4 ways to rein in Cabo Verde’s HIV epidemic

By ramping up four interventions already underway, the African archipelago nation of Cabo Verde could within 10 years, bring its HIV epidemic under control. "You don't have to scale up everything," says Filipe Monteiro. "You can just prioritize the specific groups."(Credit: no rain corp./Flickr)

The African archipelago nation of Cabo Verde could bring its HIV epidemic under control within 10 years by ramping up four interventions that are already underway.

Further, much of the progress could be achieved by just focusing the most at-risk populations.

A new computer simulation suggests that annual new cases could fall below the key threshold of 10 per 10,000 residents even if the country just focuses the additional efforts on female sex workers and drug users, two groups with unusually high prevalence of infection.

“You don’t have to scale up everything,” says Filipe Monteiro, a postdoctoral scholar at Brown University. “You can just prioritize the specific groups.”

chart
Focusing four public health interventions on female sex workers and drug users rather than on the entire population would approach the “HIV elimination phase”—10 new cases per year per 10,000 population—in 2021. View larger. (Credit: Brown University)

‘Simulate the whole country’

The modeled interventions include extending and optimizing early HIV treatment, expanding HIV testing, increasing condom distribution, and providing more substance abuse treatment.

Monteiro, a native of the country, wanted to see whether significant expansions of those programs over the decade between 2011 and 2021 could bring new cases below the 10 per 10,000 threshold that some global health experts call the “HIV elimination phase.”

To make those predictions he used a computer model co-developed by his adviser, Brandon Marshall, assistant professor of epidemiology. The implementation included 305,000 individually behaving “agents,” enough to represent every Cabo Verdean adult. “Here we were able to simulate the whole country,” Monteiro says.

In the model, “agents” (representing real people) do what’s relevant to the epidemic such as have sex with varying numbers of partners (sometimes protected and sometimes not), use drugs, start and stop medicine, get tested, transmit the virus, and sometimes die.

Combination approach

All the parameters, such as drug use, frequency of sex, response to HIV medications and so on, are based on real data.

newtwork graph
The computer simulation considers sexual or drug-use between “agents”—people with various medical and demographic characteristics. (Credit: Brown University)

For example, the percentage of people engaged in drug use and the percentage of women engaged in prostitution are based on Cabo Verde’s real rates, as are the prevalence of HIV infection in those populations and among adults nationwide. The one major missing cohort, men who have sex with men, had to be left out of the model because there is not yet reliable HIV and population data for them.

To determine the efficacy of the interventions, the researchers ran the model 100 times each for each of the following scenarios, both for the whole population and just among drug users and female sex workers: continuing the status quo of current interventions, doubling HIV testing, increasing condom distribution by 33 percent, doubling substance abuse treatment, doubling antiretroviral treatment, and doing all these interventions at the same time.

The combination approach lowered new cases the most compared to the status quo, both when the interventions were applied population-wide and when they were applied just to the at-risk groups.

Real life, not just a laptop

In the whole population scenarios, for example, the combination of all four interventions reduced new cases in 2021 from the status quo 23.8 per 10,000 to 6.7 per 10,000 among female sex workers who use drugs, and among general residents (non-drug using, non-prostitutes) from 5.1 per 10,000 to 1.4 new cases per 10,000.

Meanwhile, focusing the combination approach only on at-risk groups reduced new cases among drug-using sex workers to 7.3 per 10,000 and among general population members to 3.4 per 10,000.

According to the research, published in the International Journal of Public Health, the weakest approach would likely be either solely scaling up HIV testing, or only expanding substance abuse treatment. For example, the effect of solely increasing HIV testing, was weaker, reducing new cases among drug-using sex workers to 17.6 per 10,000, and cases among general population members to 4.5 per 10,000.

[related]

Monteiro says he’s optimistic that Cabo Verde can move forward with these interventions in real life, rather than in a laptop. Although key data, such as for men who have sex with men, are still needed, the findings provide a clear policy prescription.

“We recommend a combination prevention strategy, particularly for populations most at-risk, to decrease and eventually eliminate HIV transmission in Cabo Verde and other settings characterized by concentrated, overlapping HIV epidemics in key affected groups,” the report says.

The paper’s other authors are Tim Flanigan of Brown University and the Miriam Hospital, Sandro Galea of Boston University, and Samuel Friedman of the National Development and Research Institutes.

The National Institute of Health funded the study.

Source: Brown University