HIV-associated dementia (HAD) has received little attention in sub-Saharan Africa, and there are no data available from Malawi. We used the International HIV Dementia Scale (IHDS), a cross-cultural, simple and validated screening tool to study the prevalence of suspected HAD, defined as an IHDS score
Introduction: The potential disruption in antiretroviral therapy (ART) services in Africa at the start of the COVID-19 pandemic raised concern for increased morbidity and mortality among people living with HIV (PLHIV). We describe HIV treatment trends before and during the pandemic and interventions implemented to mitigate COVID-19 impact among countries supported by the US Centers for Disease Control and Prevention (CDC) through the President's Emergency Plan for AIDS Relief (PEPFAR). Methods: We analysed quantitative and qualitative data reported by 10,387 PEPFAR-CDC-supported ART sites in 19 African countries between October 2019 and March 2021. Trends in PLHIV on ART, new ART initiations and treatment interruptions were assessed. Viral load coverage (testing of eligible PLHIV) and viral suppression were calculated at select time points. Qualitative data were analysed to summarize facility-and community-based interventions implemented to mitigate COVID-19. Results: The total number of PLHIV on ART increased quarterly from October 2019 (n = 7,540,592) to March 2021 (n = 8,513,572). The adult population (≥15 years) on ART increased by 14.0% (7,005,983,793), while the paediatric population (<15 years) on ART declined by 2.6% (333,441). However, the number of new ART initiations dropped between March 2020 and June 2020 by 23.4% for adults and 26.1% for children, with more rapid recovery in adults than children from September 2020 onwards. Viral load coverage increased slightly from April 2020 to March 2021 (75-78%) and viral load suppression increased from October 2019 to March 2021 (91-94%) among adults and children combined. The most reported interventions included multi-month dispensing (MMD) of ART, community service delivery expansion, and technology and virtual platforms use for client engagement and site-level monitoring. MMD of ≥3 months increased from 52% in October 2019 to 78% of PLHIV ≥ age 15 on ART in March 2021. Conclusions: With an overall increase in the number of people on ART, HIV programmes proved to be resilient, mitigating the impact of COVID-19. However, the decline in the number of children on ART warrants urgent investigation and interventions to prevent further losses experienced during the COVID-19 pandemic and future public health emergencies.
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 were used to compare HIV incidence by MC status in countries implementing voluntary medical MC (VMMC) programs.Methods:Data were pooled from population-based HIV impact assessments conducted in Eswatini, Lesotho, Malawi, Namibia, Tanzania, Uganda, Zambia, and Zimbabwe from 2015 to 2017. Incidence was measured using a recent infection testing algorithm and analyzed by self-reported MC status distinguishing between medical and nonmedical 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% to 0.10%) versus 0.34% (95% CI: 0.10% to 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% to 2.39%) versus 0.55% (95% CI: 0.14% to 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.
Studies on knowledge and attitudes about HIV pre-exposure prophylaxis (PrEP) have mostly focused on key populations in North America and Europe. To inform Lesotho’s national rollout of PrEP to the general population, this study aimed to characterize knowledge and attitudes about PrEP among policy makers, implementing partners, healthcare providers, and PrEP end-users in Lesotho. Respondents were purposively selected to participate based on personal experience in the development and implementation of Lesotho’s PrEP program, or the personal use of PrEP. We conducted 106 in-depth interviews with policy makers (n = 5), implementing partners (n = 4), and end-users (current PrEP users = 55; former PrEP users = 36; and PrEP “decliners” = 6). In addition, we held 11 focus group discussions (FGDs) with a total of 105 healthcare providers. Interview and FGD transcripts were analyzed following the tenets of Grounded Theory. Respondents expressed positive attitudes toward PrEP, owing to experienced and perceived personal, familial, and societal benefits. PrEP was viewed as i) an opportunity for serodiscordant couples to remain together, ii) a means of conceiving children with minimized risk of HIV infection, iii) providing a sense of agency and control, and iv) an avenue for addressing the HIV epidemic in Lesotho. Respondents demonstrated understanding of PrEP’s intended use, eligibility requirements, and modality of use. However, respondents also reported that several important misconceptions of PrEP were common among adults in Lesotho, including a belief that PrEP protects against sexually transmitted infections other than HIV, promotes promiscuity, prevents pregnancy, causes seroconversion, and provides lifelong protection from taking the pill just once. In addition to building on the perceived advantages of PrEP to shape a positive message, Lesotho’s national rollout of PrEP will likely benefit from a communication strategy that specifically addresses the common misconceptions of PrEP identified in this study.
Background Low uptake and high discontinuation rates remain major obstacles to realizing the potential of Pre-Exposure Prophylaxis (PrEP) in changing the trajectory of the HIV epidemic in sub-Saharan Africa. Evidence on how PrEP could be successfully delivered has thus far mainly focused on key target groups rather than the general adult population. Set in the HIV-hyperendemic country of Lesotho, which is currently rolling out PrEP for the general adult population, this study aimed to determine stakeholders’ views on which are the most important barriers and most promising interventions to achieving high PrEP uptake and continuation. Methods and findings We conducted a card sorting and ranking exercise with 155 local stakeholders to identify key barriers and interventions. Stakeholders were a purposive sample of PrEP policy makers and implementing partners (n=7), healthcare providers (n=51), and end-users (n=97). End-users included adults who were currently using PrEP (n=55), formerly using PrEP (n=36), and were offered PrEP by a healthcare provider but declined (n=6). Participants sorted pre-selected interventions and barriers to PrEP coverage into three piles – most, somewhat, and least important. After sorting, participants ranked interventions and barriers in the “most important” piles in ascending order of significance. Ranked preferences were analyzed as voting data to identify the smallest set of candidates for which each candidate in the set would win a two-candidate election against any candidate outside the set. Participants viewed a lack of PrEP awareness as the most important barrier to PrEP uptake for women, and a fear of HIV testing for men. Community-based HIV testing was ranked as the most promising intervention to improve PrEP uptake for both men and women. Perceived or experienced stigma was seen as an important barrier for PrEP continuation for both men and women, with an additional important barrier for men being daily activities that compete with the time or mental bandwidth needed to take a daily pill. Adherence counseling and multi-month PrEP prescriptions were seen as the most promising interventions to improve PrEP continuation. Conclusions Our findings suggest community-based activities that generate PrEP demand (community-based HIV testing and mass media campaigns), reinforced with facility-based follow-up (counseling and multi-month prescription) could be promising interventions to improve PrEP uptake and continuation in PrEP programs that are aimed at the general adult population. The views of the wide range of stakeholders that participated in this study could provide a useful starting point for design and implementation choices of PrEP delivery programs for the general adult population.
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