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Yates TA, Cebekhulu S, Mthethwa M, Fourie PB, Newell ML, Abubakar I, Tanser F. Tuberculin skin test surveys and the Annual Risk of Tuberculous Infection in school children in Northern KwaZulu-Natal. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003263. [PMID: 38889188 PMCID: PMC11185501 DOI: 10.1371/journal.pgph.0003263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 04/29/2024] [Indexed: 06/20/2024]
Abstract
Tuberculin skin test surveys in primary school children can be used to quantify Mycobacterium tuberculosis transmission at community level. KwaZulu-Natal province, South Africa, is home to 11.5 million people and suffers a burden of tuberculosis disease that is among the highest in the world. The last tuberculin survey in the province was undertaken in 1979. We performed a tuberculin skin test survey nested within a demographic and health household surveillance programme in Northern KwaZulu-Natal. We enrolled children aged between six and eight years of age attending primary schools in this community. Mixture analysis was used to determine tuberculin skin test thresholds and the Annual Risk of Tuberculous Infection derived from age at testing and infection prevalence. The Community Infection Ratio, a measure of the relative importance of within-household and community transmission, was calculated from data on tuberculin positivity disaggregated by household tuberculosis contact. Between June and December 2013, we obtained tuberculin skin test results on 1240 children. Mixture analysis proved unstable, suggesting two potential thresholds for test positivity. Using a threshold of ≥10mm or treating all non zero reactions as positive yielded estimates of the Annual Risk of Tuberculous Infection of 1.7% (1.4-2.1%) or 2.4% (2.0-3.0%). Using the same thresholds and including children reported to be receiving TB treatment as cases, resulted in estimates of 2.0% (1.6-2.5%) or 2.7% (2.2-3.3%). The Community Infection Ratio was 0.58 (0.33-1.01). The force of infection in this community is lower than that observed in Western Cape province, South Africa, but higher than that observed in community settings in most other parts of the world. Children in this community are commonly infected with Mycobacterium tuberculosis outside the home. Interventions to interrupt transmission are urgently needed.
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Affiliation(s)
- Tom A. Yates
- Africa Health Research Institute (AHRI), Congella, South Africa
- Institute of Health Informatics, University College London, London, United Kingdom
- Division of Infection and Immunity, University College London, London, United Kingdom
| | | | - Mumsy Mthethwa
- Africa Health Research Institute (AHRI), Congella, South Africa
| | - P. Bernard Fourie
- Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
| | - Marie-Louise Newell
- School of Human Development and Health University of Southampton, Southampton, United Kingdom
| | - Ibrahim Abubakar
- Faculty of Population Health Sciences, University College London, London, United Kingdom
- MRC Clinical Trials Unit, University College London, London, United Kingdom
| | - Frank Tanser
- Africa Health Research Institute (AHRI), Congella, South Africa
- Centre for Epidemic Response and Innovation (CERI), Stellenbosch University, Stellenbosch, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of Kwa-Zulu Natal, Congella, South Africa
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Cattaneo MD, Keele L, Titiunik R. A guide to regression discontinuity designs in medical applications. Stat Med 2023; 42:4484-4513. [PMID: 37528626 DOI: 10.1002/sim.9861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 05/16/2023] [Accepted: 07/14/2023] [Indexed: 08/03/2023]
Abstract
We present a practical guide for the analysis of regression discontinuity (RD) designs in biomedical contexts. We begin by introducing key concepts, assumptions, and estimands within both the continuity-based framework and the local randomization framework. We then discuss modern estimation and inference methods within both frameworks, including approaches for bandwidth or local neighborhood selection, optimal treatment effect point estimation, and robust bias-corrected inference methods for uncertainty quantification. We also overview empirical falsification tests that can be used to support key assumptions. Our discussion focuses on two particular features that are relevant in biomedical research: (i) fuzzy RD designs, which often arise when therapeutic treatments are based on clinical guidelines, but patients with scores near the cutoff are treated contrary to the assignment rule; and (ii) RD designs with discrete scores, which are ubiquitous in biomedical applications. We illustrate our discussion with three empirical applications: the effect CD4 guidelines for anti-retroviral therapy on retention of HIV patients in South Africa, the effect of genetic guidelines for chemotherapy on breast cancer recurrence in the United States, and the effects of age-based patient cost-sharing on healthcare utilization in Taiwan. Complete replication materials employing publicly available data and statistical software in Python, R and Stata are provided, offering researchers all necessary tools to conduct an RD analysis.
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Affiliation(s)
- Matias D Cattaneo
- Dept. of Operations Research and Financial Engineering, Princeton University, Princeton, New Jersey, USA
| | - Luke Keele
- Dept. of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rocío Titiunik
- Dept. of Politics, Princeton University, Princeton, New Jersey, USA
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Hadavandsiri F, Shafaati M, Mohammad Nejad S, Ebrahimzadeh Mousavi M, Najafi A, Mirzaei M, Narouee S, Akbarpour S. Non-communicable disease comorbidities in HIV patients: diabetes, hypertension, heart disease, and obstructive sleep apnea as a neglected issue. Sci Rep 2023; 13:12730. [PMID: 37543699 PMCID: PMC10404291 DOI: 10.1038/s41598-023-39828-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/31/2023] [Indexed: 08/07/2023] Open
Abstract
The present study evaluates the non-communicable disease (NCD) patterns and related risk factors among people living with HIV (PLWH) in Iran. This national cross-sectional survey study was conducted on 1173 confirmed PLWHs with a mean age of 35.35 (56.82 Over 50 years old, 33.90 Under 50 years old) admitted from 15 different provinces in the country. Logistic regression was used to analyze the association of factors with having at least one NCD comorbidity. From 1173 PLWH, 225(19.18%) participants experienced at least one NCD (15.20% and 38.69% among under- and over-50-year-old patients, respectively). The prevalence of heart disease, hypertension, diabetes, and sleep apnea among all patients was 1.59%, 2.05%, 1.55%, and 10.26%, respectively. The similar prevalence for each NCD among those over 50 years was 10.11%, 15.71%, 9.01%, 25.44%, and 1.01%, 1.12%, 1.04%, and 9.23% among those under 50 years, respectively. The odds of being at risk of at least one NCD stood higher in patients over 50 years (ORadj = 2.93, 95% CI 1.96-4.37), married (ORadj = 2.48, 95% CI 1.41-4.35), divorced or widowed (ORadj = 2.78, 95% CI 1.48-5.20), and obese (ORadj = 3.82, 95% CI 2.46-5.91). According to our findings regarding the prevalence of NCDs among patients under 50 years of age, we recommend that policymakers give greater consideration to this group in the screening and care programs for NCDs since adults and the elderly are both vulnerable to the risk factors for developing NCDs.
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Affiliation(s)
- Fatemeh Hadavandsiri
- Department of Epidemiology, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Occupational Sleep Research Center, Baharloo Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Shafaati
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Tehran University of Medical Science, Tehran, Iran.
- Department of Microbiology, Faculty Science, Jahrom Branch, Islamic Azad University, Jahrom, Iran.
| | - Safieh Mohammad Nejad
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical, Tehran, Iran
| | | | - Arezu Najafi
- Occupational Sleep Research Center, Baharloo Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mirzaei
- Hamadan Health Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Sakineh Narouee
- Department of Epidemiology, Kerman University Medical of Sciences, Kerman, Iran
| | - Samaneh Akbarpour
- Occupational Sleep Research Center, Baharloo Hospital, Tehran University of Medical Sciences, Tehran, Iran.
- Sleep Breathing Disorders Research Center (SBDRC), Tehran University of Medical Sciences, Tehran, Iran.
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Plazy M, Diallo A, Hlabisa T, Okesola N, Iwuji C, Herbst K, Boyer S, Lert F, McGrath N, Pillay D, Dabis F, Larmarange J, Orne-Gliemann J. Implementation and effectiveness of a linkage to HIV care intervention in rural South Africa (ANRS 12249 TasP trial). PLoS One 2023; 18:e0280479. [PMID: 36662803 PMCID: PMC9858381 DOI: 10.1371/journal.pone.0280479] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/03/2023] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Timely linkage to care and ART initiation is critical to decrease the risks of HIV-related morbidity, mortality and HIV transmission, but is often challenging. We report on the implementation and effectiveness of a linkage-to-care intervention in rural KwaZulu-Natal, South Africa. METHODS In the ANRS 12249 TasP trial on Universal Testing and Treatment (UTT) implemented between 2012-2016, resident individuals ≥16 years were offered home-based HIV testing every six months. Those ascertained to be HIV-positive were referred to trial clinics. Starting May 2013, a linkage-to-care intervention was implemented in both trial arms, consisting of tracking through phone calls and/or home visits to "re-refer" people who had not linked to care to trial clinics within three months of the first home-based referral. Fidelity in implementing the planned intervention was described using Kaplan-Meier estimation to compute conditional probabilities of being tracked and of being re-referred by the linkage-to-care team. Effect of the intervention on time to linkage-to-care was analysed using a Cox regression model censored for death, migration, and end of data follow-up. RESULTS Among the 2,837 individuals (73.7% female) included in the analysis, 904 (32%) were tracked at least once, and 573 of them (63.4%) were re-referred. Probabilities of being re-referred was 17% within six months of first referral and 31% within twelve months. Compared to individuals not re-referred by the intervention, linkage-to-care was significantly higher among those with at least one re-referral through phone call (adjusted hazard ratio [aHR] = 1.82; 95% confidence interval [95% CI] = 1.47-2.25), and among those with re-referral through both phone call and home visit (aHR = 3.94; 95% CI = 2.07-7.48). CONCLUSIONS Phone calls and home visits following HIV testing were challenging to implement, but appeared effective in improving linkage-to-care amongst those receiving the intervention. Such patient-centred strategies should be part of UTT programs to achieve the UNAIDS 95-95-95 targets.
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Affiliation(s)
- Mélanie Plazy
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Adama Diallo
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Thabile Hlabisa
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
| | | | - Collins Iwuji
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - Kobus Herbst
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
| | - Sylvie Boyer
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, Marseille, France
| | - France Lert
- INSERM, Centre for Research in Epidemiology and Population Health (CESP-U 1018), Villejuif, France
| | - Nuala McGrath
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
- School of Primary Care and Population Sciences and Department of Social Statistics and Demography, University of Southampton, Southampton, United Kingdom
- School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Deenan Pillay
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - François Dabis
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Joseph Larmarange
- Centre Population et Développement, Institut de Recherche pour le Développement, Inserm, Université de Paris, Paris, France
| | - Joanna Orne-Gliemann
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
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MacLeod WB, Bor J, Candy S, Maskew M, Fox MP, Bulekova K, Brennan AT, Potter J, Nattey C, Onoya D, Mlisana K, Stevens W, Carmona S. Cohort profile: the South African National Health Laboratory Service (NHLS) National HIV Cohort. BMJ Open 2022; 12:e066671. [PMID: 36261238 PMCID: PMC9582381 DOI: 10.1136/bmjopen-2022-066671] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE South Africa's National Health Laboratory Service (NHLS) National HIV Cohort was established in 2015 to facilitate monitoring, evaluation and research on South Africa's National HIV Treatment Programme. In South Africa, 84.8% of people living with HIV know their HIV status; 70.7% who know their status are on ART; and 87.4% on ART are virologically suppressed. PARTICIPANTS The NHLS National HIV Cohort includes the laboratory data of nearly all patients receiving HIV care in the public sector since April 2004. Patients are included in the cohort if they have received a CD4 count or HIV RNA viral load (VL) test. Using an anonymised unique patient identifier that we have developed and validated to linked test results, we observe patients prospectively through their laboratory results as they receive HIV care and treatment. Patients in HIV care are seen for laboratory monitoring every 6-12 months. Data collected include age, sex, facility location and test results for CD4 counts, VLs and laboratory tests used to screen for potential treatment complications. FINDINGS TO DATE From April 2004 to April 2018, 63 million CD4 count and VL tests were conducted at 5483 facilities. 12.6 million unique patients had at least one CD4 count or VL, indicating they had accessed HIV care, and 7.1 million patients had a VL test indicating they had started antiretroviral therapy. The creation of NHLS National HIV Cohort has enabled longitudinal research on all lab-monitored patients in South Africa's national HIV programme, including analyses of (1) patient health at presentation; (2) care outcomes such as 'CD4 recovery', 'retention in care' and 'viral resuppression'; (3) patterns of transfer and re-entry into care; (4) facility-level variation in care outcomes; and (5) impacts of policies and guideline changes. FUTURE PLANS Continuous updating of the cohort, integration with available clinical data, and expansion to include tuberculosis and other lab-monitored comorbidities.
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Affiliation(s)
- William B MacLeod
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | - Jacob Bor
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
- Departments of Global Health and Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sue Candy
- Centre for HIV and STIs, National Institute for Communicable Diseases, Sandringham, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | - Matthew P Fox
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
- Departments of Global Health and Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Katia Bulekova
- Research Computing Services, IS&T, Boston University, Boston, Massachusetts, USA
| | - Alana T Brennan
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
- Departments of Global Health and Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - James Potter
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Cornelius Nattey
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | - Dorina Onoya
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | - Koleka Mlisana
- Academic Affairs, Research & Quality Assurance, National Health Laboratory Service, Johannesburg, South Africa
| | - Wendy Stevens
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
- National Priority Programmes, National Health Laboratory Service, Sandringham, South Africa
| | - Sergio Carmona
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
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Nascimento FF, Ragonnet-Cronin M, Golubchik T, Danaviah S, Derache A, Fraser C, Volz E. Evaluating whole HIV-1 genome sequence for estimation of incidence and migration in a rural South African community. Wellcome Open Res 2022. [DOI: 10.12688/wellcomeopenres.17891.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: South Africa has the largest number of people living with HIV (PLWHIV) in the world, with HIV prevalence and transmission patterns varying greatly between provinces. Transmission between regions is still poorly understood, but phylodynamics of HIV-1 evolution can reveal how many infections are attributable to contacts outside a given community. We analysed whole genome HIV-1 genetic sequences to estimate incidence and the proportion of transmissions between communities in Hlabisa, a rural South African community. Methods: We separately analysed HIV-1 for gag, pol, and env genes sampled from 2,503 PLWHIV. We estimated time-scaled phylogenies by maximum likelihood under a molecular clock model. Phylodynamic models were fitted to time-scaled trees to estimate transmission rates, effective number of infections, incidence through time, and the proportion of infections imported to Hlabisa. We also partitioned time-scaled phylogenies with significantly different distributions of coalescent times. Results: Phylodynamic analyses showed similar trends in epidemic growth rates between 1980 and 1990. Model-based estimates of incidence and effective number of infections were consistent across genes. Parameter estimates with gag were generally smaller than those estimated with pol and env. When estimating the proportions of new infections in Hlabisa from immigration or transmission from external sources, our posterior median estimates were 85% (95% credible interval (CI) = 78%–92%) for gag, 62% (CI = 40%–78%) for pol, and 77% (CI = 58%–90%) for env in 2015. Analysis of phylogenetic partitions by gene showed that most close global reference sequences clustered within a single partition. This suggests local evolving epidemics or potential unmeasured heterogeneity in the population. Conclusions: We estimated consistent epidemic dynamic trends for gag, pol and env genes using phylodynamic models. There was a high probability that new infections were not attributable to endogenous transmission within Hlabisa, suggesting high inter-connectedness between communities in rural South Africa.
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Rochat TJ, Dube S, Herbst K, Hoegfeldt CA, Redinger S, Khoza T, Bland RM, Richter L, Linsell L, Desmond C, Yousafzai AK, Craske M, Juszczak E, Abas M, Edwards T, Ekers D, Stein A. An evaluation of a combined psychological and parenting intervention for HIV-positive women depressed in the perinatal period, to enhance child development and reduce maternal depression: study protocol for the Insika Yomama cluster randomised controlled trial. Trials 2021; 22:914. [PMID: 34903257 PMCID: PMC8666837 DOI: 10.1186/s13063-021-05672-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 09/30/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The combination of poverty, HIV and depression in the perinatal period represents a major public health challenge in many Southern African countries. In some areas, up to a third of HIV-positive women experience perinatal depression. Perinatal depression is associated with negative effects on parenting and key domains of child development including cognitive, behavioural and growth, especially in socio-economically disadvantaged communities. Several studies have documented the benefits of psychological interventions for perinatal depression in low- and middle-income countries, but none have evaluated an integrated psychological and parenting intervention for HIV-positive women using task-sharing. This randomised controlled trial aims to evaluate the effect of a home-based intervention, combining a psychological treatment for depression and a parenting programme for perinatally depressed HIV-positive women. METHODS This study is a cluster randomised controlled trial, consisting of 48-60 geospatial clusters. A total of 528 pregnant HIV-positive women aged ≥ 16 years who meet the criteria for depression on the Edinburgh Postnatal Depression Scale (EPDS, score ≥ 9)) are recruited from antenatal clinics in rural KwaZulu-Natal, South Africa. The geospatial clusters are randomised on an allocation ratio of 1:1 to either the intervention or Enhanced Standard of Care (ESoC). The intervention group receives 10 home-based counselling sessions by a lay counsellor (4 antenatal and 6 postnatal sessions) and a booster session at 16 months. The intervention combines behavioural activation for depression with a parenting programme, adapted from the UNICEF/WHO Care for Child Development programme. The ESoC group receives two antenatal and two postnatal counselling support and advice telephone calls. In addition, measures have been taken to enhance the routine standard of care. The co-primary outcomes are child cognitive development at 24 months assessed on the cognitive subscale of the Bayley Scales of Infant Development-Third Edition and maternal depression at 12 months measured by the EPDS. ANALYSIS The primary analysis will be a modified intention-to-treat analysis. The primary outcomes will be analysed using mixed-effects linear regression. DISCUSSION If this treatment is successful, policymakers could use this model of mental healthcare delivered by lay counsellors within HIV treatment programmes to provide more comprehensive services for families affected by HIV. TRIAL REGISTRATION ISRCTN registry # 11284870 (14/11/2017) and SANCTR DOH-27-102020-9097 (17/11/2017).
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Affiliation(s)
- Tamsen J. Rochat
- SAMRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- DSI-NRF Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa
| | - Samukelisiwe Dube
- Africa Health Research Institute, Durban, KwaZulu-Natal South Africa
| | - Kobus Herbst
- Africa Health Research Institute, Durban, KwaZulu-Natal South Africa
- DSI-MRC South African Population Research Infrastructure Network (SAPRIN), Durban, South Africa
| | | | - Stephanie Redinger
- SAMRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- DSI-NRF Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa
| | - Thandeka Khoza
- DSI-NRF Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa
| | - Ruth Margret Bland
- Institute of Health and Wellbeing and Royal Hospital for Children, University of Glasgow, Glasgow, UK
| | - Linda Richter
- DSI-NRF Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa
| | - Louise Linsell
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Chris Desmond
- Priceless, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Ed Juszczak
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Melanie Abas
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Taygen Edwards
- DSI-NRF Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa
| | - David Ekers
- Tees Esk and Wear Valleys NHS FT, Darlington, UK
| | - Alan Stein
- DSI-NRF Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa
- DSI-MRC South African Population Research Infrastructure Network (SAPRIN), Durban, South Africa
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Chappell E, Thorne C, Collins IJ, Baisley K, Yapa HM, Gareta D, Bärnighausen T, Herbst K, Judd A. It ain't what you do, it's the way that you do it: The pitfalls of using routine data to measure early infant HIV diagnosis in HIV-exposed infants. PLoS One 2021; 16:e0257496. [PMID: 34591881 PMCID: PMC8483382 DOI: 10.1371/journal.pone.0257496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 09/02/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Early infant HIV diagnosis (EID) is critical to ensuring timely diagnosis of HIV-exposed infants, and treatment in those found to be infected. However estimates of coverage vary considerably, depending on data sources used. We used 4 methods to estimate coverage among a historical cohort of HIV-exposed infants in rural South Africa, between 2010-2016. METHODS We estimated the proportion of infants ever tested (methods 1-3) and tested by 7 weeks of age (1-4) as follows: (1) infants born to women identified as HIV-positive in demographic surveillance were linked to those with ≥1 EID result in routine laboratory surveillance; (2) the number of infants with ≥1 EID result in laboratory surveillance divided by the estimated number of HIV-exposed infants, calculated as total live births multiplied by antenatal HIV seroprevalence; (3) the number of infants with ≥1 EID result in routine laboratory surveillance, divided by the number of HIV-exposed infants as estimated by the district health service; (4) from documentation in infants' Road-to-Health-booklets. RESULTS The proportion ever tested was 43%, 88% and 138% for methods 1-3, and by 7 weeks of age was 25%, 49%, 86% and 46% for methods 1-4 respectively. CONCLUSIONS The four methods, applied to a range of routine data sources, resulted in estimates varying considerably, and the true coverage of EID remains unclear. Our findings highlight the importance of developing unique patient identifiers, improving training of healthcare providers using reporting systems, and ensuring the accuracy of healthcare records, to ensure the best possible health outcomes for HIV-exposed infants.
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Affiliation(s)
| | - Claire Thorne
- UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | | | - Kathy Baisley
- MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
| | - H. Manisha Yapa
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
- The Kirby Institute University of New South Wales, Sydney, Australia
| | - Dickman Gareta
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
| | - Till Bärnighausen
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
- Institute for Global Health UCL, Mortimer Market Centre, London, United Kingdom
| | - Kobus Herbst
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
- DSI-MRC South African Population Research Infrastructure Network (SAPRIN), Durban, KwaZulu-Natal, South Africa
| | - Ali Judd
- MRC Clinical Trials Unit at UCL, London, United Kingdom
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Moodley Y, Tomita A, de Oliveira T, Tanser F. HIV viral load and pregnancy loss: results from a population-based cohort study in rural KwaZulu-Natal, South Africa. AIDS 2021; 35:829-833. [PMID: 33587438 PMCID: PMC7969410 DOI: 10.1097/qad.0000000000002799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE With ever-expanding antiretroviral therapy (ART) access among pregnant women in sub-Saharan Africa, it is more than ever important to address the gap in knowledge around ART effectiveness, as measured by HIV viral load, and pregnancy loss. DESIGN A population-based cohort study. METHODS The study sample consisted of 3431 pregnancies from 2835 women living with HIV aged 16-35 years old. All women participated in a population-based cohort conducted between 2004 and 2018 in rural KwaZulu-Natal, South Africa. Viral load data were collected at prior surveys and an HIV care registry. The closest available viral load to the date that each pregnancy ended was used and classified as either a pre- or postconception viral load. Logistic regression was used to investigate the association between high viral load (log10 viral load >4.0 copies/ml) and pregnancy loss, defined as either a miscarriage or stillbirth. RESULTS Pregnancy loss occurred at a rate of 1.3 (95% confidence interval: 1.0-1.8) per 100 pregnancies. There were 1451 pregnancies (42.3%) with postconception viral load measurements. The median time between the viral load measurement and the pregnancy end date was 11.7 (interquartile range: 5.0-25.4) months. We found a higher likelihood of pregnancy loss in women who had high viral loads prior to the outcome of their pregnancy (adjusted odds ratio: 2.38, 95% confidence interval: 1.10-5.18). CONCLUSION Given the significant relationship between high viral load and pregnancy loss, our study lends further credence to ensuring effective ART through enrolment and retention of pregnant women living with HIV in ART programs, treatment adherence interventions, and viral load monitoring during pregnancy.
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Affiliation(s)
- Yoshan Moodley
- Africa Health Research Institute
- School of Nursing and Public Health
- KwaZulu-Natal Research Innovation and Sequencing Platform, University of KwaZulu-Natal, Durban
- Faculty of Health and Environmental Sciences, Central University of Technology, Bloemfontein
| | - Andrew Tomita
- KwaZulu-Natal Research Innovation and Sequencing Platform, University of KwaZulu-Natal, Durban
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Tulio de Oliveira
- KwaZulu-Natal Research Innovation and Sequencing Platform, University of KwaZulu-Natal, Durban
| | - Frank Tanser
- Africa Health Research Institute
- School of Nursing and Public Health
- Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, UK
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
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10
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Mejia-Pailles G, Berrington A, McGrath N, Hosegood V. Trends in the prevalence and incidence of orphanhood in children and adolescents <20 years in rural KwaZulu-Natal South Africa, 2000-2014. PLoS One 2020; 15:e0238563. [PMID: 33232331 PMCID: PMC7685426 DOI: 10.1371/journal.pone.0238563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 08/19/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In South Africa, large increases in early adult mortality during the 1990s and early 2000s have reversed since public HIV treatment rollout in 2004. In a rural population in KwaZulu-Natal, we investigate trends in parental mortality and orphanhood from 2000-2014. METHODS Using longitudinal demographic surveillance data for a population of approximately 90,000, we calculated annual incidence and prevalence of maternal, paternal and double orphanhood in children and adolescents (<20 years) and, overall and cause-specific mortality of parents by age. RESULTS The proportion of children and adolescents (<20 years) for whom one or both parents had died rose from 26% in 2000 to peak at 36% in 2010, followed by a decline to 32% in 2014. The burden of orphanhood remains high especially in the oldest age group: in 2014, 53% of adolescents 15-19 years had experienced the death of one or both parents. In all age groups and years, paternal orphan prevalence was three-five times higher than maternal orphan prevalence. Maternal and paternal orphan incidence peaked in 2005 at 17 and 27 per 1,000 person years respectively (<20 years) before declining by half through 2014. The leading cause of parental death throughout the period, HIV/AIDS and TB cause-specific mortality rates declined substantially in mothers and fathers from 2007 and 2009 respectively. CONCLUSIONS The survival of parents with children and adolescents <20 years has improved in tandem with earlier initiation and higher coverage of HIV treatment. However, comparatively high levels of parental deaths persist in this rural population in KwaZulu-Natal, particularly among fathers. Community-level surveillance to estimate levels of orphanhood remains important for monitoring and evaluation of targeted state welfare support for orphans and their guardians.
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Affiliation(s)
| | - Ann Berrington
- Department of Social Statistics & Demography, University of Southampton, Southampton, United Kingdom
| | - Nuala McGrath
- Department of Social Statistics & Demography, University of Southampton, Southampton, United Kingdom
- Department of Population Sciences & Primary Care, University of Southampton, Southampton, United Kingdom
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Victoria Hosegood
- Department of Social Statistics & Demography, University of Southampton, Southampton, United Kingdom
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11
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Edwards T, Mkwanazi N, Mitchell J, Bland RM, Rochat TJ. Empowering parents for human immunodeficiency virus prevention: Health and sex education at home. South Afr J HIV Med 2020; 21:970. [PMID: 32670624 PMCID: PMC7343931 DOI: 10.4102/sajhivmed.v21i1.970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 11/24/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Improving health literacy amongst human immunodeficiency virus (HIV)-positive mothers could strengthen child and adolescent HIV prevention. The Amagugu intervention included health literacy materials to strengthen maternal communication and has demonstrated success in low-resource HIV-endemic settings. OBJECTIVES Our aims were to (1) evaluate whether Amagugu materials improved health literacy leading to changes in parental behaviour towards communicating on topics such as HIV, health behaviours and sex education, and (2) explore what additional information and materials mothers would find helpful. METHOD The Amagugu evaluation included 281 HIV-positive mothers and their HIV-uninfected children (6-10 years). Process evaluation data from exit interviews were analysed using content analysis and logistic regression techniques. RESULTS Of 281 mothers, 276 (98.0%) requested more educational storybooks: 99 (35.2%) on moral development/future aspirations, 92 (32.7%) on general health, safety and health promotion, and 67 (23.8%) on HIV and disease management. Compared to baseline, mothers reported that the materials increased discussion on the risks of bullying from friends (150; 53.4%), teacher problems (142; 50.5%), physical abuse (147; 52.3%) and sexual abuse (126; 44.8%). Most mothers used the 'HIV Body Map' for health (274; 97.5%) and sex education (267; 95.0%). The use of a low-cost doll was reported to enhance mother-child communication by increasing mother-child play (264; 94.3%) and maternal attentiveness to the child's feelings (262; 93.6%). CONCLUSION Parent-led health education in the home seems feasible, acceptable and effective and should be capitalised on in HIV prevention strategies. Further testing in controlled studies is recommended.
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Affiliation(s)
- Taygen Edwards
- Africa Health Research Institute, Somkhele, South Africa
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Ntombizodumo Mkwanazi
- Human and Social Capabilities Division, Human Sciences Research Council, Durban, South Africa
- DSI-NRF Centre of Excellence in Human Development, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joanie Mitchell
- Lentegeur Psychiatric Hospital, Department of Health, Government of the Western Cape, Cape Town, South Africa
| | - Ruth M Bland
- Royal Hospital for Sick Children, Glasgow, Scotland
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Tamsen J Rochat
- DSI-NRF Centre of Excellence in Human Development, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- SAMRC Developmental Pathways to Health Research Unit (DPHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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12
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Retention in Care Trajectories of HIV-Positive Individuals Participating in a Universal Test-and-Treat Program in Rural South Africa (ANRS 12249 TasP Trial). J Acquir Immune Defic Syndr 2019; 80:375-385. [PMID: 30570525 PMCID: PMC6410969 DOI: 10.1097/qai.0000000000001938] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Supplemental Digital Content is Available in the Text. Objective: To study retention in care (RIC) trajectories and associated factors in
patients eligible for antiretroviral therapy (ART) in a universal
test-and-treat setting (TasP trial, South Africa, 2012–2016). Design: A cluster-randomized trial whereby individuals identified HIV positive after
home-based testing were invited to initiate ART immediately (intervention)
or following national guidelines (control). Methods: Exiting care was defined as ≥3 months late for a clinic appointment,
transferring elsewhere, or death. Group-based trajectory modeling was
performed to estimate RIC trajectories over 18 months and associated factors
in 777 ART-eligible patients. Results: Four RIC trajectory groups were identified: (1) group 1
“remained” in care (reference, n = 554, 71.3%), (2) group
2 exited care then “returned” after [median (interquartile
range)] 4 (3–9) months (n = 40, 5.2%), (3) group 3
“exited care rapidly” [after 4 (4–6) months, n =
98, 12.6%], and (4) group 4 “exited care later” [after 11
(9–13) months, n = 85, 10.9%]. Group 2 patients were less likely
to have initiated ART within 1 month and more likely to be male, young
(<29 years), without a regular partner, and to have a CD4 count
>350 cells/mm3. Group 3 patients were more likely to be
women without social support, newly diagnosed, young, and less likely to
have initiated ART within 1 month. Group 4 patients were more likely to be
newly diagnosed and aged 39 years or younger. Conclusions: High CD4 counts at care initiation were not associated with a higher risk of
exiting care. Prompt ART initiation and special support for young and newly
diagnosed patients with HIV are needed to maximize RIC.
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13
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Le Roux KW, Davis EC, Gaunt CB, Young C, Koussa M, Harris C, Rotheram-Borus MJ. A Case Study of an Effective and Sustainable Antiretroviral Therapy Program in Rural South Africa. AIDS Patient Care STDS 2019; 33:466-472. [PMID: 31682167 DOI: 10.1089/apc.2019.0055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The delivery of high-quality HIV care in rural settings is a global challenge. Despite the successful expansion of antiretroviral therapy (ART) in Africa, viral load (VL) monitoring and ART adherence are poor, especially in rural communities. This article describes a case study of an ART program in the deeply rural Eastern Cape of South Africa. The Zithulele ART Program initiated five innovations over time: (1) establishing district hospital as the logistical hub for all ART care in a rural district, (2) primary care clinic delivery of prepackaged ART and chronic medications for people living with HIV (PLH), (3) establishing central record keeping, (4) incentivizing VL monitoring, and (5) providing hospital-based outpatient care for complex cases. Using a pharmacy database, on-time VL monitoring and viral suppression were evaluated for 882 PLH initiating ART in the Zithulele catchment area in 2013. Among PLH initiating ART, 12.5% (n = 110) were lost to follow-up, 7.7% (n = 68) transferred out of the region, 10.2% (n = 90) left the program and came back at a later date, and 4.0% (n = 35) died. Of the on-treatment population, 82.9% (n = 480/579) had VL testing within 7 months and 92.6% (n = 536/579) by 1 year. Viral suppression was achieved in 85.2% of those tested (n = 457/536), or 78.9% (n = 457/579) overall. The program's VL testing and suppression rates appear about twice as high as national data and data from other rural centers in South Africa, despite fewer resources than other programs. Simple system innovations can ensure high rates of VL testing and suppression, even in rural health facilities.
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Affiliation(s)
- Karl W. Le Roux
- Zithulele Hospital, Mqanduli District, South Africa
- Woodrow Wilson School of Public International Affairs at Princeton University, Princeton, New Jersey
| | - Emily C. Davis
- Department of Psychiatry, University of California Los Angeles, Los Angeles, California
| | | | - Catherine Young
- Jabulani Rural Health Foundation, Mqanduli District, South Africa
| | - Maryann Koussa
- Department of Psychiatry, University of California Los Angeles, Los Angeles, California
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14
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Vandormael A, Bärnighausen T, Herbeck J, Tomita A, Phillips A, Pillay D, de Oliveira T, Tanser F. Longitudinal Trends in the Prevalence of Detectable HIV Viremia: Population-Based Evidence From Rural KwaZulu-Natal, South Africa. Clin Infect Dis 2019; 66:1254-1260. [PMID: 29186391 DOI: 10.1093/cid/cix976] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 11/23/2017] [Indexed: 12/11/2022] Open
Abstract
Background The prevalence of detectable viremia has previously been used to infer the potential for ongoing human immunodeficiency virus (HIV) transmission. To date, no study has evaluated the longitudinal change in the prevalence of detectable viremia within the HIV-positive community (PDV+) and the entire population (PDVP) using data from a sub-Saharan African setting. Methods In 2011, 2013, and 2014, we obtained 6752 HIV-positive and 15415 HIV-negative test results from a population-based surveillance system in the KwaZulu-Natal province of South Africa. We quantified the PDV+ as the proportion of the 6752 HIV-positive results with a viral load >1550 copies/mL and the PDVP as the proportion of the 6752 HIV-positive and 15415 HIV-negative results with a viral load >1550 copies/mL. Results Between 2011 and 2014, the PDV+ decreased by 16.5 percentage points (pp) for women (from 71.8% to 55.3%) and 10.6 pp for men (from 77.8% to 67.2%). However, a steady rise in the overall HIV prevalence, from 26.7% to 32.4%, offset the declines in the PDV+ for both sexes. For women, the PDVP decreased by only 2.1 pp, from 21.3% to 19.2%, but for men, the PDVP actually increased by 1.6 pp, from 14.6% to 16.2%, over the survey period. Conclusions The PDV+, which is currently being tracked under the UNAIDS 90-90-90 targets, may not be an accurate indicator of the potential for ongoing HIV transmission. There is a critical need for countries to monitor and report the prevalence of detectable viremia among all adults, irrespective of HIV status.
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Affiliation(s)
- Alain Vandormael
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,Africa Health Research Institute, Durban, South Africa.,Kwazulu-Natal Research Innovation and Sequencing Platform, University of KwaZulu-Natal, Durban, South Africa
| | - Till Bärnighausen
- Africa Health Research Institute, Durban, South Africa.,Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Heidelberg Institute for Public Health, Faculty of Medicine, University of Heidelberg, Germany.,Research Department of Infection and Population Health, University College London, United Kingdom
| | - Joshua Herbeck
- International Clinical Research Center, Department of Global Health, University of Washington, Seattle
| | - Andrew Tomita
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,Africa Health Research Institute, Durban, South Africa.,Kwazulu-Natal Research Innovation and Sequencing Platform, University of KwaZulu-Natal, Durban, South Africa
| | | | - Deenan Pillay
- Africa Health Research Institute, Durban, South Africa.,Division of Infection and Immunity, University College London, United Kingdom
| | - Tulio de Oliveira
- Kwazulu-Natal Research Innovation and Sequencing Platform, University of KwaZulu-Natal, Durban, South Africa.,Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Frank Tanser
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,Africa Health Research Institute, Durban, South Africa.,Research Department of Infection and Population Health, University College London, United Kingdom.,Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
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15
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Larmarange J, Diallo MH, McGrath N, Iwuji C, Plazy M, Thiébaut R, Tanser F, Bärnighausen T, Orne‐Gliemann J, Pillay D, Dabis F. Temporal trends of population viral suppression in the context of Universal Test and Treat: the ANRS 12249 TasP trial in rural South Africa. J Int AIDS Soc 2019; 22:e25402. [PMID: 31637821 PMCID: PMC6803817 DOI: 10.1002/jia2.25402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 09/03/2019] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION The universal test-and-treat (UTT) strategy aims to maximize population viral suppression (PVS), that is, the proportion of all people living with HIV (PLHIV) on antiretroviral treatment (ART) and virally suppressed, with the goal of reducing HIV transmission at the population level. This article explores the extent to which temporal changes in PVS explain the observed lack of association between universal treatment and cumulative HIV incidence seen in the ANRS 12249 TasP trial conducted in rural South Africa. METHODS The TasP cluster-randomized trial (2012 to 2016) implemented six-monthly repeat home-based HIV counselling and testing (RHBCT) and referral of PLHIV to local HIV clinics in 2 × 11 clusters opened sequentially. ART was initiated according to national guidelines in control clusters and regardless of CD4 count in intervention clusters. We measured residency status, HIV status, and HIV care status for each participant on a daily basis. PVS was computed per cluster among all resident PLHIV (≥16, including those not in care) at cluster opening and daily thereafter. We used a mixed linear model to explore time patterns in PVS, adjusting for sociodemographic changes at the cluster level. RESULTS 8563 PLHIV were followed. During the course of the trial, PVS increased significantly in both arms (23.5% to 46.2% in intervention, +22.8, p < 0.001; 26.0% to 44.6% in control, +18.6, p < 0.001). That increase was similar in both arms (p = 0.514). In the final adjusted model, PVS increase was most associated with increased RHBCT and the implementation of local trial clinics (measured by time since cluster opening). Contextual changes (measured by calendar time) also contributed slightly. The effect of universal ART (trial arm) was positive but limited. CONCLUSIONS PVS was improved significantly but similarly in both trial arms, explaining partly the null effect observed in terms of cumulative HIV incidence between arms. The PVS gains due to changes in ART-initiation guidelines alone are relatively small compared to gains obtained by strategies to maximize testing and linkage to care. The achievement of the 90-90-90 targets will not be met if the operational and implementational challenges limiting access to care and treatment, often context-specific, are not properly addressed. Clinical trial number: NCT01509508 (clinicalTrials.gov)/DOH-27-0512-3974 (South African National Clinical Trials Register).
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Affiliation(s)
- Joseph Larmarange
- Centre Population et DéveloppementInstitut de Recherche pour le DéveloppementUniversité Paris DescartesInsermParisFrance
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
| | - Mamadou H Diallo
- Centre Population et DéveloppementInstitut de Recherche pour le DéveloppementUniversité Paris DescartesInsermParisFrance
| | - Nuala McGrath
- Africa Health Research InstituteSchool of Nursing and Public HealthUniversity of KwaZulu‐NatalKwaZulu‐NatalSouth Africa
- Faculty of Medicine and Faculty of Social SciencesUniversity of SouthamptonSouthamptonUnited Kingdom
- Research Department of Infection and Population HealthUniversity College LondonLondonUnited Kingdom
| | - Collins Iwuji
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Research Department of Infection and Population HealthUniversity College LondonLondonUnited Kingdom
- Department of Global Health & InfectionBrighton and Sussex Medical SchoolBrightonUnited Kingdom
| | - Mélanie Plazy
- School of Public Health (ISPED)InsermBordeaux Population Health Research CenterUMR 1219Bordeaux UniversityBordeauxFrance
| | - Rodolphe Thiébaut
- School of Public Health (ISPED)InsermBordeaux Population Health Research CenterUMR 1219Bordeaux UniversityBordeauxFrance
| | - Frank Tanser
- Africa Health Research InstituteSchool of Nursing and Public HealthUniversity of KwaZulu‐NatalKwaZulu‐NatalSouth Africa
| | - Till Bärnighausen
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Department of Global Health & PopulationHarvard School of Public HealthHarvard UniversityBostonUSA
- Faculty of MedicineInstitute of Public HealthHeidelberg UniversityHeidelbergGermany
| | - Joanna Orne‐Gliemann
- School of Public Health (ISPED)InsermBordeaux Population Health Research CenterUMR 1219Bordeaux UniversityBordeauxFrance
| | - Deenan Pillay
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Division of Infection and ImmunityUniversity College LondonLondonUnited Kingdom
| | - François Dabis
- School of Public Health (ISPED)InsermBordeaux Population Health Research CenterUMR 1219Bordeaux UniversityBordeauxFrance
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Space-time clustering of recently-diagnosed tuberculosis and impact of ART scale-up: Evidence from an HIV hyper-endemic rural South African population. Sci Rep 2019; 9:10724. [PMID: 31341191 PMCID: PMC6656755 DOI: 10.1038/s41598-019-46455-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 06/28/2019] [Indexed: 12/26/2022] Open
Abstract
In HIV hyperendemic sub-Saharan African communities, particularly in southern Africa, the likelihood of achieving the Sustainable Development Goal of ending the tuberculosis (TB) epidemic by 2030 is low, due to lack of cost-effective and practical interventions in population settings. We used one of Africa’s largest population-based prospective cohorts from rural KwaZulu-Natal Province, South Africa, to measure the spatial variations in the prevalence of recently-diagnosed TB disease, and to quantify the impact of community coverage of antiretroviral therapy (ART) on recently-diagnosed TB disease. We collected data on TB disease episodes from a population-based sample of 41,812 adult individuals between 2009 and 2015. Spatial clusters (‘hotspots’) of recently-diagnosed TB were identified using a space-time scan statistic. Multilevel logistic regression models were fitted to investigate the relationship between community ART coverage and recently-diagnosed TB. Spatial clusters of recently-diagnosed TB were identified in a region characterized by a high prevalence of HIV and population movement. Every percentage increase in ART coverage was associated with a 2% decrease in the odds of recently-diagnosed TB (aOR = 0.98, 95% CI:0.97–0.99). We identified for the first time the clear occurrence of recently-diagnosed TB hotspots, and quantified potential benefit of increased community ART coverage in lowering tuberculosis, highlighting the need to prioritize the expansion of such effective population interventions targeting high-risk areas.
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17
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Chimukangara B, Kharsany AB, Lessells RJ, Naidoo K, Rhee SY, Manasa J, Gräf T, Lewis L, Cawood C, Khanyile D, Diallo K, Ayalew KA, Shafer RW, Hunt G, Pillay D, Abdool SK, de Oliveira T. Moderate-to-High Levels of Pretreatment HIV Drug Resistance in KwaZulu-Natal Province, South Africa. AIDS Res Hum Retroviruses 2019; 35:129-138. [PMID: 30430843 DOI: 10.1089/aid.2018.0202] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
There is evidence of increasing levels of pretreatment HIV drug resistance (PDR) in Southern Africa. We used data from two large population-based HIV surveillance studies to estimate prevalence of PDR in KwaZulu-Natal, the province with the highest HIV prevalence in South Africa. Sanger sequencing was performed on samples obtained from a longitudinal HIV surveillance program (study A, 2013-2014) and the HIV Incidence Provincial Surveillance System (study B, 2014-2015). Sequences were included for adult HIV positive participants (age ≥15 years for study A, age 15-49 years for study B) with no documented prior exposure to antiretroviral therapy (ART). Overall and drug class-specific PDR was estimated using the World Health Organization 2009 surveillance drug resistance mutation (SDRM) list, and phylogenetic analysis was performed to establish evidence of drug resistance transmission linkage. A total of 1,845 sequences were analyzed (611 study A; 1,234 study B). An overall PDR prevalence of 9.2% [95% confidence interval (CI) 7.0-11.7] was observed for study A and 11.0% (95% CI 8.9-13.2) for study B. In study B, the prevalence of non-nucleoside reverse-transcriptase inhibitor (NNRTI) PDR exceeded 10% for sequences collected in 2014 (10.2%, 95% CI 7.5-12.9). The most prevalent SDRMs were K103NS (7.5%), M184VI (2.4%), and V106AM (1.4%). There was no evidence of large transmission chains of drug-resistant virus. High level NNRTI PDR (>10%) suggests a need to modify the standard first-line ART regimen and to focus attention on improving the quality of HIV prevention, treatment, and care.
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Affiliation(s)
- Benjamin Chimukangara
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Virology, National Health Laboratory Service, University of KwaZulu-Natal, Durban, South Africa
| | - Ayesha B.M. Kharsany
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Richard J. Lessells
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Soo-Yon Rhee
- Department of Medicine, Stanford University, Stanford, California
| | - Justen Manasa
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Tiago Gräf
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Lara Lewis
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Cherie Cawood
- Epicentre AIDS Risk Management (Pty) Limited, Paarl, Cape Town, South Africa
| | - David Khanyile
- Epicentre AIDS Risk Management (Pty) Limited, Paarl, Cape Town, South Africa
| | - Karidia Diallo
- Centers for Disease Control and Prevention (CDC), Pretoria, South Africa
| | - Kassahun A. Ayalew
- Centers for Disease Control and Prevention (CDC), Pretoria, South Africa
| | - Robert W. Shafer
- Department of Medicine, Stanford University, Stanford, California
| | - Gillian Hunt
- Centre for HIV and STIs, National Institute for Communicable Diseases (NICD), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Deenan Pillay
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - Salim Karim Abdool
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Tulio de Oliveira
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
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Hontelez JAC, Bor J, Tanser FC, Pillay D, Moshabela M, Bärnighausen T. HIV Treatment Substantially Decreases Hospitalization Rates: Evidence From Rural South Africa. Health Aff (Millwood) 2019; 37:997-1004. [PMID: 29863928 DOI: 10.1377/hlthaff.2017.0820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The effect of HIV treatment on hospitalization rates for HIV-infected people has never been established. We quantified this effect in a rural South African community for the period 2009-13. We linked clinical data on HIV treatment start dates for more than 2,000 patients receiving care in the public-sector treatment program with five years of longitudinal data on self-reported hospitalizations from a community-based population cohort of more than 100,000 adults. Hospitalization rates peaked during the first year of treatment and were about five times higher, compared to hospitalization rates after four years on treatment. Earlier treatment initiation could save more than US$300,000 per 1,000 patients over the first four years of HIV treatment, freeing up scarce resources. Future studies on the cost-effectiveness of HIV treatment should include these effects.
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Affiliation(s)
- Jan A C Hontelez
- Jan A. C. Hontelez ( ) is an assistant professor at Erasmus University Medical Center, in Rotterdam, the Netherlands, and at the Heidelberg Institute of Public Health, Heidelberg University, in Germany
| | - Jacob Bor
- Jacob Bor is an assistant professor in the Departments of Global Health and Epidemiology, Boston University School of Public Health, in Massachusetts
| | - Frank C Tanser
- Frank C. Tanser is a professor of epidemiology at the University of KwaZulu-Natal and senior faculty member of the Africa Health Research Institute. He also holds an honorary professorship in the Research Department of Infection and Population Health, University College London, and is a research associate of the Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal
| | - Deenan Pillay
- Deenan Pillay is director of the Africa Health Research Institute
| | - Mosa Moshabela
- Mosa Moshabela is head of the Department of Rural Health, University of KwaZulu-Natal, and a senior researcher at the Africa Health Research Institute
| | - Till Bärnighausen
- Till Bärnighausen is the Alexander von Humboldt University Professor and director of the Heidelberg Institute of Public Health, Heidelberg University. He is also senior faculty at the Africa Health Research Institute in Somkhele, South Africa, and an adjunct professor of global health at the Harvard T. H. Chan School of Public Health, in Boston
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Rochat TJ, Houle B, Stein A, Pearson RM, Newell ML, Bland RM. Cohort Profile: The Siyakhula Cohort, rural South Africa. Int J Epidemiol 2018; 46:1755-1756n. [PMID: 29025088 PMCID: PMC5837732 DOI: 10.1093/ije/dyx148] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- T J Rochat
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa.,Human and Social Development Research Programme, Human Sciences Research Council, Durban, South Africa.,MRC Developmental Pathways to Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Psychiatry, University of Oxford, Oxford, UK
| | - B Houle
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,School of Demography, Australian National University, Canberra, Australia.,Institute of Behavioural Science, University of Colorado at Boulder, Boulder, CO, USA
| | - A Stein
- Department of Psychiatry, University of Oxford, Oxford, UK.,MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - R M Pearson
- Department of Psychiatry, University of Oxford, Oxford, UK.,Centre for Academic Mental Health, University of Bristol, Bristol, UK
| | - M L Newell
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,Global Health Research Institute, Human Development and Health, University of Southampton, UK
| | - R M Bland
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,Institute of Health and Wellbeing and Royal Hospital for Children, University of Glasgow, Glasgow, UK
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Treffry-Goatley A, Lessells RJ, Moletsane R, de Oliveira T, Gaede B. Community engagement with HIV drug adherence in rural South Africa: a transdisciplinary approach. MEDICAL HUMANITIES 2018; 44:239-246. [PMID: 30482816 PMCID: PMC6288689 DOI: 10.1136/medhum-2018-011474] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/09/2018] [Indexed: 05/22/2023]
Abstract
Digital storytelling (DST) is an emerging participatory visual method which combines storytelling traditions with computer and video production technology. In this project, at the heart of the HIV epidemic in KwaZulu-Natal, South Africa, we used DST to create a culturally grounded community engagement intervention. Our aim was to use narratives of people living with HIV on antiretroviral therapy (ART) to stimulate dialogue among the wider community and to encourage reflection on the contextual factors that influence ART adherence in this setting. We also wanted to explore whether exposure to the personal narratives might influence health literacy around HIV and ART. We ran two DST workshops, where 20 community participants were supported to create short digital stories about personal experiences of adherence. We then hosted 151 screenings of the digital stories at seven local health facilities and evaluated the impact of the intervention using a three-tiered mixed methods approach. We conducted two independent quantitative surveys of healthcare users (852 respondents during the preintervention round and 860 people during the postintervention round), five focus group discussions and observation of practice. Exposure to the digital stories did stimulate rich dialogue among community members, which broadened from the focus on ART adherence to other aspects around the impact of HIV and its treatment on individuals and the community. In the independently conducted surveys, we found no clear difference in knowledge or understanding of HIV and ART between the people exposed to the digital stories and those who were not exposed. Our findings provide support for the use of DST as an engagement intervention, but highlight some of the challenges in delivering this type of intervention and in evaluating the impact of this approach.
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Affiliation(s)
- Astrid Treffry-Goatley
- Centre for Visual Methodologies for Social Change, University of KwaZulu-Natal School of Education, Durban, South Africa
- African Health Research Institute, Durban, South Africa
| | - Richard John Lessells
- KwaZulu-Natal Research and Innovation Sequencing Platform (KRISP), School of Laboratory Medicine and Medical Science, College of Health Science, University of KwaZulu-Natal, Durban, South Africa
- Centre for the Aids Programme of Research in South Africa, Durban, South Africa
| | - Relebohile Moletsane
- Centre for Visual Methodologies for Social Change, University of KwaZulu-Natal, Durban, South Africa
| | - Tulio de Oliveira
- KwaZulu-Natal Research and Innovation Sequencing Platform (KRISP), School of Laboratory Medicine and Medical Science, College of Health Science, University of KwaZulu-Natal, Durban, South Africa
- Centre for the Aids Programme of Research in South Africa, Durban, South Africa
| | - Bernhard Gaede
- Family Medicine, University of KwaZulu-Natal, Durban, South Africa
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Tlou B, Sartorius B, Tanser F. Investigating risk factors for under-five mortality in an HIV hyper-endemic area of rural South Africa, from 2000-2014. PLoS One 2018; 13:e0207294. [PMID: 30475818 PMCID: PMC6261054 DOI: 10.1371/journal.pone.0207294] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/29/2018] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Despite global progress, there remains a disproportionate burden of under-five year old deaths in sub-Saharan Africa (SSA), where four out of five child deaths occur. Substantial progress has been made in improving sanitation, controlling communicable diseases and the spread of HIV in most parts of the world. However, significant strides to address some key risk factors related to under-five mortality are still needed in rural SSA if they are to attain relevant 2030 SDG targets. The aim of this study is to investigate the risk factors for under-five mortality in an HIV hyper-endemic area of rural South Africa, from 2000-2014. Some of the key risk factors investigated are, for example: household wealth, source of drinking water, distance to the national road and birth order. METHODS We conducted a statistical analysis of 759 births from a population-based cohort in rural KwaZulu-Natal Province, South Africa, from 2000 to 2014. A Cox Proportional Hazards model was used to identify the risk factors and key socio-demographic correlates of under-five mortality leveraging the longitudinal structure of the population cohort. RESULTS Child mortality rates declined by 80 per cent from 2000 to 2014, from >140 per 1,000 persons in years 2001-2003 to 20 per 1,000 persons in the year 2014. The highest under-five mortality rate was recorded in 2002/2003, which decreased following the start of antiretroviral therapy rollout in 2003/4. The results indicated that under-five and infant mortality are significantly associated with a low wealth index of 1.49 (1.007-2.48) for under-fives and 3.03 (1.72-5.34) for infants. Children and infants with a lower wealth index had a significantly increased risk of mortality as compared to those with a high wealth index. Other significant factors included: source of household drinking water (borehole) 3.03 (1.72-5.34) for under-fives and 2.98 (1.62-5.49) for infants; having an HIV positive mother 4.22 (2.68-6.65) for under-fives and 3.26 (1.93-5.51) for infants, and period of death 9.13 (5.70-14.6) for under-fives and 1.28 (0.75-2.20) for infants. Wealth index had the largest population attributable fraction of 25.4 per cent. CONCLUSIONS The research findings show a substantial overall reduction in under-five mortality since 2003. Unsafe household water sources and having an HIV-positive mother were associated with an increased risk of under-five mortality in this rural setting. The significant risk factors identified align well with the SDG 2030 targets for reducing child mortality, which include improved nutrition, sanitation, hygiene and reduced HIV infections. Current trajectories suggest that there is some hope for meeting the 2030 SGD targets in rural South Africa and the region if the identified significant risk factors are adequately addressed.
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Affiliation(s)
- B. Tlou
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - B. Sartorius
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - F. Tanser
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Centre for the AIDS Programme of Research in South Africa—CAPRISA, University of KwaZulu-Natal, Congella, South Africa
- Research Department of Infection and Population Health, University College London, London, United Kingdom
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"If you are here at the clinic, you do not know how many people need help in the community": Perspectives of home-based HIV services from health care workers in rural KwaZulu-Natal, South Africa in the era of universal test-and-treat. PLoS One 2018; 13:e0202473. [PMID: 30412926 PMCID: PMC6226311 DOI: 10.1371/journal.pone.0202473] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 08/03/2018] [Indexed: 12/21/2022] Open
Abstract
Background Limited engagement in clinic-based care is affecting the HIV response. We explored the field experiences and perceptions of local health care workers regarding home-based strategies as opportunities to improve the cascade of care of people living with HIV in rural South Africa as part of a Universal Test-and-Treat approach. Methods In Hlabisa sub-district, home-based HIV services, including rapid HIV testing and counselling, and support for linkage to and retention in clinic-based HIV care, were implemented by health care workers within the ANRS 12249 Treatment-as-Prevention (TasP) trial. From April to July 2016, we conducted a mixed-methods study among health care workers from the TasP trial and from local government clinics, using self-administrated questionnaires (n = 90 in the TasP trial, n = 56 in government clinics), semi-structured interviews (n = 13 in the TasP trial, n = 5 in government clinics) and three focus group discussions (n = 6–10 health care workers of the TasP trial per group). Descriptive statistics were used for quantitative data and qualitative data were analysed thematically. Results More than 90% of health care workers assessed home-based testing and support for linkage to care as feasible and acceptable by the population they serve. Many health care workers underlined how home visits could facilitate reaching people who had slipped through the cracks of the clinic-based health care system and encourage them to successfully access care. Health care workers however expressed concerns about the ability of home-based services to answer the HIV care needs of all community members, including people working outside their home during the day or those who fear HIV-related stigmatization. Overall, health care workers encouraged policy-makers to more formally integrate home-based services in the local health system. They promoted reshaping the disease-specific and care-oriented services towards more comprehensive goals. Conclusion Because home-based services allow identification of people early during their infection and encourage them to take actions leading to viral suppression, HCWs assessed them as valuable components within the panel of UTT interventions, aiming to reach the 90-90-90 UNAIDS targets, especially in the rural Southern African region. Trial registration The registration number of the ANRS 12249 TasP trial on ClinicalTrials.gov is NCT01509508.
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Oldenburg CE, Seage GR, Tanser F, De Gruttola V, Mayer KH, Mimiaga MJ, Bor J, Bärnighausen T. Antiretroviral Therapy and Mortality in Rural South Africa: A Comparison of Causal Modeling Approaches. Am J Epidemiol 2018; 187:1772-1779. [PMID: 29584868 PMCID: PMC6070080 DOI: 10.1093/aje/kwy065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 03/15/2018] [Indexed: 11/22/2022] Open
Abstract
Estimation of causal effects from observational data is a primary goal of epidemiology. The use of multiple methods with different assumptions relating to exchangeability improves causal inference by demonstrating robustness across assumptions. We estimated the effect of antiretroviral therapy (ART) on mortality in rural KwaZulu-Natal, South Africa, from 2007 to 2011, using 2 methods with substantially different assumptions: the regression discontinuity design (RDD) and inverse-probability–weighted (IPW) marginal structural models (MSMs). The RDD analysis took advantage of a CD4-cell-count–based threshold for ART initiation (200 cells/μL). The 2 methods yielded consistent but nonidentical results for the effect of immediate initiation of ART (RDD intention-to-treat hazard ratio (HR) = 0.66, 95% confidence interval (CI): 0.35, 1.26; RDD complier average causal effect HR = 0.56, 95% CI: 0.41, 0.77; IPW MSM HR = 0.49, 95% CI: 0.42, 0.58). Although RDD and IPW MSM estimates have distinct identifying assumptions, strengths, and limitations in terms of internal and external validity, results in this application were similar. The differences in modeling approaches and the external validity of each method may explain the minor differences in effect estimates. The overall consistency of the results lends support for causal inference about the effect of ART on mortality from these data.
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Affiliation(s)
- Catherine E Oldenburg
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - George R Seage
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Frank Tanser
- Africa Health Research Institute, Durban and Somkhele, South Africa
- Department of Epidemiology, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Victor De Gruttola
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Kenneth H Mayer
- The Fenway Institute, Fenway Community Health, Boston, Massachusetts
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Matthew J Mimiaga
- Department of Behavioral and Social Sciences and Department of Epidemiology, Institute for Community Health Promotion, School of Public Health, Brown University, Providence, Rhode Island
| | - Jacob Bor
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts
| | - Till Bärnighausen
- Africa Health Research Institute, Durban and Somkhele, South Africa
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Research Department of Infection and Population Health, Centre for Sexual Health, University College London, London, United Kingdom
- Heidelberg Institute of Public Health, University of Heidelberg, Heidelberg, Germany
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Tanser F, Vandormael A, Cuadros D, Phillips AN, de Oliveira T, Tomita A, Bärnighausen T, Pillay D. Effect of population viral load on prospective HIV incidence in a hyperendemic rural African community. Sci Transl Med 2018; 9:9/420/eaam8012. [PMID: 29237762 DOI: 10.1126/scitranslmed.aam8012] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/14/2017] [Accepted: 08/21/2017] [Indexed: 01/11/2023]
Abstract
Monitoring HIV population viral load (PVL) has been advocated as an important means of inferring HIV transmission potential and predicting the future rate of new HIV infections (HIV incidence) in a particular community. However, the relationship between PVL measures and directly measured HIV incidence has not been quantified in any setting and, most importantly, in a hyperendemic sub-Saharan African setting. We assessed this relationship using one of Africa's largest population-based prospective population cohorts in rural KwaZulu-Natal, South Africa in which we followed 8732 HIV-uninfected participants between 2011 and 2015. Despite clear evidence of spatial clustering of high viral loads in some communities, our results demonstrate that PVL metrics derived from aggregation of viral load data only from the HIV-positive members of a particular community did not predict HIV incidence in this typical hyperendemic, rural African population. Only once we used modified PVL measures, which combined viral load information with the underlying spatial variation in the proportion of the population infected (HIV prevalence), did we find a consistently strong relationship with future risk of HIV acquisition. For example, every 1% increase in the overall proportion of a population having detectable virus (PDV P ) was independently associated with a 6.3% increase in an individual's risk of HIV acquisition (P = 0.001). In hyperendemic African populations, these modified PVL indices could play a key role in targeting and monitoring interventions in the most vulnerable communities where the future rate of new HIV infections is likely to be highest.
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Affiliation(s)
- Frank Tanser
- Africa Health Research Institute, Durban 4001, South Africa. .,School of Nursing and Public Health, University of KwaZulu-Natal, Durban 4001, South Africa.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban 4001, South Africa.,Research Department of Infection and Population Health, University College London, London WC1E 6JB, UK
| | - Alain Vandormael
- Africa Health Research Institute, Durban 4001, South Africa.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban 4001, South Africa.,KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban 4001, South Africa
| | - Diego Cuadros
- Department of Geography and Geographic Information Science, University of Cincinnati, Cincinnati, OH 45220, USA
| | - Andrew N Phillips
- Institute for Global Health, University College London, London WC1E 6JB, UK
| | - Tulio de Oliveira
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban 4001, South Africa.,KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban 4001, South Africa.,School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban 4001, South Africa
| | - Andrew Tomita
- Africa Health Research Institute, Durban 4001, South Africa.,KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban 4001, South Africa.,Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban 4001, South Africa
| | - Till Bärnighausen
- Africa Health Research Institute, Durban 4001, South Africa.,Research Department of Infection and Population Health, University College London, London WC1E 6JB, UK.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02138, USA.,Heidelberg Institute for Public Health, University of Heidelberg, Heidelberg 69117, Germany
| | - Deenan Pillay
- Africa Health Research Institute, Durban 4001, South Africa.,Division of Infection and Immunity, University College London, London WC1E 6JB, UK
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Kluberg SA, Fox MP, LaValley M, Pillay D, Bärnighausen T, Bor J. Do HIV treatment eligibility expansions crowd out the sickest? Evidence from rural South Africa. Trop Med Int Health 2018; 23:968-979. [PMID: 29947442 PMCID: PMC6175239 DOI: 10.1111/tmi.13122] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Objective The 2015 WHO recommendation to initiate all HIV patients on antiretroviral therapy (ART) at diagnosis could potentially overextend health systems and crowd out sicker patients, mitigating the policy's impact. We evaluate whether South Africa's prior eligibility expansion from CD4 ≤ 200 to CD4 ≤ 350 cells/μl reduced ART uptake in the sickest patients. Methods Using data on all patients presenting to the Hlabisa HIV Treatment and Care Programme in KwaZulu‐Natal from April 2010 to June 2012 (n = 13 809), we assessed the impact of the August 2011 eligibility expansion on the number of patients seeking care, number initiating ART and time from HIV diagnosis to ART initiation among patients always eligible (CD4 0–200), newly eligible (CD4 201–350) and not yet eligible by CD4 count (>350). We used interrupted time series methods to control for long‐run trends and isolate the effect of the policy. Results Expanding ART eligibility led to an increased number of patients initiating ART per month [+95.5; 95% CI (−1.3; 192.3)]. Newly eligible patients (CD4 201–350) initiated treatment 47% faster than before (95% CI 19%; 82%), while the sickest patients (CD4 ≤ 200) saw no decline in the monthly number of patients initiating treatment or the rate of treatment uptake. Conclusion The Hlabisa programme successfully extended ART to patients with CD4 ≤ 350 cells/μl, while ensuring that the sickest patients did not experience delays in ART initiation. Treatment programmes must be vigilant to maintain quality of care for the sickest as countries move to treat all patients irrespective of CD4 count.
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Affiliation(s)
- Sheryl A Kluberg
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Michael LaValley
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Deenan Pillay
- Africa Health Research Institute, Durban and Somkhele, KwaZulu-Natal, South Africa.,Division of Infection and Immunity, University College London, London, UK
| | - Till Bärnighausen
- Africa Health Research Institute, Durban and Somkhele, KwaZulu-Natal, South Africa.,Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - Jacob Bor
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Africa Health Research Institute, Durban and Somkhele, KwaZulu-Natal, South Africa
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Larmarange J, Diallo MH, McGrath N, Iwuji C, Plazy M, Thiébaut R, Tanser F, Bärnighausen T, Pillay D, Dabis F, Orne‐Gliemann J. The impact of population dynamics on the population HIV care cascade: results from the ANRS 12249 Treatment as Prevention trial in rural KwaZulu-Natal (South Africa). J Int AIDS Soc 2018; 21 Suppl 4:e25128. [PMID: 30027600 PMCID: PMC6053480 DOI: 10.1002/jia2.25128] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 05/17/2018] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION The universal test and treat strategy (UTT) was developed to maximize the proportion of all HIV-positive individuals on antiretroviral treatment (ART) and virally suppressed, assuming that it will lead to a reduction in HIV incidence at the population level. The evolution over time of the cross-sectional HIV care cascade is determined by individual longitudinal trajectories through the HIV care continuum and underlying population dynamics. The purpose of this paper is to quantify the contribution of each component of population change (in- and out-migration, HIV seroconversion, ageing into the cohort and definitive exit such as death) on the HIV care cascade in the context of the ANRS 12249 Treatment as Prevention (TasP) cluster-randomized trial, investigating UTT in rural KwaZulu-Natal, South Africa, between 2012 and 2016. METHODS HIV test results and information on clinic visits, ART prescriptions, viral load and CD4 count, migration and deaths were used to calculate residency status, HIV status and HIV care status for each individual on a daily basis. Position within the HIV care continuum was considered as a score ranging from 0 (undiagnosed) to 4 (virally suppressed). We compared the cascade score of each individual joining or leaving the population of resident adults living with HIV with the average score of their cluster at the time of entry or exit. Then, we computed the contribution of each entry or exit on the average cascade score and their annualized total contribution, by component of change. RESULTS While the average cascade score increased over time in all clusters, that increase was constrained by population dynamics. Permanent exits and ageing into the people living with HIV cohort had a marginal effect. Both in-migrants and out-migrants were less likely to be retained at each step of the HIV care continuum. However, their overall impact on the cross-sectional cascade was limited as the effect of in- and out-migration balanced each other. The contribution of HIV seroconversions was negative in all clusters. CONCLUSIONS In a context of high HIV incidence, the continuous flow of newly infected individuals slows down the efforts to increase ART coverage and population viral suppression, ultimately attenuating any population-level impact on HIV incidence. CLINICAL TRIAL NUMBER NCT01509508 (clinicalTrials.gov)/DOH-27-0512-3974 (South African National Clinical Trials Register).
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Affiliation(s)
- Joseph Larmarange
- Centre Population et DéveloppementInstitut de Recherche pour le DéveloppementUniversité Paris DescartesInsermParisFrance
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
| | - Mamadou Hassimiou Diallo
- Centre Population et DéveloppementInstitut de Recherche pour le DéveloppementUniversité Paris DescartesInsermParisFrance
| | - Nuala McGrath
- School of Nursing and Public HealthAfrica Health Research InstituteUniversity of KwaZulu‐NatalKwaZulu‐NatalSouth Africa
- Faculty of Medicine and Faculty of Social, Human and Mathematical SciencesUniversity of SouthamptonSouthamptonUK
- Research Department of Infection and Population HealthUniversity College LondonLondonUK
| | - Collins Iwuji
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Research Department of Infection and Population HealthUniversity College LondonLondonUK
- Department of Global Health & InfectionBrighton and Sussex Medical SchoolFalmerBrightonUK
| | - Mélanie Plazy
- ISPEDInsermBordeaux Population Health Research CenterUniversité de BordeauxBordeauxFrance
| | - Rodolphe Thiébaut
- ISPEDInsermBordeaux Population Health Research CenterUniversité de BordeauxBordeauxFrance
| | - Frank Tanser
- School of Nursing and Public HealthAfrica Health Research InstituteUniversity of KwaZulu‐NatalKwaZulu‐NatalSouth Africa
| | - Till Bärnighausen
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Department of Global Health & PopulationHarvard School of Public HealthHarvard UniversityBostonMAUSA
- Institute of Public HealthFaculty of MedicineHeidelberg UniversityHeidelbergGermany
| | - Deenan Pillay
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Division of Infection and ImmunityUniversity College LondonLondonUK
| | - François Dabis
- ISPEDInsermBordeaux Population Health Research CenterUniversité de BordeauxBordeauxFrance
| | - Joanna Orne‐Gliemann
- ISPEDInsermBordeaux Population Health Research CenterUniversité de BordeauxBordeauxFrance
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Chetty T, Thorne C, Coutsoudis A. Preterm delivery and small-for-gestation outcomes in HIV-infected pregnant women on antiretroviral therapy in rural South Africa: Results from a cohort study, 2010-2015. PLoS One 2018; 13:e0192805. [PMID: 29470508 PMCID: PMC5823389 DOI: 10.1371/journal.pone.0192805] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 01/30/2018] [Indexed: 11/24/2022] Open
Abstract
Objectives Increasingly more women conceive on antiretroviral therapy (ART) with non-nucleoside reverse transcriptase-based regimens. This study assessed the effect of preconception tenofovir disoproxil fumarate (TDF)-lamivudine (3TC)/emtricitabine (FTC)-efavirenz (EFV) and post-conception TDF-(3TC/FTC)-EFV (versus other regimens) on preterm delivery (PTD) and small-for-gestational age (SGA) births. Methods We analysed data of 2549 HIV-infected women attending antenatal clinics in KwaZulu-Natal from 2010 through 2015 in this retrospective cohort study. Preconception, TDF-(3TC/FTC)-EFV was compared to nevirapine (NVP)-based regimens and other 3-drug EFV-based regimens. Post-conception, TDF-(3TC/FTC)-EFV was compared to NVP-based ART and zidovudine (ZDV) prophylaxis. Outcomes included PTD <37 weeks and SGA births. Generalized linear mixed effects were used to fit logistic regression models to account for repeat pregnancies. Results Among 2549 singleton live births, 10.4% (n = 264) were PTD and 10.4% (n = 265) SGA. PTD declined from 16.3% in 2010 to 9.3% in 2015 and SGA remained stable from 9.9% in 2010 to 10% in 2015. Preconception NVP-based regimens [adjusted odds ratio (aOR) 0.66; 95% CI 0.27–1.63] and other 3-drug EFV-based regimens (aOR 0.72; 95% CI 0.24–2.12) were not associated with PTD versus TDF-(3TC/FTC)-EFV. NVP-based (aOR 0.75; 95% CI 0.40–1.42) and other 3-drug EFV-based regimens (aOR 1.55; 95% CI 0.76–3.16) were not associated with SGA births versus TDF-(3TC/FTC)-EFV. Post-conception NVP-based ART (1.77; 95% CI 0.89–3.51) and ZDV (1.03; 95% CI 0.68–1.58) were not associated with PTD versus TDF-(3TC/FTC)-EFV. NVP-based ART (1.55; 95% CI 0.66–3.61) and ZDV (0.89; 95% CI 0.53–1.47) were not associated with SGA versus TDF-(3TC/FTC)-EFV. Conclusions Preconception TDF-(3TC/FTC)-EFV and post-conception TDF-(3TC/FTC)-EFV were not associated with PTD or SGA, compared with other regimens. Increasing ART use merits further study of the optimum ART regimen for safe birth outcomes.
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Affiliation(s)
- Terusha Chetty
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
- * E-mail:
| | - Claire Thorne
- UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Anna Coutsoudis
- Department of Paediatrics and Child Health, School of Clinical Medicine, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
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Mkwanazi NB, Rochat TJ, Bland RM. Living with HIV, disclosure patterns and partnerships a decade after the introduction of HIV programmes in rural South Africa. AIDS Care 2018; 27 Suppl 1:65-72. [PMID: 26616127 PMCID: PMC4697196 DOI: 10.1080/09540121.2015.1028881] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Prevention of mother-to-child Transmission and HIV Treatment programmes were scaled-up in resource-constrained settings over a decade ago, but there is still much to be understood about women's experiences of living with HIV and their HIV disclosure patterns. This qualitative study explored women's experiences of living with HIV, 6–10 years after being diagnosed during pregnancy. The area has high HIV prevalence, and an established HIV treatment programme. Participants were enrolled in a larger intervention, “Amagugu”, that supported women (n = 281) to disclose their HIV status to their children. Post-intervention we conducted individual in-depth interviews with 20 randomly selected women, stratified by clinic catchment area, from the total sample. Interviews were entered into ATLAS.ti computer software for coding. Most women were living with their current sexual partner and half were still in a relationship with the child's biological father. Household exposure to HIV was high with the majority of women knowing at least one other HIV-infected adult in their household. Eighteen women had disclosed their HIV status to another person; nine had disclosed to their current partner first. Two main themes were identified in the analyses: living with HIV and the normalisation of HIV treatment at a family level; and the complexity of love relationships, in particular in long-term partnerships. A decade on, most women were living positively with HIV, accessing care, and reported experiencing little stigma. However, as HIV became normalised new challenges arose including concerns about access to quality care, and the need for family-centred care. Women's sexual choices and relationships were intertwined with feelings of love, loyalty and trust and the important supportive role played by partners and families was acknowledged, however, some aspects of living with HIV presented challenges including continuing to practise safe sex several years after HIV diagnosis.
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Affiliation(s)
- Ntombizodumo B Mkwanazi
- a Africa Centre for Health and Population Studies , University of KwaZulu-Natal , Durban , South Africa.,b School of Public Health, Faculty of Health Sciences , University of Witwatersrand , Johannesburg , South Africa
| | - Tamsen J Rochat
- a Africa Centre for Health and Population Studies , University of KwaZulu-Natal , Durban , South Africa.,c Section of Child and Adolescent Psychiatry, Department of Psychiatry , Oxford University , Oxford , UK
| | - Ruth M Bland
- a Africa Centre for Health and Population Studies , University of KwaZulu-Natal , Durban , South Africa.,b School of Public Health, Faculty of Health Sciences , University of Witwatersrand , Johannesburg , South Africa.,d Royal Hospital for Sick Children, University of Glasgow , Glasgow , UK
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29
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Bor J, Chiu C, Ahmed S, Katz I, Fox MP, Rosen S, Yapa M, Tanser F, Pillay D, Bärnighausen T. Failure to initiate HIV treatment in patients with high CD4 counts: evidence from demographic surveillance in rural South Africa. Trop Med Int Health 2018; 23:206-220. [PMID: 29160949 PMCID: PMC5829292 DOI: 10.1111/tmi.13013] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To assess the relationship between CD4 count at presentation and ART uptake and assess predictors of timely treatment initiation in rural KwaZulu-Natal, South Africa. METHODS We used Kaplan-Meier and Cox proportional hazards models to assess the association between first CD4 count and time from first CD4 to ART initiation among all adults presenting to the Hlabisa HIV Treatment and Care Programme between August 2011 and December 2012 with treatment-eligible CD4 counts (≤ 350 cells/mm3 ). For a subset of healthier patients (200 < CD4 ≤ 350 cells) residing within the population surveillance of the Africa Health Research Institute, we assessed sociodemographic, economic and geographic predictors hypothesised to influence ART uptake. RESULTS A total of 4739 patients presented for care with eligible CD4 counts. The proportion initiating ART within six months of diagnosis was 67% (95% CI 63, 71) in patients with CD4 ≤ 50, 59% (0.55, 0.63) in patients with CD4 151-200 and 48% (95% CI 44, 51) in patients with CD4 301-350. The hazard of starting ART fell by 17% (95% CI 14, 20) for every 100-cell increase in baseline CD4 count. Among healthier patients under demographic surveillance (n = 193), observable sociodemographic, economic and geographic predictors did not add discriminatory power beyond CD4 count, age and sex to identify patients at high risk of non-initiation. CONCLUSIONS Individuals presenting for HIV care at higher CD4 counts were less likely to initiate ART than patients presenting at low CD4 counts. Overall, ART uptake was low. Under new guidelines that establish ART eligibility regardless of CD4 count, patients with high CD4 counts may require additional interventions to encourage treatment initiation.
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Affiliation(s)
- Jacob Bor
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Calvin Chiu
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shahira Ahmed
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Ingrid Katz
- Division of Women's Health, Brigham and Women's Hospital, Boston, MA, USA
- Center for Global Health, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Matthew P Fox
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Manisha Yapa
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Frank Tanser
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Research Department of Infection & Population Health, University College London, London, United Kingdom
| | - Deenan Pillay
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Virology, University College London, London, United Kingdom
| | - Till Bärnighausen
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Research Department of Infection & Population Health, University College London, London, United Kingdom
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
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30
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Gabert R, Ng M, Sogarwal R, Bryant M, Deepu RV, McNellan CR, Mehra S, Phillips B, Reitsma M, Thomson B, Wilson S, Wollum A, Gakidou E, Duber HC. Identifying gaps in the continuum of care for hypertension and diabetes in two Indian communities. BMC Health Serv Res 2017; 17:846. [PMID: 29282052 PMCID: PMC5746011 DOI: 10.1186/s12913-017-2796-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 12/13/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Non-communicable diseases (NCDs) represent the largest, and fastest growing, burden of disease in India. This study aimed to quantify levels of diagnosis, treatment, and control among hypertensive and diabetic patients, and to describe demand- and supply-side barriers to hypertension and diabetes diagnosis and care in two Indian districts, Shimla and Udaipur. METHODS We conducted household and health facility surveys, as well as qualitative focus group discussions and interviews. The household survey randomly sampled individuals aged 15 and above in rural and urban areas in both districts. The survey included questions on NCD knowledge, history, and risk factors. Blood pressure, weight, height, and blood glucose measurements were obtained. The health facility survey was administered in 48 health care facilities, focusing on NCD diagnosis and treatment capacity, including staffing, equipment, and pharmaceuticals. Qualitative data was collected through semi-structured key informant interviews with health professionals and public health officials, as well as focus groups with patients and community members. RESULTS Among 7181 individuals, 32% either reported a history of hypertension or were found to have a systolic blood pressure ≥ 140 mmHg and/or diastolic ≥90 mmHg. Only 26% of those found to have elevated blood pressure reported a prior diagnosis, and just 42% of individuals with a prior diagnosis of hypertension were found to be normotensive. A history of diabetes or an elevated blood sugar (Random blood glucose (RBG) ≥200 mg/dl or fasting blood glucose (FBG) ≥126 mg/dl) was noted in 7% of the population. Among those with an elevated RBG/FBG, 59% had previously received a diagnosis of diabetes. Only 60% of diabetics on treatment were measured with a RBG <200 mg/dl. Lower-level health facilities were noted to have limited capacity to measure blood glucose as well as significant gaps in the availability of first-line pharmaceuticals for both hypertension and diabetes. CONCLUSIONS We found high rates of uncontrolled diabetes and undiagnosed and uncontrolled hypertension. Lower level health facilities were constrained by capacity to test, monitor and treat diabetes and hypertension. Interventions aimed at improving patient outcomes will need to focus on the expanding access to quality care in order to accommodate the growing demand for NCD services.
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Affiliation(s)
- Rose Gabert
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - Marie Ng
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - Ruchi Sogarwal
- MAMTA Health Institute for Mother and Child, New Delhi, India
| | - Miranda Bryant
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - R V Deepu
- MAMTA Health Institute for Mother and Child, New Delhi, India
| | - Claire R McNellan
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - Sunil Mehra
- MAMTA Health Institute for Mother and Child, New Delhi, India
| | - Bryan Phillips
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - Marissa Reitsma
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - Blake Thomson
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - Shelley Wilson
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - Alexandra Wollum
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - Emmanuela Gakidou
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - Herbert C Duber
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA.
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31
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Chetty T, Newell ML, Thorne C, Coutsoudis A. Viraemia before, during and after pregnancy in HIV-infected women on antiretroviral therapy in rural KwaZulu-Natal, South Africa, 2010-2015. Trop Med Int Health 2017; 23:79-91. [PMID: 29121445 DOI: 10.1111/tmi.13001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Pregnancy and post-partum viral load suppression is critical to prevent mother-to-child HIV transmission and ensure maternal health. We measured viraemia risk before, during and after pregnancy in HIV-infected women. METHODS Between 2010 and 2015, 1425 HIV-infected pregnant women on lifelong antiretroviral therapy (ART) for at least six months pre-pregnancy were enrolled in a cohort study in rural KwaZulu-Natal, South Africa. Odds ratios were estimated in multilevel logistic regression, with pregnancy period time-varying. RESULTS Over half of 1425 women received tenofovir-based regimens (n = 791). Median pre-pregnancy ART duration was 2.1 years. Of 988 women (69.3%) with pre-pregnancy viral loads, 82.0%, 6.8% and 11.2% had VL <50, 50-999 and ≥1000 copies/ml, respectively. During pregnancy and at six, 12 and 24 months, viral load was ≥1000 copies/ml in 15.2%, 15.7%, 17.8% and 16.6% respectively; viral load <50 was 76.9%, 77%, 75.5% and 75.8%, respectively. Adjusting for age, clinical and pregnancy factors, viraemia risk (viral load ≥50 copies/ml) was not significantly associated with pregnancy [adjusted OR (aOR) 1.31; 95% CI 0.90-1.92], six months (aOR 1.30; 95% CI 0.83-2.04), 12 months (aOR 0.96; 95% CI 0.58-1.58) and 24 months (aOR 1.40; 95% CI 0.89-2.22) post-partum. Adjusting for ART duration-pregnancy period interaction, viraemia risk was 1.8 during pregnancy and twofold higher post-partum. CONCLUSIONS While undetectable viral load before pregnancy through post-partum was common, the UNAIDS goal to suppress viraemia in 90% of women was not met. Women on preconception ART remain vulnerable to viraemia; additional support is required to prevent mother-to-child HIV transmission and maintain maternal health.
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Affiliation(s)
- Terusha Chetty
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | - Marie-Louise Newell
- Faculty of Medicine, Institute for Developmental Sciences, University of Southampton, Southampton, UK
| | - Claire Thorne
- UCL Institute of Child Health, University College London, London, UK
| | - Anna Coutsoudis
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
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Vandormael A, de Oliveira T, Tanser F, Bärnighausen T, Herbeck JT. High percentage of undiagnosed HIV cases within a hyperendemic South African community: a population-based study. J Epidemiol Community Health 2017; 72:168-172. [PMID: 29175867 DOI: 10.1136/jech-2017-209713] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 10/18/2017] [Accepted: 10/30/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND Undiagnosed HIV infections could undermine efforts to reverse the global AIDS epidemic by 2030. In this study, we estimated the percentage of HIV-positive persons who remain undiagnosed within a hyperendemic South African community. METHODS The data come from a population-based surveillance system located in the Umkhanyakude district of the northern KwaZulu-Natal province, South Africa. We annually tested 38 661 adults for HIV between 2005 and 2016. Using the HIV-positive test results of 12 039 (31%) participants, we then back-calculated the incidence of infection and derived the number of undiagnosed cases from this result. RESULTS The percentage of undiagnosed HIV cases decreased from 29.3% in 2005 to 15.8% in 2011. During this period, however, approximately 50% of the participants refused to test for HIV, which lengthened the average time from infection to diagnosis. Consequently, the percentage of undiagnosed HIV cases reversed direction and steadily increased from 16.1% to 18.9% over the 2012-2016 period. CONCLUSIONS Results from this hyperendemic South African setting show that the HIV testing rate is low, with long infection times, and an unsatisfactorily high percentage of undiagnosed cases. A high level of repeat HIV testing is needed to minimise the time from infection to diagnosis if the global AIDS epidemic is to be reversed within the next two decades.
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Affiliation(s)
- Alain Vandormael
- Africa Health Research Institute (AHRI), Durban, South Africa.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), University of KwaZulu-Natal, South Africa
| | - Tulio de Oliveira
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), University of KwaZulu-Natal, South Africa.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Frank Tanser
- Africa Health Research Institute (AHRI), Durban, South Africa.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa.,Department of Infection and Population Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Till Bärnighausen
- Africa Health Research Institute (AHRI), Durban, South Africa.,Department of Infection and Population Health, Institute of Epidemiology and Health Care, University College London, London, UK.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Massachusetts, USA.,Heidelberg Institute for Public Health, University of Heidelberg, Heidelberg, Germany
| | - Joshua T Herbeck
- International Clinical Research Center, Department of Global Health, University of Washington, Seattle, Washington, USA
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Plazy M, Perriat D, Gumede D, Boyer S, Pillay D, Dabis F, Seeley J, Orne-Gliemann J. Implementing universal HIV treatment in a high HIV prevalence and rural South African setting - Field experiences and recommendations of health care providers. PLoS One 2017; 12:e0186883. [PMID: 29155832 PMCID: PMC5695789 DOI: 10.1371/journal.pone.0186883] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 10/09/2017] [Indexed: 12/18/2022] Open
Abstract
Background We aimed to describe the field experiences and recommendations of clinic-based health care providers (HCP) regarding the implementation of universal antiretroviral therapy (ART) in rural KwaZulu-Natal, South Africa. Methods In Hlabisa sub-district, the local HIV programme of the Department of Health (DoH) is decentralized in 18 clinics, where ART was offered at a CD4 count ≤500 cells/μL from January 2015 to September 2016. Within the ANRS 12249 TasP trial, implemented in part of the sub-district, universal ART (no eligibility criteria) was offered in 11 mobile clinics between March 2012 and June 2016. A cross-sectional qualitative survey was conducted in April–July 2016 among clinic-based nurses and counsellors providing HIV care in the DoH and TasP trial clinics. In total, 13 individual interviews and two focus groups discussions (including 6 and 7 participants) were conducted, audio-recorded, transcribed, and thematically analyzed. Results All HCPs reported an overall good experience of delivering ART early in the course of HIV infection, with most patients willing to initiate ART before being symptomatic. Yet, HCPs underlined that not feeling sick could challenge early ART initiation and adherence, and thus highlighted the need to take time for counselling as an important component to achieve universal ART. HCPs also foresaw logistical challenges of universal ART, and were especially concerned about increasing workload and ART shortage. HCPs finally recommended the need to strengthen the existing model of care to facilitate access to ART, e.g., community-based and integrated HIV services. Conclusions The provision of universal ART is feasible and acceptable according to HCPs in this rural South-African area. However their experiences suggest that universal ART, and more generally the 90-90-90 UNAIDS targets, will be difficult to achieve without the implementation of new models of health service delivery.
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Affiliation(s)
- Melanie Plazy
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
- Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
- * E-mail:
| | - Delphine Perriat
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
- Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
| | - Dumile Gumede
- Africa Health Research Institute, Somkhele, South Africa
| | - Sylvie Boyer
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France
| | - Deenan Pillay
- Africa Health Research Institute, Somkhele, South Africa
- University College London, Division of Infection and Immunity, London, United Kingdom
| | - François Dabis
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
- Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
| | - Janet Seeley
- Africa Health Research Institute, Somkhele, South Africa
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Joanna Orne-Gliemann
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
- Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
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Mkwanazi NB, Rochat TJ, Bland RM. The Amagugu intervention: a qualitative investigation into maternal experiences and perspectives of a maternal HIV disclosure support intervention in rural South Africa. Health Policy Plan 2017; 32:1231-1240. [PMID: 28981662 PMCID: PMC5886258 DOI: 10.1093/heapol/czx056] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2017] [Indexed: 11/14/2022] Open
Abstract
The World Health Organization recommends disclosure of parental HIV to children aged 6-12 years. The maternal HIV-disclosure intervention (Amagugu), a lay counsellor-led, home-based intervention with six sessions, was implemented. The intervention included provision of disclosure tools, training and support for mothers, a family session and health promotion clinic visit for mothers and children. Amagugu demonstrated success as a maternal disclosure support programme but less is known about the experiences of participants. A sub-sample of HIV-infected mothers (n = 20) with primary school-aged HIV-uninfected children, from Amagugu, was purposely selected. Using semi-structured interviews and interview-guide, we explored maternal perceptions of disclosure prior to participation and experiences of participating in Amagugu. Audio-recorded interviews conducted in participants' homes, in isiZulu, were transcribed, and content analysis was undertaken. The most common reasons for prior non-disclosure were concerns about children's developmental capacity to understand HIV, fear of HIV-related stigma towards mothers and their families, and lack of skills to undertake disclosure. Intervention materials, rapport with counsellors, and flexibility of the proposed disclosure process motivated mothers to participate. While expressing satisfaction with the intervention, some mothers remained concerned about their children's understanding of HIV and ability to maintain confidentiality. Mothers also requested support in discussing sex-related topics with their children. Despite prior high rates of disclosure to other adults, mothers had little awareness about the importance of disclosure to children and lacked skills to undertake this. The intervention approach, rapport with counsellors, and practicality of the materials, helped overcome child disclosure barriers. Mothers reported their children as very supportive following disclosure and stated they would advise other women to disclose to children for practical support around HIV treatment adherence. This qualitative evaluation suggests that mothers with primary school-aged children may require structured support when disclosing to children, which could be achieved through supportive home-based counselling and user-friendly materials.
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Affiliation(s)
- Ntombizodumo B. Mkwanazi
- Africa Health Research Institute, University of KwaZulu-Natal, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- DST-NRF Centre of Excellence in Human Development, University of Witwatersrand, Johannesburg, South Africa
| | - Tamsen J. Rochat
- Africa Health Research Institute, University of KwaZulu-Natal, South Africa
- Human and Social Development Research Programme, Human Sciences Research Council, Durban, South Africa
- MRC/Developmental Pathways to Health Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Section of Child and Adolescent Psychiatry, Department of Psychiatry, Oxford University, Oxford, UK
| | - Ruth M. Bland
- Africa Health Research Institute, University of KwaZulu-Natal, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Institute of Health and Wellbeing and Royal Hospital for Sick Children, University of Glasgow, Glasgow, UK
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35
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Bor J, Fox MP, Rosen S, Venkataramani A, Tanser F, Pillay D, Bärnighausen T. Treatment eligibility and retention in clinical HIV care: A regression discontinuity study in South Africa. PLoS Med 2017; 14:e1002463. [PMID: 29182641 PMCID: PMC5705070 DOI: 10.1371/journal.pmed.1002463] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 10/25/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Loss to follow-up is high among HIV patients not yet receiving antiretroviral therapy (ART). Clinical trials have demonstrated the clinical efficacy of early ART; however, these trials may miss an important real-world consequence of providing ART at diagnosis: its impact on retention in care. METHODS AND FINDINGS We examined the effect of immediate (versus deferred) ART on retention in care using a regression discontinuity design. The analysis included all patients (N = 11,306) entering clinical HIV care with a first CD4 count between 12 August 2011 and 31 December 2012 in a public-sector HIV care and treatment program in rural South Africa. Patients were assigned to immediate versus deferred ART eligibility, as determined by a CD4 count < 350 cells/μl, per South African national guidelines. Patients referred to pre-ART care were instructed to return every 6 months for CD4 monitoring. Patients initiated on ART were instructed to return at 6 and 12 months post-initiation and annually thereafter for CD4 and viral load monitoring. We assessed retention in HIV care at 12 months, as measured by the presence of a clinic visit, lab test, or ART initiation 6 to 18 months after initial CD4 test. Differences in retention between patients presenting with CD4 counts just above versus just below the 350-cells/μl threshold were estimated using local linear regression models with a data-driven bandwidth and with the algorithm for selecting the bandwidth chosen ex ante. Among patients with CD4 counts close to the 350-cells/μl threshold, having an ART-eligible CD4 count (<350 cells/μl) was associated with higher 12-month retention than not having an ART-eligible CD4 count (50% versus 32%), an intention-to-treat risk difference of 18 percentage points (95% CI 11 to 23; p < 0.001). The decision to start ART was determined by CD4 count for one in four patients (25%) presenting close to the eligibility threshold (95% CI 20% to 31%; p < 0.001). In this subpopulation, having an ART-eligible CD4 count was associated with higher 12-month retention than not having an ART-eligible CD4 count (91% versus 21%), a complier causal risk difference of 70 percentage points (95% CI 42 to 98; p < 0.001). The major limitations of the study are the potential for limited generalizability, the potential for outcome misclassification, and the absence of data on longer-term health outcomes. CONCLUSIONS Patients who were eligible for immediate ART had dramatically higher retention in HIV care than patients who just missed the CD4-count eligibility cutoff. The clinical and population health benefits of offering immediate ART regardless of CD4 count may be larger than suggested by clinical trials.
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Affiliation(s)
- Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Africa Health Research Institute, Somkhele, South Africa
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Matthew P. Fox
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Atheendar Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Frank Tanser
- Africa Health Research Institute, Somkhele, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
- Research Department of Infection & Population Health, University College London, London, United Kingdom
| | - Deenan Pillay
- Africa Health Research Institute, Somkhele, South Africa
- Department of Virology, University College London, London, United Kingdom
| | - Till Bärnighausen
- Africa Health Research Institute, Somkhele, South Africa
- Research Department of Infection & Population Health, University College London, London, United Kingdom
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
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Coetzee B, Kagee A, Bland R. Shortcomings of adherence counselling provided to caregivers of children receiving antiretroviral therapy in rural South Africa. AIDS Care 2017; 28 Suppl 2:60-5. [PMID: 27392000 PMCID: PMC4991232 DOI: 10.1080/09540121.2016.1176675] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
In order to achieve optimal benefits of antiretroviral therapy (ART), caregivers of children receiving ART are required to attend routine clinic visits monthly and administer medication to the child as prescribed. Yet, the level of adherence to these behaviours varies considerably in many settings. As a way to achieve optimal adherence in rural KwaZulu-Natal, caregivers are required to attend routine counselling sessions at HIV treatment clinics that are centred on imparting information, motivation, and behavioural skills related to medication administration. According to the information-motivation-behavioural skills model, information related to adherence, motivation, and behavioural skills are necessary and fundamental determinants of adherence to ART. The purpose of the study was to observe and document the content of adherence counselling sessions that caregivers attending rural clinics in KwaZulu Natal receive. We observed 25 adherence counselling sessions, which lasted on average 8.1 minutes. Counselling typically consisted of counsellors recording patient attendance, reporting CD4 count and viral load results to caregivers, emphasising dose times, and asking caregivers to name their medications and dosage amounts. Patients were seldom asked to demonstrate how they measure the medication. They were also not probed for problems regarding treatment, even when an unsuppressed VL was reported to a caregiver. This paper calls attention to the sub-optimal level of counselling provided to patients on ART and the urgent need to standardise and improve the training, support, and debriefing provided to counsellors.
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Affiliation(s)
- Bronwyne Coetzee
- a Department of Psychology , Stellenbosch University , Stellenbosch , South Africa
| | - Ashraf Kagee
- a Department of Psychology , Stellenbosch University , Stellenbosch , South Africa
| | - Ruth Bland
- b Africa Centre for Population Health , KwaZulu-Natal , South Africa.,c Institute of Health and Wellbeing and Royal Hospital for Sick Children , University of Glasgow , Glasgow , UK.,d School of Public Health, Faculty of Health Sciences , University of Witwatersrand , Johannesburg , South Africa
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Psychological morbidity and parenting stress in mothers of primary school children by timing of acquisition of HIV infection: a longitudinal cohort study in rural South Africa. J Dev Orig Health Dis 2017; 9:41-57. [PMID: 28899439 DOI: 10.1017/s204017441700068x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Longitudinal maternal mental health data are needed from high HIV prevalence settings. The Siyakhula Cohort (SC) is a population-based cohort of HIV-positive and negative mothers (n=1506) with HIV-negative children (n=1536) from rural South Africa. SC includes 767 HIV-negative mothers; 465 HIV-positive in pregnancy; 272 HIV-positive since pregnancy (n=2 missing HIV status). A subgroup (n=890) participated in a non-randomized breastfeeding intervention [Vertical Transmission Study (VTS)]; the remaining (n=616) were resident in the same area and received antenatal care at the time of the VTS, but were not part of the VTS, instead receiving the standard of care Prevention of Mother-to-Child Transmission (PMTCT) Programme. In secondary analysis we investigated the prevalence of, and factors associated with, psychological morbidity amongst mothers who were still the primary caregiver of the child (1265 out of 1506) at follow-up (7-11 years post-birth). We measured maternal depression (Patient Health Questionnaire-9), anxiety (General Anxiety Disorder Scale-7) and parenting stress (Parenting Stress Index-36), using standardized cut-offs and algorithms. In total, 75 (5.9%) mothers met criteria for depression, 37 (2.9%) anxiety and 134 (10.6%) parenting stress. Using complete case logistic regression (n=1206 out of 1265 mothers) as compared to being HIV-negative, testing HIV-positive in pregnancy doubled odds of depression [adjusted odd ratios (aOR)=1.96 [1.0-3.7] P=0.039]. Parenting stress was positively associated with acquisition of HIV after pregnancy (aOR=3.11 [1.9-5.2] P<0.001) and exposure to household crime (aOR=2.02 [1.3-3.2] P=0.003); negatively associated with higher maternal education (aOR=0.29 [0.1-0.8] P=0.014), maternal employment (aOR=0.55 [0.3-0.9] P=0.024). Compared with the standard of care PMTCT, VTS mothers had reduced odds of parenting stress (aOR=0.61 [0.4-0.9] P=0.016). Integrating parental support into mostly bio-medical treatment programmes, during and beyond pregnancy, is important.
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Space-time variations in child mortality in a rural South African population with high HIV prevalence (2000-2014). PLoS One 2017; 12:e0182478. [PMID: 28837576 PMCID: PMC5570377 DOI: 10.1371/journal.pone.0182478] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 07/19/2017] [Indexed: 11/19/2022] Open
Abstract
Objective The aim of the study was to identify the key determinants of child mortality ‘hot-spots’ in space and time. Methods Comprehensive population-based mortality data collected between 2000 and 2014 by the Africa Centre Demographic Information System located in the UMkhanyakude District of KwaZulu-Natal Province, South Africa, was analysed. We assigned all mortality events and person-time of observation for children <5 years of age to an exact homestead of residence (mapped to <2m accuracy as part of the DSA platform). Using these exact locations, both the Kulldorff and Tango spatial scan statistics for regular and irregular shaped cluster detection were used to identify clusters of childhood mortality events in both space and time. Findings Of the 49 986 children aged < 5 years who resided in the study area between 2000 and 2014, 2010 (4.0%) died. Childhood mortality decreased by 80% over the period from >20 per 1000 person-years in 2001–2003 to 4 per 1000 person-years in 2014. The two scanning spatial techniques identified two high-risk clusters for child mortality along the eastern border of the study site near the national highway, with a relative risk of 2.10 and 1.91 respectively. Conclusions The high-risk communities detected in this work, and the differential risk factor profile of these communities, can assist public health professionals to identify similar populations in other parts of rural South Africa. Identifying child mortality hot-spots will potentially guide policy interventions in rural, resource-limited settings.
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McGrath N, Grapsa E. Does antiretroviral therapy change partnership dynamics and HIV risk behaviours among HIV-infected adults. AIDS 2017; 31:1451-1460. [PMID: 28574964 PMCID: PMC5457820 DOI: 10.1097/qad.0000000000001502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Objective: We explore the impact of antiretroviral therapy (ART) on partnership acquisition and dissolution rates and changes in sexual behaviours among HIV-infected adults. Design: Using detailed longitudinal data from a prospective cohort of HIV-infected adults with CD4+ cell count below 200 cells/μl (ART-eligible) or CD4+ cell count above 500 cells/μl (pre-ART) conducted in rural KwaZulu-Natal, South Africa, from 2009 to 2012. Methods: Partnership acquisition and dissolution are explored through survival analysis methods, whereas generalized linear models were fitted for the sexual behaviour outcomes with interaction terms to allow the association with ART to vary over time. Throughout, the primary comparison of interest for each outcome is differences between the two ART groups. Results: ART is not associated with partner acquisition or relationship dissolution. During follow-up, the two ART groups do not differ in the odds of being sexually active nor the number of sex acts, whereas the odds of unprotected sex are significantly lower for partnerships of ART-eligible participants (adjusted odds ratio 0.26, 95% confidence interval 0.15, 0.43). Relationship-level characteristics including cohabitation status and wanting more children with that partner are associated with higher odds and increased frequency of sexual activity, and increased odds of unprotected sex, whereas living with partner, higher relationship quality and longer relationship duration are associated with lower risk of partnership dissolution. Conclusion: Being on ART was not associated with increased sexual risk behaviours, a reassuring finding given the WHO recommends ART initiation upon HIV diagnosis. The importance of relationship-level characteristics provides evidence that HIV care services should offer routine support for HIV disclosure and sexual risk reduction, and promotion of couples-testing and positive couple relationships.
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Bor J, Ahmed S, Fox MP, Rosen S, Meyer-Rath G, Katz IT, Tanser F, Pillay D, Bärnighausen T. Effect of eliminating CD4-count thresholds on HIV treatment initiation in South Africa: An empirical modeling study. PLoS One 2017; 12:e0178249. [PMID: 28617805 PMCID: PMC5472329 DOI: 10.1371/journal.pone.0178249] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 04/21/2017] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND The World Health Organization recommends initiating antiretroviral therapy (ART) regardless of CD4 count. We assessed the effect of ART eligibility on treatment uptake and simulated the impact of WHO's recommendations in South Africa. METHODS We conducted an empirical analysis of cohort data using a regression discontinuity design, and then used this model for policy simulation. We enrolled all patients (n = 19,279) diagnosed with HIV between August 2011 and December 2013 in the Hlabisa HIV Treatment and Care Programme in rural South Africa. Patients were ART-eligible with CD4<350 cells/mm3 or Stage III/IV illness. We estimated: (1) distribution of first CD4 counts in 2013; (2) probability of initiating ART ≤6 months of HIV diagnosis under existing criteria at each CD4 count; (3) probability of initiating ART by CD4 count if thresholds were eliminated; and (4) number of expected new initiators if South Africa eliminates thresholds. FINDINGS In 2013, 38.9% of patients diagnosed had a CD4 count ≥500. 8.0% of these patients initiated even without eligible CD4 counts. If CD4 criteria were eliminated, we project that an additional 19.2% of patients with CD4 ≥500 would initiate ART; 72.8% would not initiate ART despite being eligible. Eliminating CD4 criteria would increase the number starting ART by 26.7%. If these numbers hold nationally, this would represent an additional 164,000 initiators per year, a 5.2% increase in patients receiving ART and 5.3% increase in programme costs. CONCLUSIONS Removing CD4 criteria alone will modestly increase timely uptake of ART. However, our results suggest the majority of newly-eligible patients will not initiate. Improved testing, linkage, and initiation procedures are needed to achieve 90-90-90 targets.
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Affiliation(s)
- Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Africa Health Research Institute, Somkhele and Durban, South Africa
- Health Economics and Epidemiology Research Office, University of Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States of America
| | - Shahira Ahmed
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Health Economics and Epidemiology Research Office, University of Witwatersrand, Johannesburg, South Africa
| | - Matthew P. Fox
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Health Economics and Epidemiology Research Office, University of Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States of America
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Health Economics and Epidemiology Research Office, University of Witwatersrand, Johannesburg, South Africa
| | - Gesine Meyer-Rath
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Health Economics and Epidemiology Research Office, University of Witwatersrand, Johannesburg, South Africa
| | - Ingrid T. Katz
- Division of Women’s Health, Brigham and Women’s Hospital, Boston, MA, United States
- Center for Global Health, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Frank Tanser
- Africa Health Research Institute, Somkhele and Durban, South Africa
| | - Deenan Pillay
- Africa Health Research Institute, Somkhele and Durban, South Africa
- Department of Virology, University College London, London, United Kingdom
| | - Till Bärnighausen
- Africa Health Research Institute, Somkhele and Durban, South Africa
- Heidelberg Institute of Public Health, University of Heidelberg, Heidelberg, Germany
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
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Haber N, Tanser F, Bor J, Naidu K, Mutevedzi T, Herbst K, Porter K, Pillay D, Bärnighausen T. From HIV infection to therapeutic response: a population-based longitudinal HIV cascade-of-care study in KwaZulu-Natal, South Africa. Lancet HIV 2017. [PMID: 28153470 DOI: 10.1016/s2352–3018(16)30224–7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2023]
Abstract
BACKGROUND Standard approaches to estimation of losses in the HIV cascade of care are typically cross-sectional and do not include the population stages before linkage to clinical care. We used indiviual-level longitudinal cascade data, transition by transition, including population stages, both to identify the health-system losses in the cascade and to show the differences in inference between standard methods and the longitudinal approach. METHODS We used non-parametric survival analysis to estimate a longitudinal HIV care cascade for a large population of people with HIV residing in rural KwaZulu-Natal, South Africa. We linked data from a longitudinal population health surveillance (which is maintained by the Africa Health Research Institute) with patient records from the local public-sector HIV treatment programme (contained in an electronic clinical HIV treatment and care database, ARTemis). We followed up all people who had been newly detected as having HIV between Jan 1, 2006, and Dec 31, 2011, across six cascade stages: three population stages (first positive HIV test, HIV status knowledge, and linkage to care) and three clinical stages (eligibility for antiretroviral therapy [ART], initiation of ART, and therapeutic response). We compared our estimates to cross-sectional cascades in the same population. We estimated the cumulative incidence of reaching a particular cascade stage at a specific time with Kaplan-Meier survival analysis. FINDINGS Our population consisted of 5205 individuals with HIV who were followed up for 24 031 person-years. We recorded 598 deaths. 4539 individuals gained knowledge of their positive HIV status, 2818 were linked to care, 2151 became eligible for ART, 1839 began ART, and 1456 had successful responses to therapy. We used Kaplan-Meier survival analysis to adjust for censorship due to the end of data collection, and found that 8 years after testing positive in the population health surveillance, 16% had died. Among living patients, 82% knew their HIV status, 45% were linked to care, 39% were eligible for ART, 35% initiated ART, and 33% had reached therapeutic response. Median times to transition for these cascade stages were 52 months, 52 months, 20 months, 3 months, and 9 months, respectively. Compared with the population stages in the cascade, the transitions across the clinical stages were fast. Over calendar time, rates of linkage to care have decreased and patients presenting for the first time for care were, on average, healthier. INTERPRETATION HIV programmes should focus on linkage to care as the most important bottleneck in the cascade. Cascade estimation should be longitudinal rather than cross-sectional and start with the population stages preceding clinical care. FUNDING Wellcome Trust, PEPFAR.
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Affiliation(s)
- Noah Haber
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA; Africa Health Research Institute, Somkhele, South Africa.
| | - Frank Tanser
- Africa Health Research Institute, Somkhele, South Africa; School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa; Centre for the AIDS Programme of Research in South Africa-CAPRISA, University of KwaZulu-Natal, Congella, South Africa
| | - Jacob Bor
- Africa Health Research Institute, Somkhele, South Africa; Department of Global Health, Boston University School of Public Health, Boston, MA, USA; Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Kevindra Naidu
- Africa Health Research Institute, Somkhele, South Africa; MatCH (Maternal Adolescent and Child Health Systems), School of Public Health, University of the Witwatersrand, South Africa
| | | | - Kobus Herbst
- Africa Health Research Institute, Somkhele, South Africa
| | - Kholoud Porter
- Africa Health Research Institute, Somkhele, South Africa; Research Department of Infection and Population Health, University College London, London, UK
| | - Deenan Pillay
- Africa Health Research Institute, Somkhele, South Africa; Division of Infection and Immunity, University College London, London, UK
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA; Africa Health Research Institute, Somkhele, South Africa; Institute of Public Health, Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
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Determinants of time from HIV infection to linkage-to-care in rural KwaZulu-Natal, South Africa. AIDS 2017; 31:1017-1024. [PMID: 28252526 DOI: 10.1097/qad.0000000000001435] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To estimate time from HIV infection to linkage-to-care and its determinants. Linkage-to-care is usually assessed using the date of HIV diagnosis as the starting point for exposure time. However, timing of diagnosis is likely endogenous to linkage, leading to bias in linkage estimation. DESIGN We used longitudinal HIV serosurvey data from a large population-based HIV incidence cohort in KwaZulu-Natal (2004-2013) to estimate time of HIV infection. We linked these data to patient records from a public-sector HIV treatment and care program to determine time from infection to linkage (defined using the date of the first CD4 cell count). METHODS We used Cox proportional hazards models to estimate time from infection to linkage and the effects of the following covariates on this time: sex, age, education, food security, socioeconomic status, area of residence, distance to clinics, knowledge of HIV status, and whether other household members have initiated antiretroviral therapy. RESULTS We estimated that it would take an average of 4.9 years for 50% of HIV seroconverters to be linked to care (95% confidence intervals: 4.2-5.7). Among all cohort members who were linked to care, the median CD4 cell count at linkage was 350 cells/μl (95% confidence interval: 330-380). Men and participants aged less than 30 years were found to have the slowest rates of linkage-to-care. Time to linkage became shorter over calendar time. CONCLUSION Average time from HIV infection to linkage-to-care is long and needs to be reduced to ensure that HIV treatment-as-prevention policies are effective. Targeted interventions for men and young individuals have the largest potential to improve linkage rates.
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Collier D, Iwuji C, Derache A, de Oliveira T, Okesola N, Calmy A, Dabis F, Pillay D, Gupta RK. Virological Outcomes of Second-line Protease Inhibitor-Based Treatment for Human Immunodeficiency Virus Type 1 in a High-Prevalence Rural South African Setting: A Competing-Risks Prospective Cohort Analysis. Clin Infect Dis 2017; 64:1006-1016. [PMID: 28329393 PMCID: PMC5439490 DOI: 10.1093/cid/cix015] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 01/12/2017] [Indexed: 11/20/2022] Open
Abstract
Background Second-line antiretroviral therapy (ART) based on ritonavir-boosted protease inhibitors (bPIs) represents the only available option after first-line failure for the majority of individuals living with human immunodeficiency virus (HIV) worldwide. Maximizing their effectiveness is imperative. Methods This cohort study was nested within the French National Agency for AIDS and Viral Hepatitis Research (ANRS) 12249 Treatment as Prevention (TasP) cluster-randomized trial in rural KwaZulu-Natal, South Africa. We prospectively investigated risk factors for virological failure (VF) of bPI-based ART in the combined study arms. VF was defined by a plasma viral load >1000 copies/mL ≥6 months after initiating bPI-based ART. Cumulative incidence of VF was estimated and competing risk regression was used to derive the subdistribution hazard ratio (SHR) of the associations between VF and patient clinical and demographic factors, taking into account death and loss to follow-up. Results One hundred one participants contributed 178.7 person-years of follow-up. Sixty-five percent were female; the median age was 37.4 years. Second-line ART regimens were based on ritonavir-boosted lopinavir, combined with zidovudine or tenofovir plus lamivudine or emtricitabine. The incidence of VF on second-line ART was 12.9 per 100 person-years (n = 23), and prevalence of VF at censoring was 17.8%. Thirteen of these 23 (56.5%) virologic failures resuppressed after a median of 8.0 months (interquartile range, 2.8-16.8 months) in this setting where viral load monitoring was available. Tuberculosis treatment was associated with VF (SHR, 11.50 [95% confidence interval, 3.92-33.74]; P < .001). Conclusions Second-line VF was frequent in this setting. Resuppression occurred in more than half of failures, highlighting the value of viral load monitoring of second-line ART. Tuberculosis was associated with VF; therefore, novel approaches to optimize the effectiveness of PI-based ART in high-tuberculosis-burden settings are needed. Clinical Trials Registration NCT01509508.
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Affiliation(s)
- Dami Collier
- Department of Infection and Immunity, University College London, United Kingdom
| | - Collins Iwuji
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Research Department of Infection and Population Health, University College London, United Kingdom
| | - Anne Derache
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Sorbonne Universités, University Pierre and Marie Curie Université Paris 06, Inserm, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
| | - Tulio de Oliveira
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- University of KwaZulu-Natal, Durban, South Africa
| | | | - Alexandra Calmy
- Geneva University Hospital, HIV Unit, Department of Internal Medicine, Switzerland
| | - Francois Dabis
- INSERM U1219-Centre Inserm Bordeaux Population Health, Université de Bordeaux, France
- Université de Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, France
| | - Deenan Pillay
- Department of Infection and Immunity, University College London, United Kingdom
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Ravindra K Gupta
- Department of Infection and Immunity, University College London, United Kingdom
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
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Haber N, Tanser F, Bor J, Naidu K, Mutevedzi T, Herbst K, Porter K, Pillay D, Bärnighausen T. From HIV infection to therapeutic response: a population-based longitudinal HIV cascade-of-care study in KwaZulu-Natal, South Africa. Lancet HIV 2017; 4:e223-e230. [PMID: 28153470 DOI: 10.1016/s2352-3018(16)30224-7] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 11/02/2016] [Accepted: 11/03/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Standard approaches to estimation of losses in the HIV cascade of care are typically cross-sectional and do not include the population stages before linkage to clinical care. We used indiviual-level longitudinal cascade data, transition by transition, including population stages, both to identify the health-system losses in the cascade and to show the differences in inference between standard methods and the longitudinal approach. METHODS We used non-parametric survival analysis to estimate a longitudinal HIV care cascade for a large population of people with HIV residing in rural KwaZulu-Natal, South Africa. We linked data from a longitudinal population health surveillance (which is maintained by the Africa Health Research Institute) with patient records from the local public-sector HIV treatment programme (contained in an electronic clinical HIV treatment and care database, ARTemis). We followed up all people who had been newly detected as having HIV between Jan 1, 2006, and Dec 31, 2011, across six cascade stages: three population stages (first positive HIV test, HIV status knowledge, and linkage to care) and three clinical stages (eligibility for antiretroviral therapy [ART], initiation of ART, and therapeutic response). We compared our estimates to cross-sectional cascades in the same population. We estimated the cumulative incidence of reaching a particular cascade stage at a specific time with Kaplan-Meier survival analysis. FINDINGS Our population consisted of 5205 individuals with HIV who were followed up for 24 031 person-years. We recorded 598 deaths. 4539 individuals gained knowledge of their positive HIV status, 2818 were linked to care, 2151 became eligible for ART, 1839 began ART, and 1456 had successful responses to therapy. We used Kaplan-Meier survival analysis to adjust for censorship due to the end of data collection, and found that 8 years after testing positive in the population health surveillance, 16% had died. Among living patients, 82% knew their HIV status, 45% were linked to care, 39% were eligible for ART, 35% initiated ART, and 33% had reached therapeutic response. Median times to transition for these cascade stages were 52 months, 52 months, 20 months, 3 months, and 9 months, respectively. Compared with the population stages in the cascade, the transitions across the clinical stages were fast. Over calendar time, rates of linkage to care have decreased and patients presenting for the first time for care were, on average, healthier. INTERPRETATION HIV programmes should focus on linkage to care as the most important bottleneck in the cascade. Cascade estimation should be longitudinal rather than cross-sectional and start with the population stages preceding clinical care. FUNDING Wellcome Trust, PEPFAR.
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Affiliation(s)
- Noah Haber
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA; Africa Health Research Institute, Somkhele, South Africa.
| | - Frank Tanser
- Africa Health Research Institute, Somkhele, South Africa; School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa; Centre for the AIDS Programme of Research in South Africa-CAPRISA, University of KwaZulu-Natal, Congella, South Africa
| | - Jacob Bor
- Africa Health Research Institute, Somkhele, South Africa; Department of Global Health, Boston University School of Public Health, Boston, MA, USA; Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Kevindra Naidu
- Africa Health Research Institute, Somkhele, South Africa; MatCH (Maternal Adolescent and Child Health Systems), School of Public Health, University of the Witwatersrand, South Africa
| | | | - Kobus Herbst
- Africa Health Research Institute, Somkhele, South Africa
| | - Kholoud Porter
- Africa Health Research Institute, Somkhele, South Africa; Research Department of Infection and Population Health, University College London, London, UK
| | - Deenan Pillay
- Africa Health Research Institute, Somkhele, South Africa; Division of Infection and Immunity, University College London, London, UK
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA; Africa Health Research Institute, Somkhele, South Africa; Institute of Public Health, Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
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Maskew M, Bor J, Hendrickson C, MacLeod W, Bärnighausen T, Pillay D, Sanne I, Carmona S, Stevens W, Fox MP. Imputing HIV treatment start dates from routine laboratory data in South Africa: a validation study. BMC Health Serv Res 2017; 17:41. [PMID: 28095905 PMCID: PMC5240407 DOI: 10.1186/s12913-016-1940-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 12/08/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Poor clinical record keeping hinders health systems monitoring and patient care in many low resource settings. We develop and validate a novel method to impute dates of antiretroviral treatment (ART) initiation from routine laboratory data in South Africa's public sector HIV program. This method will enable monitoring of the national ART program using real-time laboratory data, avoiding the error potential of chart review. METHODS We developed an algorithm to impute ART start dates based on the date of a patient's "ART workup", i.e. the laboratory tests used to determine treatment readiness in national guidelines, and the time from ART workup to initiation based on clinical protocols (21 days). To validate the algorithm, we analyzed data from two large clinical HIV cohorts: Hlabisa HIV Treatment and Care Programme in rural KwaZulu-Natal; and Right to Care Cohort in urban Gauteng. Both cohorts contain known ART initiation dates and laboratory results imported directly from the National Health Laboratory Service. We assessed median time from ART workup to ART initiation and calculated sensitivity (SE), specificity (SP), positive predictive value (PPV), and negative predictive value (NPV) of our imputed start date vs. the true start date within a 6 month window. Heterogeneity was assessed across individual clinics and over time. RESULTS We analyzed data from over 80,000 HIV-positive adults. Among patients who had a workup and initiated ART, median time to initiation was 16 days (IQR 7,31) in Hlabisa and 21 (IQR 8,43) in RTC cohort. Among patients with known ART start dates, SE of the imputed start date was 83% in Hlabisa and 88% in RTC, indicating this method accurately predicts ART start dates for about 85% of all ART initiators. In Hlabisa, PPV was 95%, indicating that for patients with a lab workup, true start dates were predicted with high accuracy. SP (100%) and NPV (92%) were also very high. CONCLUSIONS Routine laboratory data can be used to infer ART initiation dates in South Africa's public sector. Where care is provided based on protocols, laboratory data can be used to monitor health systems performance and improve accuracy and completeness of clinical records.
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Affiliation(s)
- Mhairi Maskew
- Heath Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jacob Bor
- Heath Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. .,Department of Global Health, Boston University School of Public Health, Boston, MA, USA. .,Africa Health Research Institute, Somkhele, South Africa. .,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.
| | - Cheryl Hendrickson
- Heath Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - William MacLeod
- Heath Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Till Bärnighausen
- Africa Health Research Institute, Somkhele, South Africa.,Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - Deenan Pillay
- Africa Health Research Institute, Somkhele, South Africa.,Division of Infection and Immunity, University College London, London, UK
| | - Ian Sanne
- Heath Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, Clinical HIV Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sergio Carmona
- National Health Laboratory Service, Johannesburg, South Africa
| | - Wendy Stevens
- National Health Laboratory Service, Johannesburg, South Africa.,Department of Molecular Medicine and Hematology, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P Fox
- Heath Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
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Rochat TJ, Mitchell J, Lubbe AM, Stein A, Tomlinson M, Bland RM. Communication about HIV and death: Maternal reports of primary school-aged children's questions after maternal HIV disclosure in rural South Africa. Soc Sci Med 2017; 172:124-134. [PMID: 27881248 PMCID: PMC5224234 DOI: 10.1016/j.socscimed.2016.10.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 10/18/2016] [Accepted: 10/29/2016] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Children's understanding of HIV and death in epidemic regions is under-researched. We investigated children's death-related questions post maternal HIV-disclosure. Secondary aims examined characteristics associated with death-related questions and consequences for children's mental health. METHODS HIV-infected mothers (N = 281) were supported to disclose their HIV status to their children (6-10 years) in an uncontrolled pre-post intervention evaluation. Children's questions post-disclosure were collected by maternal report, 1-2 weeks post-disclosure. 61/281 children asked 88 death-related questions, which were analysed qualitatively. Logistic regression analyses examined characteristics associated with death-related questions. Using the parent-report Child Behaviour Checklist (CBCL), linear regression analysis examined differences in total CBCL problems by group, controlling for baseline. RESULTS Children's questions were grouped into three themes: 'threats'; 'implications' and 'clarifications'. Children were most concerned about the threat of death, mother's survival, and prior family deaths. In multivariate analysis variables significantly associated with asking death-related questions included an absence of regular remittance to the mother (AOR 0.25 [CI 0.10, 0.59] p = 0.002), mother reporting the child's initial reaction to disclosure being "frightened" (AOR 6.57 [CI 2.75, 15.70] p=<0.001) and level of disclosure (full/partial) to the child (AOR 2.55 [CI 1.28, 5.06] p = 0.008). Controlling for significant variables and baseline, all children showed improvements on the CBCL post-intervention; with no significant differences on total problems scores post-intervention (β -0.096 SE1.366 t = -0.07 p = 0.944). DISCUSSION The content of questions children asked following disclosure indicate some understanding of HIV and, for almost a third of children, its potential consequence for parental death. Level of maternal disclosure and stability of financial support to the family may facilitate or inhibit discussions about death post-disclosure. Communication about death did not have immediate negative consequences on child behaviour according to maternal report. CONCLUSION In sub-Saharan Africa, given exposure to death at young ages, meeting children's informational needs could increase their resilience.
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Affiliation(s)
- Tamsen J Rochat
- Africa Health Research Institute, University of KwaZulu-Natal, South Africa; Human and Social Development Research Programme, Human Sciences Research Council, South Africa; MRC/Developmental Pathways to Health Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, South Africa; Section of Child and Adolescent Psychiatry, Department of Psychiatry, University of Oxford, United Kingdom.
| | - Joanie Mitchell
- Africa Health Research Institute, University of KwaZulu-Natal, South Africa
| | - Anina M Lubbe
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | - Alan Stein
- Section of Child and Adolescent Psychiatry, Department of Psychiatry, University of Oxford, United Kingdom; MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Mark Tomlinson
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | - Ruth M Bland
- Africa Health Research Institute, University of KwaZulu-Natal, South Africa; School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa; Royal Hospital for Sick Children, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
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de Oliveira T, Kharsany ABM, Gräf T, Cawood C, Khanyile D, Grobler A, Puren A, Madurai S, Baxter C, Karim QA, Karim SSA. Transmission networks and risk of HIV infection in KwaZulu-Natal, South Africa: a community-wide phylogenetic study. Lancet HIV 2017; 4:e41-e50. [PMID: 27914874 PMCID: PMC5479933 DOI: 10.1016/s2352-3018(16)30186-2] [Citation(s) in RCA: 202] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 08/25/2016] [Accepted: 08/26/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND The incidence of HIV infection in young women in Africa is very high. We did a large-scale community-wide phylogenetic study to examine the underlying HIV transmission dynamics and the source and consequences of high rates of HIV infection in young women in South Africa. METHODS We did a cross-sectional household survey of randomly selected individuals aged 15-49 years in two neighbouring subdistricts (one urban and one rural) with a high burden of HIV infection in KwaZulu-Natal, South Africa. Participants completed structured questionnaires that captured general demographic, socioeconomic, psychosocial, and behavioural data. Peripheral blood samples were obtained for HIV antibody testing. Samples with HIV RNA viral load greater than 1000 copies per mL were selected for genotyping. We constructed a phylogenetic tree to identify clusters of linked infections (defined as two or more sequences with bootstrap or posterior support ≥90% and genetic distance ≤4·5%). FINDINGS From June 11, 2014, to June 22, 2015, we enrolled 9812 participants, 3969 of whom tested HIV positive. HIV prevalence (weighted) was 59·8% in 2835 women aged 25-40 years, 40·3% in 1548 men aged 25-40 years, 22·3% in 2224 women younger than 25 years, and 7·6% in 1472 men younger than 25 years. HIV genotyping was done in 1589 individuals with a viral load of more than 1000 copies per mL. In 90 transmission clusters, 123 women were linked to 103 men. Of 60 possible phylogenetically linked pairings with the 43 women younger than 25 years, 18 (30·0%) probable male partners were younger than 25 years, 37 (61·7%) were aged 25-40 years, and five (8·3%) were aged 41-49 years: mean age difference 8·7 years (95% CI 6·8-10·6; p<0·0001). For the 92 possible phylogenetically linked pairings with the 56 women aged 25-40 years, the age difference dropped to 1·1 years (95% CI -0·6 to 2·8; p=0·111). 16 (39·0%) of 41 probable male partners linked to women younger than 25 years were also linked to women aged 25-40 years. Of 79 men (mean age 31·5 years) linked to women younger than 40 years, 62 (78·5%) were unaware of their HIV-positive status, 76 (96·2%) were not on antiretroviral therapy, and 29 (36·7%) had viral loads of more than 50 000 copies per mL. INTERPRETATION Sexual partnering between young women and older men, who might have acquired HIV from women of similar age, is a key feature of the sexual networks driving transmission. Expansion of treatment and combination prevention strategies that include interventions to address age-disparate sexual partnering is crucial to reducing HIV incidence and enabling Africa to reach the goal of ending AIDS as a public health threat. FUNDING President's Emergency Program for AIDS Relief, US Centers for Disease Control and Prevention, South African Medical Research Council, and MAC AIDS Fund.
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Affiliation(s)
- Tulio de Oliveira
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa; University of KwaZulu-Natal, Durban, South Africa; Africa Centre for Population Health, Hlabisa, South Africa
| | - Ayesha B M Kharsany
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa; University of KwaZulu-Natal, Durban, South Africa.
| | - Tiago Gräf
- University of KwaZulu-Natal, Durban, South Africa
| | | | | | - Anneke Grobler
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Adrian Puren
- National Institute for Communicable Diseases, Johannesburg, South Africa
| | | | - Cheryl Baxter
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa; University of KwaZulu-Natal, Durban, South Africa
| | - Quarraisha Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa; University of KwaZulu-Natal, Durban, South Africa; Department of Epidemiology, Columbia University, New York, NY, USA
| | - Salim S Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa; University of KwaZulu-Natal, Durban, South Africa; Department of Epidemiology, Columbia University, New York, NY, USA
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Abstract
PURPOSE The Hlabisa pregnancy cohort was established to evaluate the effectiveness of prevention of mother-to-child transmission (PMTCT) guideline revisions. The objectives of the Hlabisa pregnancy cohort are to: (1) provide cohort-level information on maternal health up to 6 weeks postpartum in a high HIV prevalence setting; and to (2) evaluate aspects of PMTCT care that have policy relevance. PARTICIPANTS The pregnancy cohort is located in primary health clinics in the Hlabisa subdistrict of rural KwaZulu-Natal, South Africa. Baseline data collection between 2010 and 2014 has been completed with the enrolment of 25 608 pregnancies; age ranged from 15-49 years. Pregnant women were assessed during routine antenatal visits: first visit, follow-up 1 week later, 32 weeks (HIV test), infant delivery and 6 weeks postpartum. Demographic, pregnancy, clinical, laboratory and HIV data were collected through Department of Health interviews, laboratory tests and routine data linkage. Treatment data for HIV-infected pregnant women were linked to the Africa Centre Hlabisa HIV Treatment and Care Programme for detailed antiretroviral therapy (ART) history and laboratory tests. FINDINGS TO DATE The proportion of women initiated on ART post-2013 were higher (n=437; 100%) than pre-2013 (n=768; 84.2%). The proportion of women in care at 6 weeks (73.8%) was also higher post-2013 relative to earlier years (58.5%). The majority of HIV-infected pregnant women were either on lifelong ART or ART prophylaxis; pre-2013, ∼ 9.6% of women were not on any ART. Pregnancy viral load monitoring was inadequate. FUTURE PLANS This cohort will be used to: (1) determine HIV acquisition risk during pregnancy and postpartum; (2) determine the effect of HIV and ART on birth outcomes; (3) examine the effect of pregnancy on virological response to ART; and (4) characterise the effect of sequential pregnancies on access to clinical care, response to prolonged ART and birth outcomes.
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Affiliation(s)
- Terusha Chetty
- Wellcome Trust Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | - Claire Thorne
- UCL Institute of Child Health, University College London, London, UK
| | - Frank Tanser
- Wellcome Trust Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Till Bärnighausen
- Wellcome Trust Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, USA
- Institute of Public Health, Medical School, University of Heidelberg, Heidelberg, Germany
| | - Anna Coutsoudis
- Department of Paediatrics and Child Health, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
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Bärnighausen T, Bloom DE, Humair S. Human Resources for Treating HIV/AIDS: Are the Preventive Effects of Antiretroviral Treatment a Game Changer? PLoS One 2016; 11:e0163960. [PMID: 27716813 PMCID: PMC5055321 DOI: 10.1371/journal.pone.0163960] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 09/16/2016] [Indexed: 11/19/2022] Open
Abstract
Shortages of human resources for treating HIV/AIDS (HRHA) are a fundamental barrier to reaching universal antiretroviral treatment (ART) coverage in developing countries. Previous studies suggest that recruiting HRHA to attain universal ART coverage poses an insurmountable challenge as ART significantly increases survival among HIV-infected individuals. While new evidence about ART's prevention benefits suggests fewer infections may mitigate the challenge, new policies such as treatment-as-prevention (TasP) will exacerbate it. We develop a mathematical model to analytically study the net effects of these countervailing factors. Using South Africa as a case study, we find that contrary to previous results, universal ART coverage is achievable even with current HRHA numbers. However, larger health gains are possible through a surge-capacity policy that aggressively recruits HRHA to reach universal ART coverage quickly. Without such a policy, TasP roll-out can increase health losses by crowding out sicker patients from treatment, unless a surge capacity exclusively for TasP is also created.
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Affiliation(s)
- Till Bärnighausen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Africa Health Research Institute (AHRI), Mtubatuba, KwaZulu Natal, South Africa
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - David E. Bloom
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Salal Humair
- Amazon.com, Inc., Seattle, Washington, United States of America
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Feigl AB, Bloom DE, Danaei G, Pillay D, Salomon JA, Tanser F, Bärnighausen TW. The Effect of HIV and the Modifying Effect of Anti-Retroviral Therapy (ART) on Body Mass Index (BMI) and Blood Pressure Levels in Rural South Africa. PLoS One 2016; 11:e0158264. [PMID: 27552195 PMCID: PMC4995007 DOI: 10.1371/journal.pone.0158264] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 06/13/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND High BMI and blood pressure are leading chronic disease risk factors in South Africa. Longterm effects of HIV and ART on adiposity and blood pressure are poorly understood, and direct comparisons of risk factor trajectories in HIV- versus HIV+ populations are rare. METHODS In 2003 and 2010, height, weight, and blood pressure were recorded in a study population (n = 505) in KwaZulu-Natal, South Africa (30% adult HIV prevalence). We modeled change in BMI and BP longitudinally in HIV- individuals (n = 315), seroconverters (n = 32), HIV+ patients not on ART (HIV+ART-; n = 52), HIV+ patients on ART for 0-<2 years as of 2010 (HIV+ART0-<2 yrs; n = 18), patients on ART for 2-5 years (HIV+ART2-5yrs; n = 44), and a subgroup with unknown HIV status (n = 44). Difference-in-differences were assessed in reference to the HIV- population. RESULTS Between 2003 and 2010, BMI increased significantly in the HIV- group, by 0.874 (95% CI 0.339, 1.41; p = 0.001), to 30.4. BMI drop was significantly greater in HIV+ART0-<2yrs than in HIV+ART2-5yrs (p = 0.005). DID in BMI in HIV+ART0-<2yrs versus the reference was -5.21 (95% CI -7.53, -2.90; p = 0.001), and DID in HIV+ART2-5yrs versus reference was -1.35 (95% CI -2.89, 0.189; p = 0.086). DID in SBP in HIV+ART-vs HIV- DID was -7.55 mmHg (95% CI -13.2 to -1.90; p = 0.009). CONCLUSION Short-term ART (0-<2 years) was associated with larger weight loss than either no ART or long-term ART. Once on ART for 2+ years, individuals 'caught up' on weight gain with the HIV- population. Our results showcase the importance of health system readiness to address the burgeoning double burden of disease in South Africa.
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Affiliation(s)
- Andrea B. Feigl
- Harvard Medical School, Department of Global Health and Social Medicine, 641 Huntington Ave, 02115, Boston, MA, United States of America
- Africa Health Research Institute, Somkhele, South Africa
| | - David E. Bloom
- Harvard TH Chan School of Public Health, Dept. of Global Health and Population, 677 Huntington Ave, 02115, Boston, MA, United States of America
| | - Goodarz Danaei
- Harvard TH Chan School of Public Health, Dept. of Global Health and Population, 677 Huntington Ave, 02115, Boston, MA, United States of America
| | - Deenan Pillay
- Africa Health Research Institute, Somkhele, South Africa
- Division of Infection & Immunology, University College London, London, United Kingdom
| | - Joshua A. Salomon
- Harvard TH Chan School of Public Health, Dept. of Global Health and Population, 677 Huntington Ave, 02115, Boston, MA, United States of America
| | - Frank Tanser
- Africa Health Research Institute, Somkhele, South Africa
- Division of Infection & Immunology, University College London, London, United Kingdom
| | - Till W. Bärnighausen
- Harvard TH Chan School of Public Health, Dept. of Global Health and Population, 677 Huntington Ave, 02115, Boston, MA, United States of America
- Africa Health Research Institute, Somkhele, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Institute of Public Health, Heidelberg University, Heidelberg, Germany
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