug-resistant tuberculosis than in those with fully susceptible disease. In western Europe, however, no such excess mortality was recorded, probably because effective interventions are part of
e107