Bikila Balis

Department of Midwifery, School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Western Oromia, Ethiopia

Correspondence: Bikila Balis
School of Nursing, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
Tel +251 921788619
Email bik.balis2008@gmail.com

Background: Human immunodeficiency virus infection has been one of the top health-related challenges for the past four decades. Ethiopia is extremely infected by HIV pandemic every year, whereby 22,300 people were newly infected and 690,000 were living with HIV at the end of 2018. Sexual behavior of HIV positive individuals visiting treatment clinics is a neglected issue. Nonetheless, it has been a significant way of HIV transmission to serodiscordant partners.
Methods: A facility-based cross-sectional study design was used on a sample of 432 women attending treatment clinics in west Oromia from February 26 to March 26, 2019. Systematic sampling was used to select the study participants. A pretested and structured interviewer-administered questionnaires were used to collect the data. The data were coded, entered, cleaned and exported to SPSS version 20.0 for analysis. Descriptive statistics were used to present frequency distributions. Variables with P-value < 0.25 during bivariate analysis were entered into multiple logistic regression models to control for all possible confounders. Odds ratio along with 95% CI were estimated to measure the strength of the association. Level of statistical significance was declared at a p-value less than 0.05.
Results: Out of total respondents, 240 (56.9%), 95% CI: (52.1– 61.6%) were involved in risky sexual practices in the prior 12 months. Urban residence [AOR: 3.24, (95% CI: (1.52, 6.89)], those with no formal education [AOR: 2.77, (95% CI: (1.18, 6.54)], being on ART for > 2years [AOR: 2.74, (95% CI: (1.13, 6.65)] and CD4 count ≥ 200 cells/mm³ [AOR: 3.20, (95% CI: (1.50, 6.82)] were factors significantly associated with risky sexual practice.
Conclusion: A considerable number of respondents were involved in risky sexual practices 240 (56.9%) due to being rural residence, not attending formal education, being on ART for > 2 years and CD4 count ≥ 200 cells/mm³.

Keywords: women, HIV/AIDS, risky sexual practices, Oromia, Ethiopia

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In view of the reported role of parasitic infections in causing morbidity among HIV-infected patients with low CD4+ counts who are on antiretroviral therapy (ART), mainly because of immuno suppression, researchers sought to determine the extent of intestinal parasitic infection and related risk factors among HIV-infected patients attending ART clinic at Debretabor General Hospital, Northern Ethiopia. Among 383 HIV-infected patients attending the ART clinic, intestinal parasites had an overall prevalence of 25.3%, with 18% and 23.8% by direct wet-mount and formol ether–concentration technique, respectively. HIV/AIDS patients thus exhibit relatively higher prevalence of intestinal parasitic infection. Illiteracy, reduced CD4+ counts, and absence of a toilet were identified to have great influence on the distribution of intestinal parasites. Hence, they emphasize consistently diagnosing HIV/AIDS patients with low CD4+ counts for intestinal parasites with routine stool examinations, and advocate inclusion of awareness creation as an essential component of ART-monitoring strategies for improved patient care.

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Antiretroviral therapy (ART) prescribing practices in the United States do not align with current national guidelines for approximately half of pregnant women with HIV, according to a study published in JAMA Network Open.

Treatment guidelines published by the Department of Health and Human Services (HHS) for pregnant women living with HIV have been available since 1994. The study aimed to examine ART prescribing practices over time among pregnant women living with HIV and identify factors associated with receiving recommended regimens.

For the analysis, the researchers used a cohort of 1582 pregnant women with HIV to examine the proportion of regimens prescribed that qualified as preferred or alternative regimens, according to HHS guidelines, stratified by timing of initiation.

According to the results, antiretroviral medications were initiated prior to conception for 42.3% of women, resumed during pregnant for 33.5%, and initiated during pregnancy for 24.2% of women. Overall, only 49.5% of pregnancies were associated with prescribed ART designated as preferred or alternative, whereas 26.4% involved ARTs with insufficient evidence for use during pregnancy and 7.3% involved ARTs that were not recommended during pregnancy.

Other findings showed:

• A higher proportion of treatment-naïve pregnant women initiating ART were prescribed preferred or alternative ARTs compared with those resuming treatment or those treated with ART before conception.
• A total of 20.1% of women initiating ART during pregnancy were prescribed ART with insufficient evidence for use during pregnancy or not recommended during pregnancy.
• Among women resuming ART, those with a viral load greater than 1000 copies/mL early in pregnancy had higher odds of being prescribed guideline-recommended ART (adjusted odds ratio, 2.03 [95% CI, 1.33-3.10]) compared with those with a viral load of 400 copies/mL or less.

The researchers wrote that the study findings suggest that US ART prescribing practices for pregnant women do not align well with the recommended national guidelines.

“This finding is particularly concerning when treatment is initiated during pregnancy,” they wrote. “Further research is needed to understand disparities between prescribing practices and evidence-based guideline recommendations.”

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The Wistar Institute was awarded two major grants totaling more than $12 million from the National Institute on Drug Abuse (NIDA), part of the National Institutes of Health, to fund an international multidisciplinary clinical research consortium spearheaded by Wistar’s HIV Research Program. The consortium, including several partner institutions in the U.S. and abroad, will investigate the impact of opioid use disorder (OUD) and medications for opioid use disorder (MOUDs) on immune recovery in response to antiretroviral therapy (ART) in HIV-infected people.

Both HIV infection and chronic opioid exposure are associated with immune activation, which leads to T-cell depletion and progression to acquired immunodeficiency syndrome (AIDS).

OUD is commonly treated with drugs that either activate (agonists) or block (antagonists) the opioid receptor. “Yet, we have a very limited understanding of how the medications we use to treat OUD impact disease progression and the response to ART in people living with HIV,” commented Montaner.

The overarching goal of this research is to investigate the role of opioid receptor involvement in modulating the levels of immune activation, and the effects of different classes of MOUDs, in people living with HIV. Effectively controlling immune activation after ART in persons taking MOUDS can directly impact health and mortality.

The NIDA support of this initiative will fund two clinical studies:

• The first grant provides $8,373,891 over five years for an international trial conducted among the U.S., Vietnam and France, in collaboration with the Vietnam Ministry of Health, the Perelman School of Medicine at the University of Pennsylvania, the Institute of Applied Medicine and Epidemiology (a French-led initiative to expand access to HIV/hepatitis prevention and treatment services), and the Pasteur Institute.

  The goal of this three-arm randomized trial, conducted in Vietnam and co-led by Montaner and David Metzger, Ph.D., a research professor and director of the HIV Prevention Research Division at the Perelman School of Medicine at the University of Pennsylvania, is to evaluate the impact of long-term opioid receptor stimulation or blockage with MOUDs on immune reconstitution in HIV-infected people who inject drugs and are initiating ART. Early preliminary data suggest that chronic opioid receptor engagement by an opioid receptor agonist while on ART may result in increased immune activation and inflammation associated with increased levels of persistent HIV, when compared to a full opioid receptor antagonist. To verify this hypothesis, the study will assess recovery outcomes and adherence to therapy 48 weeks after initiation of ART in 225 participants with OUD who receive either methadone (opioid receptor agonist), extended-release naltrexone (antagonist) or buprenorphine (partial agonist).

• A second, complementary grant will provide $3,889,138 over five years for mechanistic studies on local persons living with HIV on ART and taking MOUDs. Collaborators on this research are the Perelman School of Medicine at the University of Pennsylvania, Jonathan Lax Treatment Center, and the Icahn School of Medicine at Mount Sinai. The study will assess the preliminary observation that greater myeloid activation and HIV persistence are present in people receiving opioid receptor agonists when compared to people treated with opioid receptor antagonist naltrexone.

  Blood and tissue samples from individuals living with HIV who are receiving ART and treatment with different MOUDs will be used to study the mechanisms that regulate persistent immune activation and residual HIV expression.

“We expect the results of this major collaborative effort, which has its hub in Philadelphia, to have broad clinical implications in informing the best pharmacologic strategy for the management of opioid use disease in HIV-infected people starting ART,” said Montaner. “This is directly relevant in light of the opioid epidemic ongoing in our nation and will help ensure that the right medications are used for both HIV and OUD, with the ultimate objective of saving lives in the future.”

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In high-income countries like the U.S., the standard of care for people infected with HIV is to provide antiretroviral pills when the virus is found, even when there are no symptoms of AIDS. The strategy staves off the disease and has a second — big — benefit. It has been shown to prevent the spread of HIV in sexual encounters. It’s called “treatment as prevention” (TasP in medical jargon), or “test and treat.”

But in low-income countries, “test and treat” is not the typical approach to prevention. There has been no research to support it.

So 10 years ago, researchers began planning a massive study of treatment as prevention in South Africa and Zambia. The team came from the London School of Hygiene and Tropical Medicine, Imperial College and from several other institutions in the U.S., Zambia and South Africa.

When they started, they said, there was some doubt in the AIDS research community about whether the effort would be successful. “People didn’t think we could provide antiretroviral therapy in sub-Saharan Africa at all,” says study co-leader Richard Hayes of the London School of Hygiene and Tropical Medicine. “There was a lot of skepticism.”

Helen Ayles, from the same institution and a Zambian research organization called Zambart, hit the same resistance. “People said you’ll never get communities to test, and you’ll never get communities to want to start treatment early and if you do they’ll never stay on the treatment.” That attitude sprang partly from past struggles to get people to follow a regimen of daily drugs, in both developed and developing countries — and from local mistrust when foreigners arrive in low-income countries to carry out a health mission.

The study provided “test and treat” to communities containing a total of about 1 million people in South Africa and Zambia from 2013 to 2018. The $130 million project is called PopART (Population Effects of Antiretroviral Therapy to Reduce HIV Transmission).

The findings show that the practice could play a crucial role in controlling the AIDS epidemic.

“The results are fantastic,” says Ayles. “We managed to demonstrate you can reduce HIV incidence by 30 percent. That’s an amazing thing.”

“This is a landmark study,” says Judith Wasserheit, a longtime AIDS researcher and head of the Department of Global Health at the University of Washington, who was not involved in the research. “Getting communities to adopt an intervention and sustain it is one of the great challenges of global health.”

Details of the new trial were revealed at the Conference on Retroviruses and Opportunistic Infections in Seattle this spring and will be published soon. The findings are likely to be a big source of discussion at the global AIDS and HIV conference in Mexico City in July.

The scale of the trial was immense. Researchers began annual HIV testing in 14 communities of 50,000 or so people each in urban neighborhoods and towns in South Africa and Zambia. Community health workers went to people’s homes, talked to them about HIV and HIV prevention, distributed condoms and offered on-the-spot testing. Those who tested positive were offered free antiretroviral therapy. Another 300,000 or so were in the control group, which did not offer “test and treat.”

The study was funded by the U.S. government and the International Initiative for Impact Evaluation with support from the Bill and Melinda Gates Foundation (which is also a funder of NPR and this blog).

In half of the 14 communities where “test and treat” was the protocol, anyone found to be HIV-positive was offered treatment immediately. The results from these communities were not that impressive: a 7 percent drop in new HIV infections compared to communities in the control arm, where testing and treatment were sometimes available but not with the concerted, door-to-door outreach of the PopART approach.

In the other half of communities where “test and treat” took place, for the first few years treatment didn’t begin until an individual’s white blood cell counts fell below a certain level. (Partway through the study, those communities were switched to immediate treatment when national guidelines changed.)

In those seven “test and treat” communities, whose combined population was about 330,000, the incidence of new infections was 30 percent lower than in the control group communities.

“We showed it’s feasible and acceptable to deliver this kind of intervention in towns in sub-Saharan Africa,” says Hayes.

The new study does leave one major question — why was the drop only 7 percent in the group in which HIV-positive people received treatment right away as opposed to 30 percent in the other treated communities where treatment was initially delayed?

“My first reaction was that the statisticians had got it the wrong way around,” says Hayes. But four different statisticians repeated the analysis and got the same results. The PopART researchers are mining the data to try and understand the difference.

There are other findings to consider from the study. Its designers believed that community buy-in would be key to getting people to accept testing and treatment. So at the start of PopART, the researchers solicited community leaders to serve on advisory boards to oversee the project and help the researchers find and train 700-plus community members to serve as health care workers. The process, says Hayes, “was like mobilizing an army.”

The idea was that these community health workers, who understood their patients’ lives and languages, could make a difference. “What PopART has shown is how important local health workers can be,” says Maryam Shahmanesh, an associate professor at University College London and an HIV prevention and sexual health expert.

Rosemary Phiri, a Zambian with no medical training, found a listing for health workers while looking for a job in her local newspaper. She wound up overseeing 112 workers in the program and went out on community visits.

“It was an amazing experience for me,” says Phiri, now 34 years old. “At first people were not sure what was going on.” Testing centers existed in some of the towns already, but this was a door-to-door effort. “When people realized we were there to help them stop this terrible infection, they became so receptive,” she says. “They saw we were there for their own good.”

Myron Cohen, a professor at the University of North Carolina, calls the new study “a road map.” Cohen is a principal investigator in a worldwide collaboration of researchers who run clinical trials on AIDS interventions, including this one. Cohen had headed the study that in 2011 showed that intensive attention — frequent visits to the health center and counseling on risk reduction and the use of condoms — and antiretroviral drugs can stop transmission between partners when one is known to be HIV-positive.

PopART builds on Cohen’s findings and other efforts, including a major study in South Africa. That study showed that HIV transmission is less frequent in communities where treatment is available compared to similar communities where it is not, suggesting that HIV transmission could be controlled on a population level.

And in early June, a study of a single community in KwaZulu-Natal done by Doctors Without Borders showed that engaging patient groups, local health workers and political leaders encourages people to be tested and treated. The study provided preliminary evidence that widespread outreach could decrease the spread of HIV in a poor area.

The U.N. has set eliminating the public health threat of HIV as a goal for the year 2030. Is that possible? Cohen quickly says yes, if an adequate effort is made — if every HIV infected person can be found, started on treatment and persuaded to stay on treatment. PopART co-leader Richard Hayes hesitates before answering. “I think it can be done,” he finally says. “But I think it will be a real challenge.”

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