Condom avoidance and determinants of demand for male circumcision in Johannesburg, South Africa

BACKGROUND Circumcision is efficacious in reducing HIV acquisition in heterosexual males. The South Africa government has been reluctant to adopt a national circumcision programme, possibly due to concerns that circumcision may result in decreased condom use. OBJECTIVE To identify the determinants of demand for male circumcision, to examine variations by ethnicity, and to determine whether it is demanded to avoid condom use. METHODS 403 parents and 237 sons in Johannesburg, South Africa, were recruited through a randomized household survey, with oversampling to balance between blacks (n  =  220), 'coloured' (mixed ethnicity) (n  =  202) and whites (n  =  218). The demand for male circumcision was estimated using a conjoint analysis, with each respondent randomly receiving four tasks comparing seven possible benefits-six identified through key informant interviews and one for condom avoidance. Respondents' choices were analysed using logistic regression, including stratified analyses to test for homogeneity. RESULTS Overall, circumcision's beneficial effects on HIV transmission (P  <  0.001), sexually transmitted infection (STI) transmission (P <  0.001), hygiene (P  <  0.05) and sex (P  <  0.05) were identified as determinants of demand, but the condom avoidance hypothesis was rejected as it was 'repulsive' to respondents (P  <  0.001). Consistent results were found for blacks (P  <  0.001) and coloured (P  <  0.001), but not for whites who found condom avoidance attractive (P  <  0.04), a result not explained by variations in wealth, age or paternal circumcision status. CONCLUSIONS Male circumcision programmes should be tailored to accommodate variations in the determinants of demand across the target population. We find that circumcision's protective effect against HIV acquisition in men is the only determinant to be found consistently across all ethnic groups in Johannesburg. We also find that concerns over condom avoidance may have been overstated. This said, male circumcision strategies should reinforce a range of HIV prevention strategies, including condom use, as we find evidence that whites may view circumcision as a means to avoid condom use.

Preferences for characteristics of antiretroviral therapy provision in Johannesburg, South Africa: results of a conjoint analysis

A survey was administered to HIV-infected patients and a sample in Soweto and the Johannesburg inner city to measure preferences for antiretroviral therapy (ART) provision. The 25 to 49-year-old male and female respondents viewed 20 sets of three hypothetical ART clinic choices after reading information on ART. Each set had a permutation of four levels of: monthly ART price, clinic waiting times, HIV clinic branding and clinic staff attitudes. For each set, respondents selected the preferred mix of characteristics and indicated if they would pay for it. For every ZAR 100 (USD PPP 25) increase in price, the average probability of selecting a clinic decreased by 2.8 and 3.0% in the HIV patient and household samples, respectively. Cost as well as staff attitude, wait time, and clinic branding may constitute important barriers to ART uptake and adherence in resource-poor settings.

Male circumcision for HIV prevention: developments from sub-Saharan Africa

The demonstration of a strong effect of male circumcision on reducing HIV acquisition has provided impetus for this intervention to be adopted more widely in areas of the world where HIV prevalence is high and rates of male circumcision are low. This perspective reviews recent research findings and provides a summary of progress in various countries.

Efficacy of short-course AZT plus 3TC to reduce nevirapine resistance in the prevention of mother-to-child HIV transmission: a randomized clinical trial

BACKGROUND

Single-dose nevirapine (sdNVP)-which prevents mother-to-child transmission of HIV-selects non-nucleoside reverse-transcriptase inhibitor (NNRTI) resistance mutations in the majority of women and HIV-infected infants receiving it. This open-label, randomised trial examined the efficacy of short-course zidovudine (AZT) and lamivudine (3TC) with sdNVP in reducing NNRTI resistance in mothers, and as a secondary objective, in infants, in a setting where sdNVP was standard-of-care.

METHODS AND FINDINGS

sdNVP alone, administered at the onset of labour and to the infant, was compared to sdNVP with AZT plus 3TC, given as combivir (CBV) for 4 (NVP/CBV4) or 7 (NVP/CBV7) days, initiated simultaneously with sdNVP in labour; their newborns received the same regimens. Women were randomised 1ratio1ratio1. HIV-1 resistance was assessed by population sequencing at: baseline, 2, and 6 wk after birth. An unplanned interim analysis resulted in early stopping of the sdNVP arm. 406 pregnant women were randomised and took study medication (sdNVP 74, NVP/CBV4 164, and NVP/CBV7 168). HIV-1 resistance mutations emerged in 59.2%, 11.7%, and 7.3% of women in the sdNVP, NVP/CBV4, and NVP/CBV7 arms by 6 wk postpartum; differences between NVP-only and both NVP/CBV arms were significant (p<0.0001), but the difference between NVP/CBV4 and NVP/CBV7 was not (p = 0.27). Estimated efficacy comparing combined CBV arms with sdNVP was 85.6%. Similar resistance reductions were seen in infants who were HIV-infected by their 6-wk visit.

CONCLUSIONS

A short course of AZT plus 3TC, supplementing maternal and infant sdNVP, reduces emergent NNRTI resistance mutations in both mothers and their infants. However, this trial was not powered to detect small differences between the CBV arms.

TRIAL REGISTRATION

www.ClinicalTrials.govNCT 00144183.

When to start antiretroviral therapy in resource-limited settings

BACKGROUND

The results of international clinical trials that are assessing when to initiate antiretroviral therapy (ART) will not be available for several years.

OBJECTIVE

To inform HIV treatment decisions about the optimal CD4 threshold at which to initiate ART in South Africa while awaiting the results of these trials.

DESIGN

Cost-effectiveness analysis by using a computer simulation model of HIV disease.

DATA SOURCES

Published data from randomized trials and observational cohorts in South Africa.

TARGET POPULATION

HIV-infected patients in South Africa.

TIME HORIZON

5-year and lifetime.

PERSPECTIVE

Modified societal.

INTERVENTION

No treatment, ART initiated at a CD4 count less than 0.250 x 10(9) cells/L, and ART initiated at a CD4 count less than 0.350 x 10(9) cells/L.

OUTCOME MEASURES

Morbidity, mortality, life expectancy, medical costs, and cost-effectiveness.

RESULTS OF BASE-CASE ANALYSIS

If 10% to 100% of HIV-infected patients are identified and linked to care, a CD4 count threshold for ART initiation of 0.350 x 10(9) cells/L would reduce severe opportunistic diseases by 22,000 to 221,000 and deaths by 25,000 to 253,000 during the next 5 years compared with ART initiation at 0.250 x 10(9) cells/L; cost increases would range from $142 million (10%) to $1.4 billion (100%). Either ART initiation strategy would increase long-term survival by at least 7.9 years, with a mean per-person life expectancy of 3.8 years with no ART and 12.5 years with an initiation threshold of 0.350 x 10(9) cells/L. Compared with an initiation threshold of 0.250 x 10(9) cells/L, a threshold of 0.350 x 10(9) cells/L has an incremental cost-effectiveness ratio of $1200 per year of life saved.

RESULTS OF SENSITIVITY ANALYSIS

Initiating ART at a CD4 count less than 0.350 x 10(9) cells/L would remain cost-effective over the next 5 years even if the probability that the trial would demonstrate the superiority of earlier therapy is as low as 17%.

LIMITATION

This model does not consider the possible benefits of initiating ART at a CD4 count greater than 0.350 x 10(9) cells/L or of reduced HIV transmission.

CONCLUSION

Earlier initiation of ART in South Africa will probably reduce morbidity and mortality, improve long-term survival, and be cost-effective. While awaiting trial results, treatment guidelines should be liberalized to allow initiation at CD4 counts less than 0.350 x 10(9) cells/L, earlier than is currently recommended.

PRIMARY FUNDING SOURCE

National Institute of Allergy and Infectious Diseases and the Doris Duke Charitable Foundation.

HAART and risk of tuberculosis in HIV-infected South African children: a multi-site retrospective cohort

SETTING

Four human immunodeficiency virus (HIV) clinics located at South African tertiary hospitals.

OBJECTIVE

To assess the effectiveness of highly active antiretroviral therapy (HAART) in reducing incident tuberculosis (TB) in HIV-infected children.

DESIGN

Retrospective cohort.

RESULTS

A total of 1132 children's records were included in the study. At entry to the cohort, the median (interquartile range [IQR]) age, CD4%, CD4 count and viral load of all children was respectively 6.3 years (4.1-8.8), 15% (9.0-22.2), 576 cells/mm(3) (287-960) and 160 000 copies/ml (54 941.5-449 683); 75.9% were started on HAART. The male:female ratio was 1:1, and median follow-up time was 1.7 years. In children whose follow-up included both pre-HAART and on-HAART periods, the incidence of clinically diagnosed TB was respectively 21.1 per 100 person-years (py; 95%CI 18.2-24.4) and 6.4/100 py (95%CI 4.8-8.1), and when restricted to confirmed cases, respectively 3.1/100 py (95%CI 2.2-4.2) and 0.8/100 py (95%CI 0.5-1.4). Only 23% of all cases of TB were microbiologically confirmed. Multivariate analyses showed that HAART reduced incident TB by approximately 70%, both for confirmed and all TB cases.

CONCLUSIONS

In this high TB burden country, the incidence of diagnosis of TB in HIV-infected children is at least as high as that of adults. HAART reduces incident TB, but further prospective TB preventive and diagnostic studies are urgently needed in children.

Isoniazid preventive therapy, HAART and tuberculosis risk in HIV-infected adults in South Africa: a prospective cohort

BACKGROUND

The World Health Organization recommends isoniazid preventive therapy (IPT) for preventing tuberculosis in HIV-infected adults, although few countries have instituted this policy. Both IPT and highly active antiretroviral therapy (HAART) used separately result in reductions in tuberculosis risk. There is less information on the combined effect of IPT and HAART. We assessed the effect of IPT, HAART or both IPT and HAART on tuberculosis incidence in HIV-infected adults in South Africa.

METHODS

Two clinical cohorts of HIV-infected patients were studied. Primary exposures were receipt of IPT and/or HAART and the primary outcome was incident tuberculosis. Crude incident rates and incident rate ratios were calculated and Cox proportional hazards models investigated associations with tuberculosis risk.

RESULTS

Among 2778 HIV-infected patients followed for 4287 person-years, 267 incident tuberculosis cases were diagnosed [incidence rate ratio (IRR)=6.2/100 person-years; 95% CI 5.5-7.0]. For person-time without IPT or HAART, the IRR was 7.1/100 person-years (95% CI 6.2-8.2); for person-time receiving HAART but without IPT, the IRR was 4.6/100 person-years (95% CI 3.4-6.2); for person-time after IPT but prior to HAART, the IRR was 5.2/100 person-years (95% CI 3.4-7.8); during follow-up in patients treated with HAART after receiving IPT the IRR was 1.1/100 person-years (95% CI 0.02-7.6). Compared to treatment-naive patients, HAART-only patients had a 64% decreased hazard for tuberculosis [adjusted hazard ratio (aHR)=0.36; 95% CI 0.25-0.51], and patients receiving HAART after IPT had a 89% reduced hazard (aHR=0.11; 95% CI 0.02-0.78).

CONCLUSION

Tuberculosis risk is significantly reduced by IPT in HAART-treated adults in a high-incidence operational setting in South Africa. IPT is an inexpensive and cost-effective strategy and our data strengthen calls for the implementation of IPT in conjunction with the roll-out of HAART.

Predictors of persistent cytologic abnormalities after treatment of cervical intraepithelial neoplasia in Soweto, South Africa: a cohort study in a HIV high prevalence population

BACKGROUND

In the presence of both HIV infection and cervical intraepithelial neoplasia (CIN), the risk of cancer development despite treatment may be greater. We investigated clinical predictors of persistent cytological abnormalities in women who had had a large loop excision of the transformation zone (LLETZ).

METHODS

Women with high grade squamous intraepithelial lesions or worse (HSIL), less severe abnormalities which persisted and any abnormality in women who are HIV-infected, were referred to the colposcopy clinic. HIV infection was ascertained by self-report. A LLETZ was performed on all patients with HSIL or higher on Papanicolaou (Pap) smear or colposcopy, LSIL or higher in patients who are HIV-infected, where the colposcopy is inadequate, and when there was a discrepancy between colposcopy and cytology by one or more grades. Women with abnormal follow-up smears were compared to those with normal smears. We examined the association between abnormal follow-up smears and demographic and clinical predictors using logistic regression

RESULTS

The median time between LLETZ and first follow-up Pap smear was rather short at 122 days. Persistent cytological abnormalities occurred in 49% of our patients after LLETZ. Predictors of persistence included the presence of disease at both margins and HIV infection. Among the latter, disease at the excision margins and CD4+ cell count were important predictors. In these women, disease at the endocervical margin, both margins, and disease only at the ectocervical margin were associated with increased odds of persistent abnormalities on follow-up cervical smear.

CONCLUSION

We showed extremely high risk of cytological abnormality at follow-up after treatment more so in patients with incomplete excision and in the presence of immunocompromise. It remains uncertain whether recurrent CIN is a surrogate marker for invasive cervical cancer.

Scaling up antiretroviral therapy in South Africa: the impact of speed on survival

BACKGROUND

Only 33% of eligible human immunodeficiency virus (HIV)-infected patients in South Africa receive antiretroviral therapy (ART). We sought to estimate the impact of alternative ART scale-up scenarios on patient outcomes from 2007-2012.

METHODS

Using a simulation model of HIV infection with South African data, we projected HIV-associated mortality with and without effective ART for an adult cohort in need of therapy (2007) and for adults who became eligible for treatment (2008-2012). We compared 5 scale-up scenarios: (1) zero growth, with a total of 100,000 new treatment slots; (2) constant growth, with 600,000; (3) moderate growth, with 2.1 million; (4) rapid growth, with 2.4 million); and (5) full capacity, with 3.2 million.

RESULTS

Our projections showed that by 2011, the rapid growth scenario fully met the South African need for ART; by 2012, the moderate scenario met 97% of the need, but the zero and constant growth scenarios met only 28% and 52% of the need, respectively. The latter scenarios resulted in 364,000 and 831,000 people alive and on ART in 2012. From 2007 to 2012, cumulative deaths in South Africa ranged from 2.5 million under the zero growth scenario to 1.2 million under the rapid growth scenario.

CONCLUSIONS

Alternative ART scale-up scenarios in South Africa will lead to differences in the death rate that amount to more than 1.2 million deaths by 2012. More rapid scale-up remains critically important.

Comparative costs of inpatient care for HIV-infected and uninfected children and adults in Soweto, South Africa

BACKGROUND

HIV/AIDS creates a massive burden of care for health systems. A better understanding of the impact of HIV infection on health care utilization and costs may enable better use of limited resources.

METHODS

We compared public sector inpatient costs of HIV-infected versus uninfected adults and children at a large hospital in Soweto, South Africa. Daily hotel costs estimated from hospital financial data and total patient visits were combined with utilization, abstracted from patients' charts, and costed using government price lists to estimate total inpatient costs.

RESULTS

A total of 1185 eligible records were included over a 6-week period in 2005. Eight hundred twelve were from HIV-infected patients, and of these, 77 were on antiretroviral (ARV) therapy. The mean length of stay (LOS) and mean drug and intravenous fluid utilization of HIV-infected adults not on ARVs was greater than those of uninfected adults, resulting in a $200 higher total average admission cost. Patients on ARVs had longer LOS and incurred a total average admission cost of $750 more than HIV-infected adults not on ARVs.

CONCLUSIONS

Inpatient costs were greater for this selected group of HIV-infected adults, and even higher for the small proportion of individuals receiving ARVs. Budget allocations should incorporate case mix by HIV and ARV status as a key determinant of hospital expenditure.

Causes of death in hospitalized adults with a premortem diagnosis of tuberculosis: an autopsy study

OBJECTIVE

To ascertain the immediate and underlying causes of death in adults who died in hospital with a premortem diagnosis of tuberculosis.

DESIGN

Causes of death were assessed independently by internists and pathologists in 50 adults admitted to two Soweto hospitals who died 24 h or more after admission. Detailed record reviews and complete autopsies, including HIV tests when not performed premortem, were performed. In addition, a variety of postmortem microbiological tests were performed.

RESULTS

Forty-seven patients had HIV infection; all were antiretroviral naive. Their median age was 34.5 years, median CD4 cell count was 48 cells/microl and median length of hospitalization before death was 6 days. Autopsy confirmed the premortem diagnosis of tuberculosis in 37 HIV-infected patients (79%), whereas 10 (21%) did not demonstrate tuberculosis. Bronchopneumonia and cytomegalovirus pneumonitis were the leading pathologies in these 10 patients. In 47 HIV-infected cadavers immediate or contributory causes of death were: extensive pulmonary tuberculosis, 32 (68%); disseminated tuberculosis, 28 (60%); bacterial pneumonia, 13 (26%); cytomegalovirus pneumonitis in seven (15%); cytomegalovirus DNA was found in 31 (66%) and Pneumocystis pneumonia was found in five cadavers (11%). The lung, followed by lymph nodes, liver and kidney, were the commonest sites of tuberculosis. Mycobacterium tuberculosis was cultured from 19 spleens, one of which was multidrug resistant, and Salmonella spp. was cultured from 11 splenic specimens.

CONCLUSION

We demonstrated disseminated, extensive tuberculosis associated with advanced HIV disease. Severe bacterial infections, including salmonellosis, were the leading co-morbidity, suggesting that hospitalized HIV-infected adults in whom tuberculosis is suspected may benefit from broad-spectrum antibiotic therapy.

Transmission rates in consecutive pregnancies exposed to single-dose nevirapine in Soweto, South Africa and Abidjan, Côte d'Ivoire

BACKGROUND

Large numbers of women receive single-dose nevirapine (sdNVP) to prevent mother-to-child transmission (MTCT) of HIV; over time, an increasing proportion will return to prevention of MTCT programs for a second pregnancy. Because sdNVP selects resistance in a high percentage of women, we compared the effectiveness of sdNVP in preventing peripartum MTCT in successive pregnancies.

METHODS

Prospective cohorts were recruited from MTCT programs in South Africa and Côte d'Ivoire. HIV-1-infected women and their infants exposed to sdNVP in 2 consecutive pregnancies-used alone or with zidovudine (ZDV) or ZDV plus lamivudine-were included.

RESULTS

The median age of women at their initial exposure to sdNVP in Soweto (n = 120) and Abidjan (n = 41) was 26 (interquartile range [IQR]: 22-29) years and 28 (IQR: 24-31) years, respectively, and their median delivery interval was 21 (IQR: 15-29) months and 26 (IQR: 20-32) months, respectively. Transmission rates in Soweto and in Abidjan were 11.1% and 13.2% for the first pregnancy and 11.1% and 5.4% for the second pregnancy (P = 1.000 and P = 0.449 for Soweto and Abidjan, respectively, in unpaired analysis).

CONCLUSION

This analysis suggests that the effectiveness of sdNVP when used in successive pregnancies is probably not impaired, possibly because viral resistance selected by prior exposure to sdNVP may wane with time.

Selection and Persistence of Viral Resistance in HIV-Infected Children After Exposure to Single-Dose Nevirapine

BACKGROUND

Single-dose nevirapine (sd-NVP) is the mainstay of prevention of mother-to-child transmission programs in developing countries. Exposure to sd-NVP selects for resistance mutations, however. We longitudinally assessed these mutations in HIV-1-infected infants from Soweto and Durban, South Africa.

METHODS

We prospectively followed 465 infants who received sd-NVP after enrolling their mothers when pregnant. If HIV infected, their virus was genotyped, using the ViroSeq HIV-1 Genotyping System, to detect resistant mutations. Those with resistance were genotyped at 6 months and then every 6 months out to 18 months if resistance was detected at the previous visit.

RESULTS

Of 53 HIV-infected infants, 24 (45.3%) had detectable resistance at their first visit, when the most frequent mutations were Y181C (75%), K103N (25%), and Y188C (12%). Of those whose visit was before 12 weeks of age, 2 of 42 infants shared identical resistance mutations with their mothers. By 18 months of age, 11 of 24 infants with resistance had died and 1 still had the Y181C mutation.

CONCLUSIONS

Resistant mutations were selected in half of the infants exposed to sd-NVP, but fewer were detected over time and, unlike the case in their mothers, Y181C dominated initially and persists. Transient resistance mutations may have a negative impact on highly active antiretroviral therapy in infants and children.

Circumcision for prevention against HIV: marked seasonal variation in demand and potential public sector readiness in Soweto, South Africa

The public sector delivery of male circumcision in the only public sector hospital in Soweto, South Africa was examined to gauge local capacity to deliver this procedure as an intervention for prevention of HIV acquisition. During the period from July 1998 to March 2006, approximately 360 procedures were performed per annum. Striking seasonal variations and the relatively few procedures performed may create challenges for program planning, if male circumcision is increased to a level required to have an impact on the incidence of HIV among this population.

Linking the global positioning system (GPS) to a personal digital assistant (PDA) to support tuberculosis control in South Africa: a pilot study

BACKGROUND

Tuberculosis (TB) is the leading clinical manifestation of HIV infection and caseloads continue to increase in high HIV prevalence settings. TB treatment is prolonged and treatment interruption has serious individual and public health consequences. We assessed the feasibility of using a handheld computing device programmed with customised software and linked to a GPS receiver, to assist TB control programmes to trace patients who interrupt treatment in areas without useful street maps. In this proof of concept study, we compared the time taken to re-find a home comparing given residential addresses with a customised personalised digital assistant linked to a global positioning system (PDA/GPS) device. Additionally, we assessed the feasibility of using aerial photographs to locate homes.

RESULTS

The study took place in two communities in Greater Johannesburg, South Africa: Wheillers Farm, a relatively sparsely populated informal settlement, and a portion of Alexandra, an urban township with densely populated informal settlements. Ten participants in each community were asked to locate their homes on aerial photographs. Nine from Wheillers Farm and six from Alexandra were able to identify their homes. The total time taken by a research assistant, unfamiliar with the area, to locate 10 homes in each community using the given addresses was compared with the total time taken by a community volunteer with half an hour of training to locate the same homes using the device. Time taken to locate the ten households was reduced by 20% and 50% in each community respectively using the PDA/GPS device.

CONCLUSION

In this pilot study we show that it is feasible to use a simple PDA/GPS device to locate the homes of patients. We found that in densely populated informal settlements, GPS technology is more accurate than aerial photos in identifying homes and more efficient than addresses provided by participants. Research assessing issues of, confidentiality and cost effectiveness would have to be undertaken before implementing PDA/GPS - based technology for this application. However, this PDA/GPS device could be used to reduce part of the burden on TB control programs.

Combining PMTCT with active case finding for tuberculosis

Tuberculosis (TB) is the preeminent manifestation of HIV infection and has become a leading cause of maternal mortality and morbidity in high HIV-prevalence settings. Active TB in pregnant women has potentially serious consequences for fetuses and newborns. In Soweto, South Africa, there is a more than 90% uptake of voluntary counseling and HIV testing during routine antenatal care, and almost one third of pregnant women are HIV-infected. The posttest counseling session of the prevention of mother-to-child transmission program provides an opportunity to screen HIV-infected pregnant women for TB. In this study, 370 HIV-infected pregnant women were screened for symptoms of active TB by lay counselors at the posttest counseling session. If symptomatic, they were referred to nurses who investigated them further. Eight women were found to have previously undiagnosed, smear-negative, culture-confirmed TB (2160/100,000). The mean CD4 count in those with active TB compared to those without TB was 276 x 10(6) cells per liter vs 447 x 10(6) cells per liter (P = 0.051). Symptoms most associated with active TB were hemoptysis and fever. We conclude that rates of TB in HIV-infected pregnant women are high, and screening for TB during routine antenatal care should be implemented in high HIV-prevalence settings.

High rates of HIV in surgical patients in Soweto, South Africa: impact on resource utilisation and recommendations for HIV testing

Interactions between HIV and surgical diseases are relatively poorly described in high HIV prevalence settings. We report HIV prevalence and its associations in a prospective study of adults admitted to surgical units in Soweto, South Africa. Voluntary counselling and testing (VCT) for HIV was offered to surgical inpatients. Research nurses interviewed participants at enrolment and doctors reviewed records after discharge. In HIV-infected participants, CD4 counts and viral loads were ascertained. Of 1000 participants, 537 consented to VCT, of whom 176 (32.8%, 95% CI 28.8-36.9%) tested HIV positive. A history of tuberculosis (adjusted odds ratio (AOR) 3.0, 95% CI 1.5-6.2) or sexually transmitted infection (AOR 2.7, 95% CI 1.8-4.2) was associated with HIV infection. Diagnoses of cutaneous abscesses (OR 3.4, 95% CI 1.4-8.1) and anorectal sepsis (OR 3.1, 95% CI 1.1-9.0) were associated with HIV and indicated advanced disease. There were no differences in rates of operative procedures, wound sepsis, investigations or length of stay by HIV status. Hospital-acquired pneumonia was more common in HIV-infected participants (P=0.028). In conclusion, in this high HIV prevalence setting, resource utilisation is similar between HIV-infected and uninfected patients in surgical wards where high rates of HIV in young adults support routine HIV testing. WHO clinical staging of HIV should include anal sepsis as an indicator of advanced HIV disease.

Optimizing treatment for HIV-infected South African women exposed to single-dose nevirapine: balancing efficacy and cost

INTRODUCTION

Nevirapine (NVP) resistance may decrease the effectiveness of viral suppression with NVP-based antiretroviral therapy (ART) in women infected with human immunodeficiency virus (HIV) with previous exposure to single-dose NVP. However, the alternative lopinavir-ritonavir-based ART regimen is more expensive. Our objectives were to project the tradeoffs regarding life expectancy, cost, and cost-effectiveness of these ART regimens for NVP-exposed, HIV-infected women in South Africa.

METHODS

We developed a simulation model in which NVP-exposed, HIV-infected South African women received 1 of 5 treatment strategies: HIV care without ART, NVP-based ART, lopinavir-ritonavir-based ART, NVP-based ART followed by lopinavir-ritonavir-based ART, or lopinavir-ritonavir-based ART followed by NVP-based ART. The prevalence of NVP resistance was 39%; other data were obtained from the published literature.

RESULTS

Projected life expectancy was 43.7 months for women who did not receive ART, 77.4 months for women who received a single NVP-based regimen, and 84.5 months for women who received a single lopinavir-ritonavir-based regimen. NVP resistance reduced survival time by up to 11.6 months among women who received NVP-based ART. The cost-effectiveness of NVP-based ART was $800 (US dollars) per year of life saved, compared with no ART, and the cost-effectiveness of lopinavir-ritonavir-based therapy was $4400 per year of life saved, compared with NVP-based ART. Lopinavir-ritonavir followed by NVP-based ART yielded the greatest life expectancy (105.4 months), had a cost-effectiveness of $2300 per year of life saved, and, if the efficacy of NVP-based regimens improved >6 months postpartum, further increased survival.

CONCLUSIONS

NVP resistance substantially decreased the projected survival time associated with NVP-based ART, and lopinavir-ritonavir-based ART resulted in a superior survival time but at higher cost. A sequential regimen starting with lopinavir-ritonavir-based ART followed by NVP-based ART maximized projected survival and was cost effective in South Africa.