Browsing by Author "Guy Harling"
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Item Antiretroviral therapy based HIV prevention targeting young women who sell sex: A mixed method approach to understand the implementation of PrEP in a rural area of KwaZulu-Natal, South Africa(2022-02) Natsayi Chimbindi; Nondumiso Mthiyane; Thembelihle Zuma; Kathy Baisley; Deenan Pillay; Nuala McGrath; Guy Harling; Lorraine Sherr; Isolde Birdthistle; Sian Floyd; Jaco Dreyer; Sarah Nakasone; Janet Seeley; Maryam Shahmanesh§Pre-Exposure Prophylaxis (PrEP) is a potential game-changer for HIV. We used PrEP introduction for Young Women Who Sell Sex (YWSS) in a rural South Africa district to understand community norms and PrEP coverage in YWSS. Between 2017 and 2018, we measured awareness and uptake of PrEP in a representative cohort of 2184 Adolescent Girls and Young Women (AGYW) aged 13-22. We conducted group discussions with young people and community members (19); key informant interviews (9), in-depth interviews with 15-24 year-olds (58) and providers (33). Interviews were analysed using thematic analysis. PrEP awareness increased from 2% to 9%. Among 965 AGYW sexually-active by 2018, 13.4% (95%CI: 11.4%-15.7%) reported transactional sex and 10.6% (95%CI: 8.85-12.7%) sex for money. Of the 194 YWSS, 21 were aware of PrEP, but none had used it. Youth were enthusiastic about PrEP as tool for HIV prevention; whilst older community members were cautious about a technology they had limited experience with but could benefit select groups. Teachers and healthcare providers were concerned that PrEP would lower personal responsibility for sexual health. In conclusion, the narrow and limited introduction of PrEP to YWSS reduced the accessibility and reach. Introducing PrEP as part of sexual healthcare may improve demand and access for YWSS.Item Clinical Impact Costs and Costeffectiveness of Expanded Severe Acute Respiratory Syndrome Coronavirus 2 Testing in MassachusettsAnne M Neilan; Elena Losina; Audrey C Bangs; Clare Flanagan; A Et Al; Guy HarlingItem Clinical Outcomes, Costs, and Cost-effectiveness of Strategies for People Experiencing Sheltered Homelessness During the COVID-19 Pandemic(2020-08-11) Travis P. Baggett; Justine A. Scott; Mylinh H. Le; Fatma M. Shebl; Christopher Panella; Elena Losina; Clare Flanagan; Jessie M. Gaeta; Anne Neilan; Emily P. Hyle; Amir Mohareb; Krishna P. Reddy; Mark J. Siedner; Guy Harling; Milton C. Weinstein; Andrea Ciaranello; Pooyan Kazemian; Kenneth A. FreedbergImportance: Approximately 356,000 people stay in homeless shelters nightly in the US. They are at high risk for COVID-19. Objective: To assess clinical outcomes, costs, and cost-effectiveness of strategies for COVID-19 management among sheltered homeless adults. Design: We developed a dynamic microsimulation model of COVID-19 in sheltered homeless adults in Boston, Massachusetts. We used cohort characteristics and costs from Boston Health Care for the Homeless Program. Disease progression, transmission, and outcomes data were from published literature and national databases. We examined surging, growing, and slowing epidemics (effective reproduction numbers [Re] 2.6, 1.3, and 0.9). Costs were from a health care sector perspective; time horizon was 4 months, from April to August 2020. Setting & Participants: Simulated cohort of 2,258 adults residing in homeless shelters in Boston. Interventions: We assessed daily symptom screening with polymerase chain reaction (PCR) testing of screen-positives, universal PCR testing every 2 weeks, hospital-based COVID-19 care, alternate care sites [ACSs] for mild/moderate COVID-19, and temporary housing, each compared to no intervention. Main Outcomes and Measures: Cumulative infections and hospital-days, costs to the health care sector (US dollars), and cost-effectiveness, as incremental cost per case prevented of COVID-19. Results: We simulated a population of 2,258 sheltered homeless adults with mean age of 42.6 years. Compared to no intervention, daily symptom screening with ACSs for pending tests or confirmed COVID-19 and mild/moderate disease led to 37% fewer infections and 46% lower costs (Re=2.6), 75% fewer infections and 72% lower costs (Re=1.3), and 51% fewer infections and 51% lower costs (Re=0.9). Adding PCR testing every 2 weeks further decreased infections; incremental cost per case prevented was $1,000 (Re=2.6), $27,000 (Re=1.3), and $71,000 (Re=0.9). Temporary housing with PCR every 2 weeks was most effective but substantially more costly than other options. Results were sensitive to cost and sensitivity of PCR and ACS efficacy in preventing transmission. Conclusions & Relevance: In this modeling study of simulated adults living in homeless shelters, daily symptom screening and ACSs were associated with fewer COVID-19 infections and decreased costs compared with no intervention. In a modeled surging epidemic, adding universal PCR testing every 2 weeks was associated with further decrease in COVID-19 infections at modest incremental cost and should be considered during future surges.Item Common mental disorders and HIV status in the context of DREAMS among adolescent girls and young women in rural KwaZuluNatal South AfricaN Mthiyane; Guy Harling; N Chimbindi; K Baisley; J Seeley; E et alItem Common mental disorders and HIV status in the context of DREAMS among adolescent girls and young women in rural KwaZuluNatal South AfricaN Mthiyane; Guy Harling; N Chimbindi; K Baisley; J Seeley; E et alItem Corona virus disease 2019 COVID19 transmission in the US before versus after relaxation of statewide social distancingA Tsai; Guy Harling; ZC Reynolds; RF Gilbert; M SiednerItem Counting adolescents in the development of an adolescent health indicator framework for populationbased settingsS Shinde; Guy Harling; N Assefa; B Till; J Bukenya; A Chukwu; E et alItem Effectiveness and resource requirements of test trace and isolate strategies for COVID19 in the UKB He; S Zaidy; B Elesedy; M Hutchinson; E et al; Guy HarlingItem Exploring risk factors of drive for muscularity and muscle dysmorphia in male adolescents from a resourcelimited setting in Burkina FasoV Terhoeven; C Nikendei; M Bountogo; Hans-Christoph Friederich; E et al; Guy Harling; B TillItem Health and economic benefits of secondary education in the context of poverty Evidence from Burkina FasoL K Werner; J.O Ludwig; A Sie; C H Bagagnan; Guy Harling; E et alItem Health and economic benefits of secondary education in the context of poverty: Evidence from Burkina Faso(2022-07-06) Luisa K. Werner; Jan-Ole Ludwig; Ali Sie4; Cheik H. Bagagnan; Pascal Zabre; Alain Vandormael; Guy Harling; Jan-Walter De Neve; Gu¨nther FinkEven though formal education is considered a key determinant of individual well-being globally, enrollment in secondary schooling remains low in many low- and middle-income countries, suggesting that the perceived returns to such schooling may be low. We jointly estimate survival and monetary benefits of secondary schooling using detailed demographic and surveillance data from the Boucle du Mouhoun region, Burkina Faso, where national upper secondary schooling completion rates are among the lowest globally (<10%). We first explore surveillance data from the Nouna Health and Demographic Surveillance System from 1992 to 2016 to determine long-term differences in survival outcomes between secondary and higher and primary schooling using Cox proportional hazards models. To estimate average increases in asset holdings associated with secondary schooling, we use regionally representative data from the Burkina Faso Demographic Health Surveys (2003, 2010, 2014, 2017–18; N = 3,924). Survival was tracked for 14,892 individuals. Each year of schooling was associated with a mortality reduction of up to 16% (95% CI 0.75–0.94), implying an additional 1.9 years of life expectancy for men and 5.1 years for women for secondary schooling compared to individuals completing only primary school. Relative to individuals with primary education, individuals with secondary or higher education held 26% more assets (SE 0.02; CI 0.22–0.30). Economic returns for women were 3% points higher than male returns with 10% (SE 0.03; CI 0.04–0.16) vs. 7% (SE 0.02; CI 0.02–0.012) and in rural areas 20% points higher than in urban areas with 30% (SE 0.06; CI 0.19–0.41) vs. 4% (SE 0.01; CI 0.02–0.07). Our results suggest that secondary education is associated with substantial health and economic benefits in the study area and should therefore be considered by researchers, governments, and other major stakeholders to create for example school promotion programs.Item HIV seroconcordance among heterosexual couples in rural KwaZulu Natal South Africa a populationbased analysisH-Y Kim; Guy Harling; A Vandormael; A Tomita; DF Cuadros; Barnighausen Till; F TanserItem Isisekelo Sempilo study protocol for the efectiveness of HIV prevention embedded in sexual health with or without peer navigator support (Thetha Nami) to reduce prevalence of transmissible HIV amongst adolescents and young adults in rural KwaZulu-Natal: a 2×2 factorial randomised controlled trial(2022) Glory Chidumwa; Natsayi Chimbindi; Carina Herbst; Nonhlanhla Okeselo; Jaco Dreyer; Thembelihle Zuma; Theresa Smith; Jean‑Michel Molina; Thandeka Khoza; Nuala McGrath; Janet Seeley; Deenan Pillay; Frank Tanser; Guy Harling; Lorraine Sherr; Andrew Copas; Kathy Baisley; Maryam ShahmaneshBackground: Antiretroviral therapy (ART) through universal test and treat (UTT) and HIV pre-exposure prophylaxis (PrEP) substantially reduces HIV-related mortality, morbidity and incidence. Efective individual-level prevention modalities have not translated into population-level impact in southern Africa due to sub-optimal coverage among adolescents and youth who are hard to engage. We aim to investigate the feasibility, acceptability, and preliminary population level efectiveness of HIV prevention services with or without peer support to reduce prevalence of trans‑ missible HIV amongst adolescents and young adults in KwaZulu-Natal. Methods: We are conducting a 2×2 factorial trial among young men and women aged 16–29 years, randomly selected from the Africa Health Research Institute demographic surveillance area. Participants are randomly allocated to one of four intervention combinations: 1) Standard of Care (SOC): nurse-led services for HIV testing plus ART if posi‑ tive or PrEP for those eligible and negative; 2) Sexual and Reproductive Health (SRH): Baseline self-collected vaginal and urine samples with study-organized clinic appointments for results, treatment and delivery of HIV testing, ART and PrEP integrated with SRH services; 3) Peer-support: Study referral of participants to a peer navigator to assess their health, social and educational needs and provide risk-informed HIV prevention, including facilitating clinic attendance; or 4) SRH+peer-support. The primary outcomes for efectiveness are: (1) the proportion of individuals with infectious HIV at 12 months and (2) uptake of risk-informed comprehensive HIV prevention services within 60 days of enrolment. At 12 months, all participants will be contacted at home and the study team will collect a dried blood spot for HIV ELISA and HIV viral load testing. Discussion: This trial will enable us to understand the relative importance of SRH and peer support in creating demand for efective and risk informed biomedical HIV prevention and preliminary data on their efectiveness on reducing the prevalence of transmissible HIV amongst all adolescents and youth. Trial registration: Trial Registry: clincialtrials.gov. ClinicalTrials.gov Identifer NCT04532307. Registered: March 2020. Keywords: Peer navigator, HIV prevention, Community-based care, Contraception, Pre-Exposure prophylaxisItem Older persons experiences of healthcare in rural Burkina Faso: Results of a cross sectional household survey(2022-06-09) Ellen M. Goldberg; Mamadou Bountogo; Guy Harling; Till Baernighausen; Justine I. Davies; Lisa R. HirschhornEnsuring responsive healthcare which meets patient expectations and generates trust is important to increase rates of access and retention. This need is important for aging populations where non-communicable diseases (NCDs) are a growing cause of morbidity and mortality. We performed a cross-sectional household survey including socio-demographic; morbidities; and patient-reported health system utilization, responsiveness, and quality outcomes in individuals 40 and older in northwestern Burkina Faso. We describe results and use exploratory factor analysis to derive a contextually appropriate grouping of health system responsiveness (HSR) variables. We used linear or logistic regression to explore associations between socio-demographics, morbidities, and the grouped-variable, then between these variables and health system quality outcomes. Of 2,639 eligible respondents, 26.8% had least one NCD, 56.3% were frail or pre-frail and 23.9% had a recent healthcare visit, including only 1/3 of those with an NCD. Highest ratings of care experience (excellent/very good) included ease of following instructions (86.1%) and trust in provider skills (81.1%). The HSR grouping with the greatest factor loading included involvement in decision-making, clarity in communication, trust in the provider, and confidence in providers’ skills, labelled Shared Understanding and Decision Making (SUDM). In multivariable analysis, higher quality of life (OR 1.02,95%CI 1.01–1.04), frailty (OR 1.47,95%CI 1.00–2.16), and SUDM (OR 1.06,95%CI 1.05–1.09) were associated with greater health system trust and confidence. SUDM was associated with overall positive assessment of the healthcare system (OR 1.02,95%CI 1.01–1.03) and met healthcare needs (OR 1.09,95%CI 1.08–1.11). Younger age and highest wealth quintile were also associated with higher met needs. Recent healthcare access was low for people with existing NCDs, and SUDM was the most consistent factor associated with higher health system quality outcomes. Results highlight the need to increase continuity of care for aging populations with NCDs and explore strengthening SUDM to achieve this goal.Item Prevalence and correlates of adolescent selfinjurious thoughts and behaviors A populationbased study in Burkina Faso(SAGE PUBLICATIONS) T I Ebalu; J C Kearns; L Ouermi; M Bountogo; A Sié; B Till; Guy HarlingItem Process evaluation of peer-to-peer delivery of HIV self-testing and sexual health information to support HIV prevention among youth in rural KwaZulu-Natal, South Africa: qualitative analysis(2022-01-19) Oluwafemi Atanda Adeagbo; Janet Seeley; Dumsani Gumede; Sibongiseni Xulu; Nondumiso Dlamini; Manono Luthuli; Jaco Dreyer; Carina Herbst; F Cowan; Natsayi Chimbindi; Karin Hatzold; Nonhlanhla Okesola; Cheryl Johnson; Guy Harling; Hasina Subedar; Lorraine Sherr; Nuala McGrath; Liz Corbett; Maryam ShahmaneshObjective: Peer-to-peer (PTP) HIV self-testing (HIVST) distribution models can increase uptake of HIV testing and potentially create demand for HIV treatment and pre-exposure prophylaxis (PrEP). We describe the acceptability and experiences of young women and men participating in a cluster randomised trial of PTP HIVST distribution and antiretroviral/PrEP promotion in rural KwaZulu-Natal. Methods: Between March and September 2019, 24 pairs of trained peer navigators were randomised to two approaches to distribute HIVST packs (kits+HIV prevention information): incentivised-peer-networks where peer-age friends distributed packs within their social network for a small incentive, or direct distribution where peer navigators distributed HIVST packs directly. Standard-of-care peer navigators distributed information without HIVST kits. For the process evaluation, we conducted semi-structured interviews with purposively sampled young women (n=30) and men (n=15) aged 18-29 years from all arms. Qualitative data were transcribed, translated, coded manually and thematically analysed using an interpretivist approach. Results: Overall, PTP approaches were acceptable and valued by young people. Participants were comfortable sharing sexual health issues they would not share with adults. Coupled with HIVST, peer (friends) support facilitated HIV testing and solidarity for HIV status disclosure and treatment. However, some young people showed limited interest in other sexual health information provided. Some young people were wary of receiving health information from friends perceived as non-professionals while others avoided sharing personal issues with peer navigators from their community. Referral slips and youth-friendly clinics were facilitators to PrEP uptake. Family disapproval, limited information, daily pills and perceived risks were major barriers to PrEP uptake. Conclusion: Both professional (peer navigators) and social network (friends) approaches were acceptable methods to receive HIVST and sexual health information. Doubts about the professionalism of friends and overly exclusive focus on HIVST information materials may in part explain why HIVST kits, without peer navigators support, did not create demand for PrEP.Item Protocol: Mapping social networks, social influence and sexual health among youth in rural KwaZulu-Natal, the Sixhumene cohort study(2022-05-26) Vuyiswa Nxumalo; Siyabonga Nxumalo; Theresa Smit; Thandeka Khoza; Fikile Mdaba; Thulile Khumalo; Beniamino Cislaghi; Nuala McGrath; Janet Seeley; Maryam Shahmanesh; Guy HarlingBackground: Sexual behaviour and sexually transmitted infections are strongly affected by social connections, and interventions are often adapted more readily when diffused through social networks. However, evidence on how young people acquire ideas and change behaviour through the influence of important social contacts is not well understood in high-HIV-prevalence settings, with the result that past peer-led HIV-prevention interventions have had limited success. Methods: We therefore designed a cohort study (named Sixhumene or ‘we are connected’) to follow young people in three rural and small-town communities in uMkhanyakude district, KwaZulu-Natal, South Africa, and the people that these youth identify as important in their lives. We will interview them five times over three years, at each visit collecting information on their socioeconomic, social and sexual health lives, and testing them for HIV and herpes simplex virus 2 (HSV-2). We will use this information to understand how these young people’s sexual health decisions are formed. This will include evaluating how poor sexual health outcomes are correlated across social networks, how youth mimic the attitudes and behaviours of those around them, who is at greatest risk of acquiring HIV and HSV-2, and who might be most influential within communities and thus best able to promote protective interventions. Discussion: The information gathered through this study will allow us to describe social connection and influence spread through these real-world social networks, and how this leads to sexual health outcomes. Sixhumene will provide vital inputs for mathematical models of communities and spreading processes, as well as inform the development of effective interventions to protect the sexual health of community members through appropriate targeting with optimised messaging requiring fewer resources.Item Reaching for the 'first 95': a cross-country analysis of HIV self-testing in nine countries in sub-Saharan Africa(2022-02) Eva van Empel; Rebecca A De Vlieg; Guy Harling; Maja E Marcus; Kathleen Kahn; Till W Bärnighausen; Livia Montana; Augustine T Choko; Jennifer Manne-GoehlerObjectives: HIV self-testing (HIVST) offers a promising approach to increase HIV diagnosis and advance progress towards the UNAIDS 95-95-95 targets. We aimed to understand patterns of HIVST awareness and utilization in nine sub-Saharan African (SSA) countries, with the goal of identifying populations to target in disseminating this technology. Design: A cross-sectional study. Methods: We pooled individual-level population-based data from nine Demographic and Health Surveys (DHS) in SSA conducted 2015-2019 (Burundi, Cameroon, Guinea, Malawi, Senegal, Sierra Leone, South Africa, Zambia, Zimbabwe). Primary outcomes were HIVST awareness and utilization. We used logistic regression with survey fixed effects to explore the relationship between sociodemographic characteristics and these outcomes. Models were adjusted for sex, age, rural/urban residence, education, wealth, and marital status. We accounted for complex survey design. Results: The study sample included 177 572 people (66.0% women, mean age 29 ± 10 years), of whom 86.6% [95% confidence interval (95% CI) 86.4-86.7] were unaware of HIVST, 11.7% (95% CI 11.6-11.9) were aware of but never used HIVST, and 1.7% (95% CI 1.6-1.8) had used HIVST. In adjusted models, women were less likely to be aware of HIVST [odds ratio (OR) 0.75, 95% CI 0.71-0.79], but more likely to have used HIVST (OR 1.17, 95% CI 1.03-1.32) compared with men. Rural residents, those who were least educated, and poorest were less likely to have heard of or used HIVST. Conclusion: HIVST awareness and uptake were low. Rural, less educated, and lower income populations were least likely to have heard of or used HIVST. Efforts to scale-up HIVST in these settings should aim to reach these less advantaged groups.Item Social distancing to slow the US Covid19 epidemic longitudinal pretestposttest comparison group studyM Siedner; Guy Harling; L Reynold; RF Gilbert; S Haneuse; E et alItem Subjective social position and cognitive function in a longitudinal cohort of older, rural South African adults, 2014–2019(2021-09-23) Lindsay C Kobayashi; Emily P Morris; Guy Harling; Meagan T Farrell; Mohammed U Kabeto; Ryan G Wagner; Lisa F BerkmanBackground The relationship between subjective social position (SSP) and cognitive ageing unclear, especially in low-income settings. We aimed to investigate the relationship between SSP and cognitive function over time among older adults in rural South Africa. Methods Data were from 3771 adults aged ≥40 in the population-representative ’Health and Ageing in Africa: A Longitudinal Study of an INDEPTH Community in South Africa’ from 2014/2015 (baseline) to 2018/2019 (followup). SSP was assessed at baseline with the 10-rung MacArthur Network social position ladder. Outcomes were composite orientation and episodic memory scores at baseline and follow-up (range: 0–24). Mortality- and attrition-weighted linear regression estimated the associations between baseline SSP with cognitive scores at each of the baseline and follow-up. Models were adjusted for age, age2 , sex, country of birth, father’s occupation, education, employment, household assets, literacy, marital status and health-related covariates. Results SSP responses ranged from 0 (bottom ladder rung/lowest social position) to 10 (top ladder rung/ highest social position), with a mean of 6.6 (SD: 2.3). SSP was positively associated with baseline cognitive score (adjusted β=0.198 points per ladder rung increase; 95%CI 0.145 to 0.253) and follow-up cognitive score (adjusted β=0.078 points per ladder rung increase; 95%CI 0.021 to 0.136). Conclusion Independent of objective socioeconomic position measures, SSP is associated with orientation and episodic memory scores over two time points approximately 3 years apart among older rural South Africans. Future research is needed to establish the causality of the observed relationships, whether they persist over longer follow-up periods and their consistency in other populations.