Global health agencies have recently put a new emphasis on geography. UNAIDS have called for programmes to focus on “location and population”. PEPFAR (The US President’s Emergency Plan for AIDS Relief) says there is a “need to do the right things in the right places at the right time”. The Global Fund believes there is a need to “target resources to areas with the greatest need”.
But how can these principles be applied in practice? Speakers at the 21st International AIDS Conference (AIDS 2016) in Durban, South Africa, last week outlined examples in which maps and geographic analyses have helped improve HIV services. Their examples came from the United States and South Africa.
Comprehensive services for sex workers reduce detectable viral load, but enhanced ARV services provide no extra benefit
A randomised trial in female sex workers in Zimbabwe, offering enhanced access to HIV treatment and pre-exposure prophylaxis (PrEP), has failed to show that the extra services helped reduce the proportion with detectable viral load, Frances Cowan told the 21st International AIDS Conference (AIDS 2016) in Durban today.
It appears that the comprehensive set of sex worker-friendly services which were offered in the control arm may have already been enough to substantially improve the health of participants.
While this set of services was described as the ‘usual care’ and is in line with World Health Organization guidelines, the reality is that a comprehensive package of quality services for sex workers is rarely fully delivered. The services included free condoms and contraception, HIV testing and counselling, referral to government clinics for HIV treatment, management of sexually transmitted infections, health education and legal advice supported by a network of peer educators.
In seven communities – forming the control group – this package of care was provided.
In a further seven communities – forming the intervention group – the same services were provided, as well as the following additional elements:
- HIV treatment available at the sex worker clinic (rather than referral to a government clinic)
- For women testing HIV-negative, SMS reminders to encourage repeat HIV testing
- For women testing HIV-negative, the offer of PrEP
- Adherence support programme for women taking HIV treatment or PrEP
- Intensified community mobilisation activities.
The communities, spread across Zimbabwe, were locations where several hundred women sold sex and where there was a primary care clinic providing dedicated services to sex workers.
The primary endpoint was the proportion of female sex workers who could be infectious with HIV, in other words with an HIV viral load above 1000 copies/ml. The trial was therefore innovative in considering a woman with an undetectable viral load as equivalent to a woman who does not have HIV.
When the trial began in 2013, approximately 200 female sex workers were recruited in each community and tested for HIV antibodies and viral load. In April this year, 200 female sex workers in each community (not necessarily the same individuals) were recruited and tested in the same way.
The women were recruited through respondent-driven sampling (RDS), in which the first women recruited by the researchers invite their peers to participate too. Women who took part in the surveys were not necessarily clients of the interventions, but were women living and working in the area. more