TB/HIV Theme, Malawi-Liverpool-Wellcome Clinical Research Programme (MLW), Blantyre, Malawi.
London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom.
PLoS One. 2018 Nov 14;13(11):e0207263. doi: 10.1371/journal.pone.0207263. eCollection 2018.
INTRODUCTION: Linkage to HIV treatment is a vital step in the cascade of HIV services and is critical to slowing down HIV transmission in countries with high HIV prevalence. Equally, linkage to voluntary medical male circumcision (VMMC) has been shown to decrease HIV transmission by 60% and increasing numbers of men receiving VMMC has a substantial impact on HIV incidence. However, only 48% of newly diagnosed HIV positive people link to HIV treatment let alone access HIV prevention methods such as VMMC globally. METHODS: A systematic review investigating the effect of demand-side financial incentives (DSFIs) on linkage into HIV treatment or VMMC for studies conducted in low- and middle-income countries. We searched the title, abstract and keywords in eight bibliographic databases: MEDLINE, EMBASE, Web of Science, Econlit, Cochrane, SCOPUS, IAS Conference database of abstracts, and CROI Conference database of abstracts. Searches were done in December 2016 with no time restriction. We fitted random effects (RE) models and used forest plots to display risk ratios (RR) and 95% CIs separately for the linkage to VMMC outcome. The RE model was also used to assess heterogeneity for the linkage to HIV treatment outcome. RESULTS: Of the 1205 citations identified from searches, 48 full text articles were reviewed culminating in nine articles in the final analysis. Five trials investigated the effect of DSFIs on linkage to HIV treatment while four trials investigated linkage to VMMC. Financial incentives improved linkage to HIV treatment in three of the five trials that investigated this outcome. Significant improvements were observed among postpartum women RR 1.26 (95% CI: 1.08; 1.48), among people who inject drugs RR 1.42 (95% CI: 1.09; 1.96), and among people testing at the clinic RR 1.10 (95% CI: 1.07; 1.14). One of the two trials that did not find significant improvement in linkage to ART was among people testing HIV positive in clinics RR 0.96 (95% CI: 0.81; 1.16) while the other was among new HIV positive individuals identified through a community testing study RR 0.82 (95% CI: 0.56; 1.22). We estimate an average 4-fold increase in the uptake of circumcision among HIV negative uncircumcised men from our fitted RE model with overall RR 4.00 (95% CI: 2.17; 7.37). There was negligible heterogeneity in the estimates from the different studies with I-squared = 0.0%; p = 0.923. CONCLUSIONS: Overall, DSFIs appeared to improve linkage for both HIV treatment and VMMC with greater effect for VMMC. Demand-side financial incentives could improve linkage to HIV treatment or VMMC in low- and middle-income countries although uptake by policy makers remains a challenge.
简介:将艾滋病毒感染者与艾滋病毒治疗联系起来是艾滋病毒服务级联中的一个重要步骤,对于减缓艾滋病毒在高艾滋病毒流行国家的传播至关重要。同样,自愿医疗男性包皮环切术(VMMC)的联系也已被证明可以将艾滋病毒传播降低 60%,并且越来越多的男性接受 VMMC 会对艾滋病毒发病率产生重大影响。然而,在全球范围内,只有 48%的新诊断出艾滋病毒阳性的人能够联系到艾滋病毒治疗,更不用说获得艾滋病毒预防方法,如 VMMC。
方法:系统评价调查了在中低收入国家进行的需求方财政激励措施(DSFIs)对艾滋病毒治疗或 VMMC 联系的影响。我们在八个书目数据库中搜索了标题、摘要和关键词:MEDLINE、EMBASE、Web of Science、Econlit、Cochrane、SCOPUS、IAS 会议摘要数据库和 CROI 会议摘要数据库。2016 年 12 月进行了搜索,没有时间限制。我们拟合了随机效应(RE)模型,并使用森林图分别显示 VMMC 联系的风险比(RR)和 95%置信区间。RE 模型还用于评估艾滋病毒治疗联系结果的异质性。
结果:从搜索中确定了 1205 条引文,对 48 篇全文文章进行了审查,最终有 9 篇文章进入最终分析。五项试验研究了 DSFIs 对艾滋病毒治疗联系的影响,四项试验研究了与 VMMC 的联系。在调查这一结果的五项试验中,有三项发现财政激励措施改善了与艾滋病毒治疗的联系。在以下人群中观察到显著改善:产后妇女 RR 1.26(95%CI:1.08;1.48)、注射吸毒者 RR 1.42(95%CI:1.09;1.96)和在诊所检测的人 RR 1.10(95%CI:1.07;1.14)。两项没有发现艾滋病毒治疗联系显著改善的试验之一是在诊所检测艾滋病毒阳性的人群中 RR 0.96(95%CI:0.81;1.16),另一个是在通过社区检测研究发现的新艾滋病毒阳性个体中 RR 0.82(95%CI:0.56;1.22)。我们估计,通过我们拟合的 RE 模型,艾滋病毒阴性未割包皮男性的割礼率平均增加了 4 倍,总体 RR 为 4.00(95%CI:2.17;7.37)。来自不同研究的估计值几乎没有异质性,I-平方=0.0%;p=0.923。
结论:总体而言,DSFIs 似乎改善了艾滋病毒治疗和 VMMC 的联系,VMMC 的效果更大。需求方财政激励措施可以改善中低收入国家的艾滋病毒治疗或 VMMC 联系,但政策制定者的接受程度仍然是一个挑战。
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