Factors associated with antiretroviral treatment initiation amongst HIV-positive individuals linked to care within a universal test and treat programme: early findings of the ANRS 12249 TasP trial in rural South Africa

Prompt uptake of antiretroviral treatment (ART) is essential to ensure the success of universal test and treat (UTT) strategies to prevent HIV transmission in high-prevalence settings. We describe ART initiation rates and associated factors within an ongoing UTT cluster-randomized trial in rural South Africa. HIV-positive individuals were offered immediate ART in the intervention arm vs. national guidelines recommended initiation (CD4≤350 cells/mm3) in the control arm. We used data collected up to July 2015 among the ART-eligible individuals linked to TasP clinics before January 2015. ART initiation rates at one (M1), three (M3) and six months (M6) from baseline visit were described by cluster and CD4 count strata (cells/mm3) and other eligibility criteria: ≤100; 100–200; 200–350; CD4>350 with WHO stage 3/4 or pregnancy; CD4>350 without WHO stage 3/4 or pregnancy. A Cox model accounting for covariate effect changes over time was used to assess factors associated with ART initiation. The 514 participants had a median [interquartile range] follow-up duration of 1.08 [0.69; 2.07] months until ART initiation or last visit. ART initiation rates at M1 varied substantially (36.9% in the group CD4>350 without WHO stage 3/4 or pregnancy, and 55.2–71.8% in the three groups with CD4≤350) but less at M6 (from 85.3% in the first group to 96.1–98.3% in the three other groups). Factors associated with lower ART initiation at M1 were a higher CD4 count and attending clinics with both high patient load and higher cluster HIV prevalence. After M1, having a regular partner was the only factor associated with higher likelihood of ART initiation. These findings suggest good ART uptake within a UTT setting, even among individuals with high CD4 count. However, inadequate staffing and healthcare professional practices could result in prioritizing ART initiation in patients with the lowest CD4 counts

Access to HIV care in the context of universal test and treat: challenges within the ANRS 12249 TasP cluster-randomized trial in rural South Africa

Introduction: We aimed to quantify and identify associated factors of linkage to HIV care following home-based HIV counselling and testing (HBHCT) in the ongoing ANRS 12249 treatment-as-prevention (TasP) cluster-randomized trial in rural KwaZulu-Natal, South Africa. Methods: Individuals ]16 years were offered HBHCT; those who were identified HIV positive were referred to cluster-based TasP clinics and offered antiretroviral treatment (ART) immediately (five clusters) or according to national guidelines (five clusters). HIV care was also available in the local Department of Health (DoH) clinics. Linkage to HIV care was defined as TasP or DoH clinic attendance within three months of referral among adults not in HIV care at referral. Associated factors were identified using multivariable logistic regression adjusted for trial arm. Results: Overall, 1323 HIV-positive adults (72.9% women) not in HIV care at referral were included, of whom 36.9% (n488) linked to care B3 months of referral (similar by sex). In adjusted analyses (n1222), individuals who had never been in HIV care before referral were significantly less likely to link to care than those who had previously been in care (B33% vs. 42%, pB0.001). Linkage to care was lower in students (adjusted odds-ratio [aOR] 0.47; 95% confidence interval [CI] 0.240.92) than in employed adults, in adults who completed secondary school (aOR0.68; CI 0.490.96) or at least some secondary school (aOR0.59; CI 0.410.84) versus 5 primary school, in those who lived at 1 to 2 km (aOR0.58; CI 0.440.78) or 25 km from the nearest TasP clinic (aOR0.57; CI 0.410.77) versus B1 km, and in those who were referred to clinic after ]2 contacts (aOR0.75; CI 0.580.97) versus those referred at the first contact. Linkage to care was higher in adults who reported knowing an HIV-positive family member (aOR1.45; CI 1.121.86) versus not, and in those who said that they would take ART as soon as possible if they were diagnosed HIV positive (aOR2.16; CI 1.134.10) versus not. Conclusions: Fewer than 40% of HIV-positive adults not in care at referral were linked to HIV care within three months of HBHCT in the TasP trial. Achieving universal test and treat coverage will require innovative interventions to support linkage to HIV care

Barrières à l'initiation des traitements antirétroviraux : le cas d'une zone rurale de la région du KwaZulu Natal en Afrique du Sud.

Antiretroviral treatments (ART) have been available in sub-Saharan Africa for more than ten years.Their use was initially targeted with the strict aim to control severe morbidity in individuals with an advancedHIV disease. International guidelines for initiating ART have subsequently evolved as clinical andepidemiological studies highlighted the therapeutic and preventive benefits of early ART initiation. Randomizedtrials are currently underway in several southern African countries to measure the benefits of the universal“Test and Treat” approach on HIV incidence in a community. However, ART coverage is still far from optimal insub-Saharan Africa, especially in South Africa where 6.3 millions of individuals are living with HIV. We thusaimed to better understand what are the barriers to ART initiation by focusing on a rural area heavily affectedby HIV in the province of KwaZulu-Natal, South Africa. We first briefly described the journey HIV-infectedindividuals embark on, from entry into a large HIV treatment and care programme to ART initiation. Then wemeasured the temporal evolutions of ART initiation rates according to the changes of clinical guidelines. Wefinally identified some barriers to ART initiation linking data from the HIV care programme with those from ademographic surveillance system. The results of this thesis will help to better understand the issues relative toaccess to ART that might arise with the universal “Test and Treat” approach, especially in South Africa.Les traitements antirétroviraux (TARV) sont proposés à large échelle en Afrique sub-Sahariennedepuis plus de dix ans, au départ destinés à contrôler la morbidité sévère des personnes à un stade avancé del’infection à VIH. Les recommandations pour initier les TARV ont ensuite évolué à mesure que les étudescliniques et épidémiologiques mettaient en évidence les bénéfices thérapeutiques et préventifs d’une initiationprécoce des TARV. Des essais randomisés sont actuellement en cours en Afrique australe pour vérifier lesbénéfices d’une approche universelle de dépistage et de traitement à des stades précoces de l’infection à VIH(approche « Test and Treat ») sur l’incidence du VIH en communauté. Cependant, la couverture antirétroviraleest encore loin d’être optimale au sud du Sahara, notamment en Afrique du Sud où 6,3 millions de personnesvivent avec le VIH. L’objectif de cette thèse est de comprendre quelles sont les barrières à l’initiation des TARVen nous intéressant à une zone rurale fortement touchée par le VIH au sein de la province sud-africaine duKwaZulu-Natal. Après avoir brièvement décrit le suivi des patients de l’entrée dans un large programme desoins VIH jusqu’à l’initiation des TARV, nous avons mesuré l’évolution des taux d’initiation des TARV suite àl’expansion des critères d’éligibilité dans ce programme. Nous avons ensuite identifié certaines barrières àl’initiation des TARV en croisant les données du programme de soins VIH à celles recueillies au sein d’unesurveillance démographique. Les résultats de cette thèse permettent de mieux appréhender les questionsrelatives à l’accès aux TARV qui pourraient se poser avec une approche « Test and Treat »

La vie d’un groupe à l’école : fabrique et dynamiques

La Manufacture-Haute école de théâtre de Suisse romande (HETSR) a ouvert ses portes en septembre 2003. Fondée, en 2002, dans le cadre des réformes de l’enseignement supérieur consécutives aux accords de Bologne, elle est la première Haute École Spécialisée en Arts de la Scène de Suisse romande, autorisée à délivrer aux élèves, à l’issue de leur formation, un diplôme de Bachelor ou de Master en Arts. D’abord dirigée par le metteur en scène Yves Beaunesne, puis, à partir de janvier 2007, par le..

Retention and mortality outcomes from a community-supported public–private HIV treatment programme in Myanmar

Introduction: There is a growing interest in the potential contribution the private sector can make towards increasing access to antiretroviral therapy (ART) in low- and middle-income settings. This article describes a public–private partnership that was developed to expand HIV care capacity in Yangon, Myanmar. The partnership was between private sector general practitioners (GPs) and a community-based non-governmental organization (International HIV/AIDS Alliance). Methods: Retrospective analysis of 2119 patient records dating from March 2009 to April 2015 was conducted. Outcomes assessed were immunological response, loss to follow-up, all-cause mortality, and alive and retained in care. Follow-up time was calculated from the date of registration to the date of death, loss to follow-up, transfer out, or if still alive and known to be in care, until April 2015. Cox proportional hazards model was used to identify predictors of loss to follow-up and mortality. Kaplan–Meier survival analysis was used to estimate survival function of being alive and retained in care. Results: The median number of patients for each of the 16 GPs was 42 (interquartile range (IQR): 25–227), and the median follow-up period was 13 months. The median patient age was 35 years (IQR: 30–41); 56.6% were men, 62 and 11.8% were in WHO Stage III and Stage IV at registration, respectively; median CD4 count at registration was 177 cells/mm3; and 90.7% were on ART in April 2015. The median CD4 count at registration increased from 122 cells/mm3 in 2009 to 194 cells/mm3 in 2014. Among patients on ART, CD4 counts increased from a median of 187 cells/mm3 at registration to 436 cells/mm3 at 36 months. The median time to initiation of ART among eligible patients was 29 days, with 93.8% of eligible patients being initiated on ART within 90 days. Overall, 3.3% patients were lost to follow-up, 4.2% transferred out to other health facilities, and 8.3% died during the follow-up period. Crude mortality rate was 48.6/1000 person-years; 42% (n=74) of deaths occurred during the pre-ART period and 39.8% (n=70) occurred during the first six months of ART. Of those who died during the pre-ART period, 94.5% were eligible for ART. In multivariate regression, baseline CD4 count and ART status were independent predictors of mortality, whereas ART status, younger age and patient volumes per provider were predictors of loss to follow-up. Probability of being alive and retained in care at six months was 96.8% among those on ART, 38.5% among pre-ART but eligible patients, and 20.0% among ART-ineligible patients. Conclusions: Effectively supported private sector GPs successfully administered and monitored ART in Myanmar, suggesting that community-supported private sector partnerships can contribute to expansion of HIV treatment and care capacity. To further improve patient outcomes, early testing and initiation of ART, combined with close clinical monitoring and support during the initial periods of enrolling in treatment and care, are required

Temporal trends of population viral suppression in the context of Universal Test and Treat: the ANRS 12249 TasP trial in rural South Africa

Introduction: The universal test-and-treat (UTT) strategy aims to maximize population viral suppression (PVS), that is, the proportion of all people living with HIV (PLHIV) on antiretroviral treatment (ART) and virally suppressed, with the goal of reducing HIV transmission at the population level. This article explores the extent to which temporal changes in PVS explain the observed lack of association between universal treatment and cumulative HIV incidence seen in the ANRS 12249 TasP trial conducted in rural South Africa. Methods: The TasP cluster-randomized trial (2012 to 2016) implemented six-monthly repeat home-based HIV counselling and testing (RHBCT) and referral of PLHIV to local HIV clinics in 2 9 11 clusters opened sequentially. ART was initiated according to national guidelines in control clusters and regardless of CD4 count in intervention clusters. We measured residency status, HIV status, and HIV care status for each participant on a daily basis. PVS was computed per cluster among all resident PLHIV (≥16, including those not in care) at cluster opening and daily thereafter. We used a mixed linear model to explore time patterns in PVS, adjusting for sociodemographic changes at the cluster level. Results: 8563 PLHIV were followed. During the course of the trial, PVS increased significantly in both arms (23.5% to 46.2% in intervention, +22.8, p < 0.001; 26.0% to 44.6% in control, +18.6, p < 0.001). That increase was similar in both arms (p = 0.514). In the final adjusted model, PVS increase was most associated with increased RHBCT and the implementation of local trial clinics (measured by time since cluster opening). Contextual changes (measured by calendar time) also contributed slightly. The effect of universal ART (trial arm) was positive but limited. Conclusions: PVS was improved significantly but similarly in both trial arms, explaining partly the null effect observed in terms of cumulative HIV incidence between arms. The PVS gains due to changes in ART-initiation guidelines alone are relatively small compared to gains obtained by strategies to maximize testing and linkage to care. The achievement of the 90-90-90 targets will not be met if the operational and implementational challenges limiting access to care and treatment, often context-specific, are not properly addressed. Clinical trial number: NCT01509508 (clinicalTrials.gov)/DOH-27-0512-3974 (South African National Clinical Trials Register)

Temporal trends of population viral suppression in the context of Universal Test and Treat: the ANRS 12249 TasP trial in rural South Africa

Introduction: The universal test-and-treat (UTT) strategy aims to maximize population viral suppression (PVS), that is, the proportion of all people living with HIV (PLHIV) on antiretroviral treatment (ART) and virally suppressed, with the goal of reducing HIV transmission at the population level. This article explores the extent to which temporal changes in PVS explain the observed lack of association between universal treatment and cumulative HIV incidence seen in the ANRS 12249 TasP trial conducted in rural South Africa. Methods: The TasP cluster-randomized trial (2012 to 2016) implemented six-monthly repeat home-based HIV counselling and testing (RHBCT) and referral of PLHIV to local HIV clinics in 2 9 11 clusters opened sequentially. ART was initiated according to national guidelines in control clusters and regardless of CD4 count in intervention clusters. We measured residency status, HIV status, and HIV care status for each participant on a daily basis. PVS was computed per cluster among all resident PLHIV (≥16, including those not in care) at cluster opening and daily thereafter. We used a mixed linear model to explore time patterns in PVS, adjusting for sociodemographic changes at the cluster level. Results: 8563 PLHIV were followed. During the course of the trial, PVS increased significantly in both arms (23.5% to 46.2% in intervention, +22.8, p < 0.001; 26.0% to 44.6% in control, +18.6, p < 0.001). That increase was similar in both arms (p = 0.514). In the final adjusted model, PVS increase was most associated with increased RHBCT and the implementation of local trial clinics (measured by time since cluster opening). Contextual changes (measured by calendar time) also contributed slightly. The effect of universa

« Avant on traitait un peu à l’aveugle, c’était un diagnostic syndromique. » Perceptions des médecins dans une prise en charge globale des infections sexuellement transmissibles chez des travailleuses du sexe en Côte d’Ivoire

ObjectifsLe projet ANRS 12381 Princesse a proposé une offre de soins globale et communautaire en santé sexuelle et reproductive (SSR), dont la prise en charge des infections sexuellement transmissibles (IST) auprès des travailleuses du sexe (TS) ≥ 18 ans dans la région de San Pedro. Notre objectif est d’analyser les perceptions des médecins dans la prise en charge globale (PEC) des IST.Matériels et MéthodesLe dispositif de santé Princesse (26/11/2019 – 30/06/2023) comprenait pour la PEC des IST, à la fois en clinique mobile et fixe, un dépistage syndromique trimestriel des IST, ainsi que des prélèvements vaginaux et anaux pour la recherche annuelle de chlamydia trachomatis et de neisseria gonorrhée. Des entretiens individuels ont été réalisés en juin/juillet 2023 avec les quatre médecins intervenant dans la PEC des IST des participantes du projet, afin d’analyser leurs perceptions sur cette PEC.RésultatsL’offre de dépistage et de PEC des IST a été bien appréciée par l’équipe médicale. Pour les médecins, l’acquisition de nouvelles connaissances pour la PEC des IST, la possibilité de réaliser des examens de laboratoire directement sur site et en clinique fixe, et le fait de pouvoir remettre directement des kits de soins IST aux patientes ont été un atout du projet et une source de motivation à travailler sur du long terme. Cela a également favorisé la création d’une relation de confiance entre les médecins et les TS.Cependant, certaines difficultés opérationnelles, incluant notamment un retard fréquent en approvisionnement des kits IST et le rendu tardif des analyses médicales, ont contribué, par moments, à entacher cette relation de confiance et ont compliqué la PEC des IST en temps voulu, la mise en place d’un traitement adéquat et un suivi régulier en cas d’IST, dans un contexte déjà tendu en raison de la forte mobilité des TS. Une autre limite relevée était la non PEC du ou des partenaires stables de la TS traitée, car ne permettant pas de rompre la chaîne de contamination et d’éviter les éventuelles réinfections. Enfin, l’inaccessibilité de certains sites du fait du mauvais état des routes en saisons pluvieuses a également compliqué la PEC des IST.ConclusionLe dépistage et la PEC des IST ont été perçus comme une réponse adaptée aux besoins en SSR des TS. Cependant, des barrières à la fois structurelles et opérationnelles ont rendu sa mise en œuvre complexe. La mise à disposition d’outils point of care, notamment l’utilisation de tests rapides IST, pourrait être pertinente pour cette population particulièrement mobile