Adjusting for Network Size and Composition Effects in Exponential-Family Random Graph Models

Exponential-family random graph models (ERGMs) provide a principled way to model and simulate features common in human social networks, such as propensities for homophily and friend-of-a-friend triad closure. We show that, without adjustment, ERGMs preserve density as network size increases. Density invariance is often not appropriate for social networks. We suggest a simple modification based on an offset which instead preserves the mean degree and accommodates changes in network composition asymptotically. We demonstrate that this approach allows ERGMs to be applied to the important situation of egocentrically sampled data. We analyze data from the National Health and Social Life Survey (NHSLS).Comment: 37 pages, 2 figures, 5 tables; notation revised and clarified, some sections (particularly 4.3 and 5) made more rigorous, some derivations moved into the appendix, typos fixed, some wording change

Uptake of home-based voluntary HIV testing in sub-Saharan Africa: a systematic review and meta-analysis

Improving access to HIV testing is a key priority in scaling up HIV treatment and prevention services. Home-based voluntary counselling and testing (HBT) as an approach to delivering wide-scale HIV testing is explored here

Addressing social issues in a universal HIV test and treat intervention trial (ANRS 12249 TasP) in South Africa: methods for appraisal

Background: The Universal HIV Test and Treat (UTT) strategy represents a challenge for science, but is also a challenge for individuals and societies. Are repeated offers of provider-initiated HIV testing and immediate antiretroviral therapy (ART) socially-acceptable and can these become normalized over time? Can UTT be implemented without potentially adding to individual and community stigma, or threatening individual rights? What are the social, cultural and economic implications of UTT for households and communities? And can UTT be implemented within capacity constraints and other threats to the overall provision of HIV services? The answers to these research questions will be critical for routine implementation of UTT strategies. Methods/design: A social science research programme is nested within the ANRS 12249 Treatment-as-Prevention (TasP) cluster-randomised trial in rural South Africa. The programme aims to inform understanding of the (i) social, economic and environmental factors affecting uptake of services at each step of the continuum of HIV prevention, treatment and care and (ii) the causal impacts of the TasP intervention package on social and economic factors at the individual, household, community and health system level. We describe a multidisciplinary, multi-level, mixed-method research protocol that includes individual, household, community and clinic surveys, and combines quantitative and qualitative methods. Discussion: The UTT strategy is changing the overall approach to HIV prevention, treatment and care, and substantial social consequences may be anticipated, such as changes in social representations of HIV transmission, prevention, HIV testing and ART use, as well as changes in individual perceptions and behaviours in terms of uptake and frequency of HIV testing and ART initiation at high CD4. Triangulation of social science studies within the ANRS 12249 TasP trial will provide comprehensive insights into the acceptability and feasibility of the TasP intervention package at individual, community, patient and health system level, to complement the trial's clinical and epidemiological outcomes. It will also increase understanding of the causal impacts of UTT on social and economic outcomes, which will be critical for the long-term sustainability and routine UTT implementation. Trial registration: Clinicaltrials.gov: NCT01509508; South African Trial Register: DOH-27-0512-3974

HIV control in low-income countries in sub-Saharan Africa: are the right things done?

HIV control efforts in sub-Saharan Africa meet with difficulties. Incidence and prevalence remains high, and little behaviour change seems to have taken place. The focus on HIV control has shifted to anti-retroviral therapy (ART), although this is unlikely either to be cost-effective or the reduce the incidence of HIV. There is reason to change the current approach. Three questions arise: Is there a need to adjust the view on the determinants of the HIV epidemic in sub-Saharan Africa? Are the right things being done to control HIV? Are the things that are being done, done in the right way? We try to answer these questions. The determinants of the epidemic are reviewed and summarized in Figure 2. The need to adjust the view on the determinants and get rid of myths is stressed. A possible, locally adaptable intervention mix is outlined. Male circumcision is a key intervention where socially acceptable. Operationalisation and organisational changes are briefly discussed. Conclusively, the need for a “social revolution” through the opening up of a discussion on sexuality in the community, as well as a focus on cost-effective interventions and a slimmed down, more effective organisation is underlined. Such steps might make it possible to considerably reduce HIV-incidence, even in low-income countries

Neonatal and child mortality data in retrospective population-based surveys compared with prospective demographic surveillance: EN-INDEPTH study.

BACKGROUND: Global mortality estimates remain heavily dependent on household surveys in low- and middle-income countries, where most under-five deaths occur. Few studies have assessed the accuracy of mortality data or determinants of capturing births in surveys. METHODS: The Every Newborn-INDEPTH study (EN-INDEPTH) included a large, multi-country survey of women aged 15-49 interviewed about livebirths and their survival status in five Health and Demographic Surveillance Systems (HDSSs). The HDSSs undertake regular household visits to register births and deaths for a given population. We analysed EN-INDEPTH survey data to assess background factors associated with not recalling a complete date-of-birth. We calculated Kaplan-Meier survival estimates for both survey and HDSS data and describe age-at-death distributions during the past 5 years for children born to the same women. We assessed the proportion of HDSS-births that could be matched on month-of-birth to survey-births and used regression models to identify factors associated with matching. RESULTS: 69,176 women interviewed in the survey reported 109,817 births and 3064 deaths in children under 5 years in the 5 years prior to the survey. In the HDSS data, the same women had 83,768 registered births and 2335 under-five deaths in the same period. A complete date-of-birth was not reported for 1-7% of survey-births. Birthdates were less likely to be complete for dead children and children born to women of higher parity or with little/no education. Distributions of reported age-at-death indicated heaping at full weeks (neonatal period) and at 12 months. Heaping was more pronounced in the survey data. Survey estimates of under-five mortality rates were similar to HDSS estimates of under-five mortality in two of five sites, higher in the survey in two sites (15%, 41%) and lower (24%) in one site. The proportion of HDSS-births matched to survey-births ranged from 51 to 89% across HDSSs and births of children who had died were less likely to be matched. CONCLUSIONS: Mortality estimates in the survey and HDSS were not markedly different for most sites. However, neither source is a "gold standard" and both sources miss some events. Research is required to improve capture and accuracy to better track newborn and child survival targets

Controlling the first wave of the COVID–19 pandemic in Malawi: results from a multi-round study

We investigated behavioral responses to COVID–19 in Malawi, where a first wave of the pandemic occurred between June and August 2020. Contrary to many countries on the African continent, the Government of Malawi did not impose a lockdown or a stay-at-home order in response to the initial spread of SARS-CoV-2. We hypothesized that, in the absence of such requirements to restrict social interactions, individuals would primarily seek to reduce the risk of SARS-CoV-2 transmission during contacts, rather than reduce the extent of their social contacts. We analyzed 4 rounds of a panel survey spanning time periods before, during and after the first wave of the COVID-19 pandemic in Malawi. Five hundred and forty-three participants completed 4 survey interviews between April and November 2020. We found that the likelihood of attending various places and events where individuals work and/or socialize remained largely unchanged during that time. Over the same time frame, however, participants reported adopting on a large scale several behaviors that reduce the transmissibility of SARS-CoV-2 during contacts. The percentage of panel participants who reported practicing physical distancing thus increased from 9.8% to 47.0% in rural areas between April-May 2020 and June-July 2020, and from 11.4% to 59.4% in urban areas. The percentage of respondents who reported wearing a facial mask to prevent the spread of SARS-CoV-2 also increased, reaching 67.7% among rural residents in August-September 2020, and 89.6% among urban residents. The pace at which these behaviors were adopted varied between population groups, with early adopters of mask use more commonly found among more educated office workers, residing in urban areas. The adoption of mask use was also initially slower among women, but later caught up with mask use among men. These findings stress the importance of behavioral changes in containing future SARS-CoV-2 outbreaks in settings where access to vaccination remains low. They also highlight the need for targeted outreach to members of socioeconomic groups in which the adoption of protective behaviors, such as mask use, might be delayed

Controlling the first wave of the COVID–19 pandemic in Malawi: results from a panel study

Many African countries have experienced a first wave of the COVID–19 pandemic between June and August of 2020. According to case counts reported daily by epidemiological surveillance systems, infection rates remained low in most countries. This defied early models of the potential impact of COVID–19 on the continent, that projected large outbreaks and massive strain on health systems. Theories proposed to explain the apparently limited spread of the novel coronavirus in most African countries have emphasized 1) early actions by health authorities (e.g., border closures) and 2) biological or environmental determinants of the transmissibility of SARS-CoV-2 (e.g., warm weather, cross-immunity). In this paper, we explored additional factors that might contribute to the low recorded burden of COVID–19 in Malawi, a low-income country in Southeastern Africa. To do so, we used 4 rounds of panel data collected among a sample of adults during the first 6 months of the pandemic in the country. Our analyses of survey data on SARS-CoV-2 testing and COVID-related symptoms indicate that the size of the outbreak that occurred in June-August 2020 might be larger than recorded by surveillance systems that rely on RT-PCR testing. Our data also document the widespread adoption of physical distancing and mask use in response to the outbreak, whereas most measured patterns of social contacts remained stable during the course of the panel study. These findings will help better project, and respond to, future waves of the pandemic in Malawi and similar settings

Expanding HIV Testing Efforts in Concentrated Epidemic Settings: A Population-Based Survey from Rural Vietnam

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Effect of variable transmission rate on the dynamics of HIV in sub-Saharan Africa

<p>Abstract</p> <p>Background</p> <p>The cause of the high HIV prevalence in sub-Saharan Africa is incompletely understood, with heterosexual penile-vaginal transmission proposed as the main mechanism. Heterosexual HIV transmission has been estimated to have a very low probability; but effects of cofactors that vary in space and time may substantially alter this pattern.</p> <p>Methods</p> <p>To test the effect of individual variation in the HIV infectiousness generated by co-infection, we developed and analyzed a mathematical sexual network model that simulates the behavioral components of a population from Malawi, as well as the dynamics of HIV and the co-infection effect caused by other infectious diseases, including herpes simplex virus type-2, gonorrhea, syphilis and malaria.</p> <p>Results</p> <p>The analysis shows that without the amplification effect caused by co-infection, no epidemic is generated, and HIV prevalence decreases to extinction. But the model indicates that an epidemic can be generated by the amplification effect on HIV transmission caused by co-infection.</p> <p>Conclusion</p> <p>The simulated sexual network demonstrated that a single value for HIV infectivity fails to describe the dynamics of the epidemic. Regardless of the low probability of heterosexual transmission per sexual contact, the inclusion of individual variation generated by transient but repeated increases in HIV viral load associated with co-infections may provide a biological basis for the accelerated spread of HIV in sub-Saharan Africa. Moreover, our work raises the possibility that the natural history of HIV in sub-Saharan Africa cannot be fully understood if individual variation in infectiousness is neglected.</p

Knowledge of HIV status prior to a community HIV counseling and testing intervention in a rural district of south Africa: results of a community based survey

<p>Abstract</p> <p>Background</p> <p>The low uptake of facility-based HIV counseling and testing (HCT) in South Africa, particularly amongst men and youth has hindered attempts to increase access to effective treatment and prevention strategies. Many barriers to HIV testing have been described including long waiting times, transport to reach facilities, fear of lack of confidentiality and health systems factors such as stock outs of HIV test kits. The aim of this study was to undertake a community survey to determine rates of HCT in a rural area in order to plan a community intervention.</p> <p>Methods</p> <p>A community-based survey was undertaken in 16 communities in Sisonke district, KwaZulu-Natal between September and November 2008. A total of 5821 individuals participated in the survey of which 66% were females. Gender specific mixed effects logistic regression models were used to describe differences in socio-economic characteristics, and their association with HIV testing histories.</p> <p>Results</p> <p>Overall 1833 (32%) individuals in this rural area knew their HIV status. Prior testing was higher amongst women (39%) than amongst men (17%). Older men (> 24 years) were more likely to report having tested for HIV previously, with the highest likelihood (adjusted OR = 4.02; 95% CI: 2.71-5.99) among men in age group, 35-49 years. For women, age group 25-34 years had the highest likelihood of having been previously tested (adjusted OR = 1.30; 95% CI: 1.05-1.66). Being currently pregnant (adjusted OR 3.31; 95% CI: 2.29 - 4.78) or having a child under five (adjusted OR 7.00; 95% CI: 5.84 - 8.39) were also associated with prior HIV testing amongst women.</p> <p>Conclusions</p> <p>Overall, knowledge of HIV status in this rural sub-district is low. The relatively higher uptake of HIV testing among women is encouraging as it shows that PMTCT services are well functioning. However, these data suggest that there is an urgent need for scaling up HIV testing services in rural communities specifically targeting men and youth.</p