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Osman M, van Schalkwyk C, Naidoo P, Seddon JA, Dunbar R, Dlamini SS, Welte A, Hesseling AC, Claassens MM. Mortality during tuberculosis treatment in South Africa using an 8-year analysis of the national tuberculosis treatment register. Sci Rep 2021; 11:15894. [PMID: 34354135 PMCID: PMC8342475 DOI: 10.1038/s41598-021-95331-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 07/20/2021] [Indexed: 11/18/2022] Open
Abstract
In 2011, the South African HIV treatment eligibility criteria were expanded to allow all tuberculosis (TB) patients lifelong ART. The impact of this change on TB mortality in South Africa is not known. We evaluated mortality in all adults (≥ 15 years old) treated for drug-susceptible TB in South Africa between 2009 and 2016. Using a Cox regression model, we quantified risk factors for mortality during TB treatment and present standardised mortality ratios (SMR) stratified by year, age, sex, and HIV status. During the study period, 8.6% (219,618/2,551,058) of adults on TB treatment died. Older age, male sex, previous TB treatment and HIV infection (with or without the use of ART) were associated with increased hazard of mortality. There was a 19% reduction in hazard of mortality amongst all TB patients between 2009 and 2016 (adjusted hazard ratio: 0.81 95%CI 0.80-0.83). The highest SMR was in 15-24-year-old women, more than double that of men (42.3 in 2016). Between 2009 and 2016, the SMR for HIV-positive TB patients increased, from 9.0 to 19.6 in women, and 7.0 to 10.6 in men. In South Africa, case fatality during TB treatment is decreasing and further interventions to address specific risk factors for TB mortality are required. Young women (15-24-year-olds) with TB experience a disproportionate burden of mortality and interventions targeting this age-group are needed.
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Affiliation(s)
- Muhammad Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Parow, Cape Town, 7505, South Africa.
| | - Cari van Schalkwyk
- DSI-NRF South African Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Pren Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Parow, Cape Town, 7505, South Africa
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Parow, Cape Town, 7505, South Africa
- Department of Infectious Diseases, Imperial College London, London, UK
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Parow, Cape Town, 7505, South Africa
| | - Sicelo S Dlamini
- Research Information Monitoring, Evaluation & Surveillance (RIMES), National TB Control & Management Cluster, National Department of Health, Pretoria, South Africa
| | - Alex Welte
- DSI-NRF South African Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Parow, Cape Town, 7505, South Africa
| | - Mareli M Claassens
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Parow, Cape Town, 7505, South Africa.
- Department of Biochemistry and Microbiology, School of Medicine, University of Namibia, Bach Street, Windhoek, Namibia.
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Kim H, Tanser F, Tomita A, Vandormael A, Cuadros DF. Beyond HIV prevalence: identifying people living with HIV within underserved areas in South Africa. BMJ Glob Health 2021; 6:bmjgh-2020-004089. [PMID: 33883186 PMCID: PMC8061852 DOI: 10.1136/bmjgh-2020-004089] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 03/10/2021] [Accepted: 03/12/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Despite progress towards the Joint United Nations Programme on HIV/AIDS 95-95-95 targets, South Africa is still suffering from one of the largest HIV epidemics globally. In this study, we generated high-resolution HIV prevalence maps and identified people living with HIV (PLHIV) in underserved areas to provide essential information for the optimal allocation of HIV-related services. METHODS The data come from the South Africa Demographic and Health Survey conducted in 2016 and spatial variables from other published literature. We produced high-resolution maps of HIV prevalence and underserved areas, defined as a greater than 30 min travel time to the nearest healthcare facility. Using these maps and the population density, we mapped PLHIV and the PLHIV within underserved areas for 30, 60 and 120 min thresholds. RESULTS There was substantial geographic variation in HIV prevalence, ranging from 1.4% to 24.2%, with a median of 11.5% for men, and from 2.1% to 48.1%, with a median of 20.6% for women. Gauteng province showed the highest density for both HIV prevalence and PLHIV. 80% of all areas in the country were identified as underserved areas (30 min threshold), which contained more than 16% and 20% of the total men and women living with HIV, respectively. KwaZulu-Natal province had the largest number of PLHIV in underserved areas (30 min threshold) and showed less than one healthcare facility per 1000 PLHIV. CONCLUSION Our study showed extensive spatial variation of HIV prevalence and significant numbers of PLHIV in underserved areas in South Africa. Moreover, we identified locations where HIV-related services need to be intensified to reach the ~1.5 million PLHIV in underserved areas, particularly in KwaZulu-Natal province, with less than one healthcare facility per 1000 PLHIV.
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Affiliation(s)
- Hana Kim
- Department of Geography and Geographic Information Science, University of Cincinnati, Cincinnati, Ohio, USA.,Health Geography and Disease Modeling Laboratory, University of Cincinnati, Cincinnati, Ohio, USA
| | - Frank Tanser
- Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, UK.,Africa Health Research Institute, KwaZulu-Natal, South Africa.,School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.,Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Andrew Tomita
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,KwaZulu-Natal Research Innovation and Sequencing Platform, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Alain Vandormael
- Heidelberg Institute of Global Health (HIGH), Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Diego F Cuadros
- Department of Geography and Geographic Information Science, University of Cincinnati, Cincinnati, Ohio, USA .,Health Geography and Disease Modeling Laboratory, University of Cincinnati, Cincinnati, Ohio, USA
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53
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Parker E, Judge MA, Macete E, Nhampossa T, Dorward J, Langa DC, Schacht CD, Couto A, Vaz P, Vitoria M, Molfino L, Idowu RT, Bhatt N, Naniche D, Le Souëf PN. HIV infection in Eastern and Southern Africa: Highest burden, largest challenges, greatest potential. South Afr J HIV Med 2021; 22:1237. [PMID: 34192070 PMCID: PMC8182467 DOI: 10.4102/sajhivmed.v22i1.1237] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 04/01/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The burden of HIV is especially concerning for Eastern and Southern Africa (ESA), as despite expansion of test-and-treat programmes, this region continues to experience significant challenges resulting from high rates of morbidity, mortality and new infections. Hard-won lessons from programmes on the ground in ESA should be shared. OBJECTIVES This report summarises relevant evidence and regional experts' recommendations regarding challenges specific to ESA. METHOD This commentary includes an in-depth review of relevant literature, progress against global goals and consensus opinion from experts. RESULTS Recommendations include priorities for essential research (surveillance data collection, key and vulnerable population education and testing, in-country testing trials and evidence-based support services to improve retention in care) as well as research that can accelerate progress towards the prevention of new infections and achieving ambitious global goals in ESA. CONCLUSION The elimination of HIV in ESA will require continued investment, commitment to evidence-based programmes and persistence. Local research is critical to ensuring that responses in ESA are targeted, efficient and evaluated.
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Affiliation(s)
- Erica Parker
- Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia
| | - Melinda A Judge
- Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia
| | | | | | - Jienchi Dorward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Denise C Langa
- Department of Surveillance, Instituto Nacional de Saúde, Maputo, Mozambique
| | | | - Aleny Couto
- National STI, HIV/AIDS Programme, Ministry of Health, Maputo, Mozambique
| | - Paula Vaz
- Fundaçao Ariel Glaser contra o SIDA pediátrico, Maputo, Mozambique
| | - Marco Vitoria
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | | - Rachel T Idowu
- Center for Global Health, Centers for Disease Control and Prevention, Maputo, Mozambique
| | - Nilesh Bhatt
- Elizabeth Glaser Pediatric AIDS Foundation, Maputo, Mozambique
| | - Denise Naniche
- Manhiça Health Research Centre, Manhiça, Mozambique
- Barcelona Institute for Global Health (ISGlobal), Spain
| | - Peter N Le Souëf
- Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia
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Cassidy T, Grimsrud A, Keene C, Lebelo K, Hayes H, Orrell C, Zokufa N, Mutseyekwa T, Voget J, Gerstenhaber R, Wilkinson L. Twenty-four-month outcomes from a cluster-randomized controlled trial of extending antiretroviral therapy refills in ART adherence clubs. J Int AIDS Soc 2021; 23:e25649. [PMID: 33340284 PMCID: PMC7749539 DOI: 10.1002/jia2.25649] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION The antiretroviral therapy (ART) adherence club (AC) model has supported clinically stable HIV patients' retention with group ART refills and psychosocial support. Reducing visit frequency by increasing ART refills to six months could further benefit patients and unburden health systems. We conducted a pragmatic non-inferiority cluster randomized trial comparing standard of care (SoC) ACs and six-month refill intervention ACs in a primary care facility in Khayelitsha, South Africa. METHODS Existing community-based and facility-based ACs were randomized to either SoC or intervention ACs. SoC ACs met five times annually, receiving two-month refills with a four-month refill over year-end. Blood was drawn at one AC visit with a clinical assessment at the next. Intervention ACs met twice annually receiving six-month refills, with an individual blood collection visit before the annual clinical assessment AC visit. The first study visits were in October and November 2017 and participants followed for 27 months. We report retention in care, viral load completion and viral suppression (<400 copies/mL) 24 months after enrolment and calculated intention-to-treat risk differences for the primary outcomes using generalized estimating equations specifying for clustering by AC. RESULTS Of 2150 participants included in the trial, 977 were assigned to the intervention arm (40 ACs) and 1173 to the SoC (48 ACs). Patient characteristics at enrolment were similar across groups. Retention in care at 24 months was similarly high in both arms: 93.6% (1098/1173) in SoC and 92.6% (905/977) in the intervention arm, with a risk difference of -1.0% (95% CI: -3.2 to 1.3). The intervention arm had higher viral load completion (90.8% (999/1173) versus 85.1% (887/977)) and suppression (87.3% (969 /1173) versus 82.6% (853/977)) at 24 months, with a risk difference for completion of 5.5% (95% CI: 1.5 to 9.5) and suppression of 4.6% (95% CI: 0.2 to 9.0). CONCLUSIONS Intervention AC patients receiving six-month ART refills showed non-inferior retention in care, viral load completion and viral load suppression to those in SoC ACs, adding to a growing literature showing good outcomes with extended ART dispensing intervals.
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Affiliation(s)
- Tali Cassidy
- Médecins Sans Frontières, Khayelitsha, South Africa.,Department of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Claire Keene
- Médecins Sans Frontières, Khayelitsha, South Africa
| | | | - Helen Hayes
- Western Cape Government Department of Health, Cape Town, South Africa
| | - Catherine Orrell
- Department of Medicine, Faculty of Health Sciences, Cape Town, South Africa.,The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | - Jacqueline Voget
- Western Cape Government Department of Health, Cape Town, South Africa
| | | | - Lynne Wilkinson
- International AIDS Society, Cape Town, South Africa.,Center for Infectious Disease and Epidemiological Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Louw Q, Grimmer K, Berner K, Conradie T, Bedada DT, Jesus TS. Towards a needs-based design of the physical rehabilitation workforce in South Africa: trend analysis [1990-2017] and a 5-year forecasting for the most impactful health conditions based on global burden of disease estimates. BMC Public Health 2021; 21:913. [PMID: 33985469 PMCID: PMC8116643 DOI: 10.1186/s12889-021-10962-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 04/27/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Rehabilitation can improve function in many people with chronic health conditions. It is important to consider priority conditions requiring rehabilitation, so it can be realistically positioned and costed in national health financing systems like South Africa (SA)'s proposed National Health Insurance (NHI). This paper describes temporal trends of top-ranked conditions on years lived with disability (YLDs) rates in SA, for which physical rehabilitation can ameliorate associated disability. METHODS This study is a systematic synthesis of publicly available Global Burden of Disease (GBD) 2017 estimates. The top 11 conditions contributing most to YLDs and for which evidence-based rehabilitation interventions exist were identified. Age-standardized rates per 100,000 and YLDs counts were extracted from 1990 to 2017. Significance of changes in temporal trends was determined using Mann-Kendall trend tests. Best-fit rates of yearly changes were calculated per condition, using GBD estimates (2012-2017), and extrapolated (by imposing the best-fit regression line onto results for each subsequent predicted year) as forecasts (2018-2022). RESULTS Trends for YLDs counts per condition year (1990-2017) and forecasted values (2018-2022) showed an overall steady increase for all conditions, except HIV and respiratory conditions. YLDs counts almost doubled from 1990 to 2017, with a 17% predicted increase from 2017 to 2022. The proportionate contribution to YLDs counts reduced over time for all conditions, except HIV. Although age-standardized YLDs rates appear relatively stable over the analyzed periods for all conditions (except HIV, respiratory conditions and type 2 diabetes), trend changes in YLDs rates over 28 years were significant for all conditions, except neonatal (p = 0.855), hearing loss (p = 0.100) and musculoskeletal conditions (p = 0.300). Significant trend decreases were apparent for 4/9 conditions, implying that another 5/9 conditions showed trend increases over 28 years. Predicted all-age prevalence in 2022 suggests relatively large increases for cardiovascular disease and heart failure, and burns, while relative decreases are predicted for fractures and dislocations, stroke, and musculoskeletal conditions. CONCLUSION Rehabilitation needs in SA are potentially massive and unmet, highlighting the need for innovative and context-specific rehabilitation that considers current local needs and projected changes. These findings should be considered when designing the NHI and other schemes in SA to ensure human and financial resources are deployed efficiently.
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Affiliation(s)
- Q Louw
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa.
| | - K Grimmer
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
| | - K Berner
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
| | - T Conradie
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
| | - D T Bedada
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - T S Jesus
- Global Health and Tropical Medicine (GHTM) & WHO Collaborating Centre for Health Workforce Policy and Planning, Institute of Hygiene and Tropical Medicine - NOVA University of Lisbon (IHMT-UNL), Rua da Junqueira 100, 1349-008, Lisbon, Portugal
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56
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Woldesenbet S, Kufa-Chakezha T, Lombard C, Manda S, Cheyip M, Ayalew K, Chirombo B, Barron P, Diallo K, Parekh B, Puren A. Recent HIV infection among pregnant women in the 2017 antenatal sentinel cross-sectional survey, South Africa: Assay-based incidence measurement. PLoS One 2021; 16:e0249953. [PMID: 33852629 PMCID: PMC8046194 DOI: 10.1371/journal.pone.0249953] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 03/27/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction New HIV infection during pre-conception and pregnancy is a significant contributor of mother–to–child transmission of HIV in South Africa. This study estimated HIV incidence (defined as new infection within the last one year from the time of the survey which included both new infections occurred during pregnancy or just before pregnancy) among pregnant women and described the characteristics of recently infected pregnant women at national level. Methods Between 1 October and 15 November 2017, we conducted a national cross–sectional survey among pregnant women aged 15–49 years old attending antenatal care at 1,595 public facilities. Blood specimens were collected from pregnant women and tested for HIV in a centralised laboratory. Plasma viral load and Limiting Antigen Avidity Enzyme Immunosorbent Assay (LAg) tests were further performed on HIV positive specimens to differentiate between recent and long–term infections. Recent infection was defined as infection that occurred within one year from the date of collection of blood specimen for the survey. Data on age, age of partner, and marital status were collected through interviews. Women whose specimens were classified as recent by LAg assay and with viral loads >1,000 copies/mL were considered as recently infected. The calculated proportion of HIV positive women with recent infection was adjusted for assay–specific parameters to estimate annual incidence. Survey multinomial logistic regression was used to examine factors associated with being recently infected using HIV negative women as a reference group. Age–disparate relationship was defined as having a partner 5 or more years older. Results Of 10,049 HIV positive participants with LAg and viral load data, 1.4% (136) were identified as recently infected. The annual HIV incidence was 1.5% (95% confidence interval (CI): 1.2–1.7). In multivariable analyses, being single (adjusted odds ratio, aOR: 3.4, 95% CI: 1.8–6.2) or cohabiting (aOR: 3.8, 95% CI: 1.8–7.7), compared to being married as well as being in an age–disparate relationship among young women (aOR: 3.1, 95% CI: 2.0–4.7; reference group: young women (15–24years) whose partners were not 5 years or more older) were associated with higher odds of recent infection. Conclusions Compared to previous studies among pregnant women, the incidence estimated in this study was substantially lower. However, the UNAIDS target to reduce incidence by 75% by 2020 (which is equivalent to reducing incidence to <1%) has not been met. The implementation of HIV prevention and treatment interventions should be intensified, targeting young women engaged in age–disparate relationship and unmarried women to fast track progress towards the UNAIDS target.
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Affiliation(s)
- Selamawit Woldesenbet
- Center for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Tendesayi Kufa-Chakezha
- Center for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
| | - Samuel Manda
- Biostatistics Unit, South African Medical Research Council, Pretoria, South Africa
- Department of Statistics, University of Pretoria, Pretoria, South Africa
| | - Mireille Cheyip
- Strategic Information Unit, Center for Disease Control and Prevention, Pretoria, South Africa
| | - Kassahun Ayalew
- Strategic Information Unit, Center for Disease Control and Prevention, Pretoria, South Africa
| | - Brian Chirombo
- HIV and Hepatitis Program, World Health Organization, Pretoria, South Africa
| | - Peter Barron
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Karidia Diallo
- Laboratory Branch, Centers for Disease Control and Prevention South Africa, Pretoria, South Africa
| | - Bharat Parekh
- Division of Global HIV/AIDS, International Laboratory Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Adrian Puren
- Center for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
- Division of Virology, School of Pathology University of the Witwatersrand, Johannesburg, South Africa
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Meisner J, Roberts DA, Rodriguez P, Sharma M, Newman Owiredu M, Gomez B, de Mello MB, Bobrik A, Vodianyk A, Storey A, Githuka G, Chidarikire T, Barnabas R, Farid S, Essajee S, Jamil MS, Baggaley R, Johnson C, Drake AL. Optimizing HIV retesting during pregnancy and postpartum in four countries: a cost-effectiveness analysis. J Int AIDS Soc 2021; 24:e25686. [PMID: 33787064 PMCID: PMC8010369 DOI: 10.1002/jia2.25686] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 02/04/2021] [Accepted: 02/17/2021] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION HIV retesting during late pregnancy and breastfeeding can help detect new maternal infections and prevent mother-to-child HIV transmission (MTCT), but the optimal timing and cost-effectiveness of maternal retesting remain uncertain. METHODS We constructed deterministic models to assess the health and economic impact of maternal HIV retesting on a hypothetical population of pregnant women, following initial testing in pregnancy, on MTCT in four countries: South Africa and Kenya (high/intermediate HIV prevalence), and Colombia and Ukraine (low HIV prevalence). We evaluated six scenarios with varying retesting frequencies from late in antenatal care (ANC) through nine months postpartum. We compared strategies using incremental cost-effectiveness ratios (ICERs) over a 20-year time horizon using country-specific thresholds. RESULTS We found maternal retesting once in late ANC with catch-up testing through six weeks postpartum was cost-effective in Kenya (ICER = $166 per DALY averted) and South Africa (ICER=$289 per DALY averted). This strategy prevented 19% (Kenya) and 12% (South Africa) of infant HIV infections. Adding one or two additional retests postpartum provided smaller benefits (1 to 2 percentage point increase in infections averted versus one retest). Adding three retests during the postpartum period averted additional infections (1 to 3 percentage point increase in infections averted versus one retest) but ICERs ($7639 and in Kenya and $11 985 in South Africa) greatly exceeded the cost-effectiveness thresholds. In Colombia and Ukraine, all retesting strategies exceeded the cost-effectiveness threshold and prevented few infant infections (up to 31 and 5 infections, respectively). CONCLUSIONS In high HIV burden settings with MTCT rates similar to those seen in Kenya and South Africa, HIV retesting once in late ANC, with subsequent intervention, is the most cost-effective strategy for preventing infant HIV infections. In these settings, two HIV retests postpartum marginally reduced MTCT and were less costly than adding three retests. Retesting in low-burden settings with MTCT rates similar to Colombia and Ukraine was not cost-effective at any time point due to very low HIV prevalence and limited breastfeeding.
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Affiliation(s)
| | - D Allen Roberts
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
| | - Patricia Rodriguez
- The Comparative Health Outcomes Policy & Economics InstituteUniversity of WashingtonSeattleWAUSA
| | - Monisha Sharma
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | | | - Bertha Gomez
- Pan American Health Organization/World Health OrganizationColombia OfficeBogotáColombia
| | - Maeve B de Mello
- Department of Communicable Diseases and Environmental Determinants of HealthPan American Health Organization/World Health OrganizationWashingtonDCUSA
| | - Alexey Bobrik
- Global Fund to Fight AIDS, Tuberculosis and MalariaGenevaSwitzerland
| | | | | | | | - Thato Chidarikire
- HIV Prevention ProgrammesNational Department of HealthPretoriaSouth Africa
| | - Ruanne Barnabas
- Department of EpidemiologyUniversity of WashingtonSeattleWAUSA
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
| | - Shiza Farid
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | | | - Muhammad S Jamil
- Global HIV, Hepatitis and STI programmeWorld Health OrganizationGenevaSwitzerland
| | - Rachel Baggaley
- Global HIV, Hepatitis and STI programmeWorld Health OrganizationGenevaSwitzerland
| | - Cheryl Johnson
- Global HIV, Hepatitis and STI programmeWorld Health OrganizationGenevaSwitzerland
| | - Alison L Drake
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
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Osman M, du Preez K, Seddon JA, Claassens MM, Dunbar R, Dlamini SS, Welte A, Naidoo P, Hesseling AC. Mortality in South African Children and Adolescents Routinely Treated for Tuberculosis. Pediatrics 2021; 147:peds.2020-032490. [PMID: 33692161 PMCID: PMC8405866 DOI: 10.1542/peds.2020-032490] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/09/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND In South Africa, tuberculosis (TB) is a leading cause of death among those <20 years of age. We describe changes in TB mortality among children and adolescents in South Africa over a 13-year period, identify risk factors for mortality, and estimate excess TB-related mortality. METHODS Retrospective analysis of all patients <20 years of age routinely recorded in the national electronic drug-susceptible TB treatment register (2004-2016). We developed a multivariable Cox regression model for predictors of mortality and used estimates of mortality among the general population to calculate standardized mortality ratios (SMRs). RESULTS Between 2004 and 2016, 729 463 children and adolescents were recorded on TB treatment; 84.0% had treatment outcomes and 2.5% (18 539) died during TB treatment. The case fatality ratio decreased from 3.3% in 2007 to 1.9% in 2016. In the multivariable Cox regression model, ages 0 to 4, 10 to 14, and 15 to 19 years (compared with ages 5 to 9 years) were associated with increased risk of mortality, as was HIV infection, previous TB treatment, and extrapulmonary involvement. The SMR of 15 to 19-year-old female patients was more than double that of male patients the same age (55.3 vs 26.2). Among 10 to 14-year-olds and those who were HIV-positive, SMRs increased over time. CONCLUSIONS Mortality in South African children and adolescents treated for TB is declining but remains considerable, with 2% dying during 2016. Adolescents (10 to 19 years) and those people living with HIV have the highest risk of mortality and the greatest SMRs. Interventions to reduce mortality during TB treatment, specifically targeting those at highest risk, are urgently needed.
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Affiliation(s)
- Muhammad Osman
- Desmond Tutu Tuberculosis Centre, Departments of Paediatrics and Child Health and
| | - Karen du Preez
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - James A. Seddon
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa,Department of Infectious Diseases, Imperial College London, London, United Kingdom
| | - Mareli M. Claassens
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa,Department of Biochemistry and Microbiology, School of Medicine, University of Namibia, Windhoek, Namibia
| | - Rory Dunbar
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Sicelo S. Dlamini
- Research Information Monitoring, Evaluation, and Surveillance, National Tuberculosis Control and Management Cluster, National Department of Health, Pretoria, South Africa
| | - Alex Welte
- Department of Science and Innovation – National Research Foundation South African Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Pren Naidoo
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Anneke C. Hesseling
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
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Mouton JP, Blockman M, Sekaggya-Wiltshire C, Semakula J, Waitt C, Pirmohamed M, Cohen K. Improving anticoagulation in sub-Saharan Africa: What are the challenges and how can we overcome them? Br J Clin Pharmacol 2021; 87:3056-3068. [PMID: 33586223 PMCID: PMC8359270 DOI: 10.1111/bcp.14768] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 01/04/2021] [Accepted: 02/05/2021] [Indexed: 12/12/2022] Open
Abstract
Patients in sub-Saharan Africa generally have poor anticoagulation control. We review the potential reasons for this poor control, as well as the potential solutions. Challenges include the affordability and centralisation of anticoagulation care, problems with access to medicines and international normalised ratio monitoring, the lack of locally validated standardized dosing protocols, and low levels of anticoagulation knowledge among healthcare workers and patients. Increasing numbers of patients will need anticoagulation in the future because of the increasing burden of noncommunicable disease in the region. We propose that locally developed "warfarin care bundles" which address multiple anticoagulation challenges in combination may be the most appropriate solution in this setting currently.
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Affiliation(s)
- Johannes P Mouton
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marc Blockman
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Jerome Semakula
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Catriona Waitt
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.,Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Tiwari R, Wildschut-February A, Nkonki L, English R, Karangwa I, Chikte U. Reflecting on the current scenario and forecasting the future demand for medical doctors in South Africa up to 2030: towards equal representation of women. HUMAN RESOURCES FOR HEALTH 2021; 19:27. [PMID: 33653366 PMCID: PMC7923812 DOI: 10.1186/s12960-021-00567-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 02/18/2021] [Indexed: 05/05/2023]
Abstract
BACKGROUND Increasing feminization of medical professions is well-acknowledged. However, this does not always equate to equitable representation of women within medicine, regarding their socio-demographic indicators, regions, sectors and fields of practice. Thus, this paper quantifies the gap in supply of female medical doctors in relation to demand, towards reaching different gender equity scenarios. METHODS A retrospective review of the Health Professions Council of South Africa's (HPCSA) database on registered medical doctors (medical practitioners and medical specialists) from 2002 until 2019 was utilized as an indicator of supply. Descriptive statistics were used to summarize data, and inferential statistics (considering a significance level of 0.05) were utilized to determine the association between the number of male and female doctors, disaggregated by demographic variables. We forecasted future gaps of South African male and female doctors up to 2030, based on maintaining the current male-to-female ratio and attaining an equitable ratio of 1:1. RESULTS While the ratio of female doctors per 10 000 population has increased between 2000 and 2019, from 1.2 to 3.2, it remains substantially lower than the comparative rate for male doctors per 10 000 population which increased from 3.5 in 2000 to 4.7 in 2019. Men continue to dominate the medical profession in 2019, representing 59.4% (27,579) of medical doctors registered with the HPCSA with females representing 40.6% (18,841), resulting in a male-to-female ratio of 1:0.7. Female doctors from the Black population group have constantly grown in the medical workforce from 4.4% (2000), to 12.5% (2019). There would be a deficit of 2242 female doctors by 2030 to achieve a 1:1 ratio between male and female medical doctors. An independent-samples t-test revealed that there was a significant difference in the number of male and female doctors. The Kruskal-Wallis test indicated that there was a sustained significant difference in terms of the number of male and female doctors by population groups and geographical distribution. CONCLUSIONS Based on the investigation, we propose that HRH planning incorporate forecasting methodologies towards reaching gender equity targets to inform planning for production of healthcare workers.
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Affiliation(s)
- Ritika Tiwari
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Health and Medical Sciences, Stellenbosch University, Tygerberg Hospital, Francie Van Zijl Dr, Cape Town, 7505, South Africa
| | - Angelique Wildschut-February
- Research and Policy, The National Student Financial Aid Scheme, Cape Town, South Africa
- Department of Sociology, University of Pretoria, Pretoria, South Africa
| | - Lungiswa Nkonki
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Health and Medical Sciences, Stellenbosch University, Tygerberg Hospital, Francie Van Zijl Dr, Cape Town, 7505, South Africa
| | - René English
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Health and Medical Sciences, Stellenbosch University, Tygerberg Hospital, Francie Van Zijl Dr, Cape Town, 7505, South Africa
| | - Innocent Karangwa
- Department of Statistics and Population Studies Programme, University of the Western Cape, Cape Town, South Africa
| | - Usuf Chikte
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Health and Medical Sciences, Stellenbosch University, Tygerberg Hospital, Francie Van Zijl Dr, Cape Town, 7505, South Africa.
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Mouton JP, Jobanputra N, Njuguna C, Gunter H, Stewart A, Mehta U, Lahri S, Court R, Igumbor E, Maartens G, Cohen K. Adult medical emergency unit presentations due to adverse drug reactions in a setting of high HIV prevalence. Afr J Emerg Med 2021; 11:46-52. [PMID: 33437593 PMCID: PMC7787921 DOI: 10.1016/j.afjem.2020.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/22/2020] [Accepted: 10/19/2020] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION South Africa has the world's largest antiretroviral treatment programme, which may contribute to the adverse drug reaction (ADR) burden. We aimed to determine the proportion of adult non-trauma emergency unit (EU) presentations attributable to ADRs and to characterise ADR-related EU presentations, stratified according to HIV status, to determine the contribution of drugs used in management of HIV and its complications to ADR-related EU presentations, and identify factors associated with ADR-related EU presentation. METHODS We conducted a retrospective folder review on a random 1.7% sample of presentations over a 12-month period in 2014/2015 to the EUs of two hospitals in Cape Town, South Africa. We identified potential ADRs with the help of a trigger tool. A multidisciplinary panel assessed potential ADRs for causality, severity, and preventability. RESULTS We included 1010 EU presentations and assessed 80/1010 (7.9%) as ADR-related, including 20/239 (8.4%) presentations among HIV-positive attendees. Among HIV-positive EU attendees with ADRs 17/20 (85%) were admitted, versus 22/60 (37%) of HIV-negative/unknown EU attendees. Only 5/21 (24%) ADRs in HIV-positive EU attendees were preventable, versus 24/63 (38%) in HIV-negative/unknown EU attendees. On multivariate analysis, only increasing drug count was associated with ADR-related EU presentation (adjusted odds ratio 1.10 per additional drug, 95% confidence interval 1.03 to 1.18), adjusted for age, sex, HIV status, comorbidity, and hospital. CONCLUSIONS ADRs caused a significant proportion of EU presentations, similar to findings from other resource-limited settings. The spectrum of ADR manifestations in our EUs reflects South Africa's colliding epidemics of infectious and non-communicable diseases. ADRs among HIV-positive EU attendees were more severe and less likely to be preventable.
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New-Aaron M, Ganesan M, Dagur RS, Kharbanda KK, Poluektova LY, Osna NA. Pancreatogenic Diabetes: Triggering Effects of Alcohol and HIV. BIOLOGY 2021; 10:108. [PMID: 33546230 PMCID: PMC7913335 DOI: 10.3390/biology10020108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/29/2021] [Accepted: 01/29/2021] [Indexed: 02/07/2023]
Abstract
Multiorgan failure may not be completely resolved among people living with HIV despite HAART use. Although the chances of organ dysfunction may be relatively low, alcohol may potentiate HIV-induced toxic effects in the organs of alcohol-abusing, HIV-infected individuals. The pancreas is one of the most implicated organs, which is manifested as diabetes mellitus or pancreatic cancer. Both alcohol and HIV may trigger pancreatitis, but the combined effects have not been explored. The aim of this review is to explore the literature for understanding the mechanisms of HIV and alcohol-induced pancreatotoxicity. We found that while premature alcohol-inducing zymogen activation is a known trigger of alcoholic pancreatitis, HIV entry through C-C chemokine receptor type 5(CCR5)into pancreatic acinar cells may also contribute to pancreatitis in people living with HIV (PLWH). HIV proteins induce oxidative and ER stresses, causing necrosis. Furthermore, infiltrative immune cells induce necrosis on HIV-containing acinar cells. When necrotic products interact with pancreatic stellate cells, they become activated, leading to the release of both inflammatory and profibrotic cytokines and resulting in pancreatitis. Effective therapeutic strategies should block CCR5 and ameliorate alcohol's effects on acinar cells.
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Affiliation(s)
- Moses New-Aaron
- Department of Environmental Health, Occupational Health and Toxicology, University of Nebraska Medical Center, Omaha, NE 68198, USA
- Veteran Affairs Nebraska—Western Iowa Health Care System, Omaha, NE 68105, USA; (M.G.); (R.S.D.); (K.K.K.)
| | - Murali Ganesan
- Veteran Affairs Nebraska—Western Iowa Health Care System, Omaha, NE 68105, USA; (M.G.); (R.S.D.); (K.K.K.)
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Raghubendra Singh Dagur
- Veteran Affairs Nebraska—Western Iowa Health Care System, Omaha, NE 68105, USA; (M.G.); (R.S.D.); (K.K.K.)
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Kusum K. Kharbanda
- Veteran Affairs Nebraska—Western Iowa Health Care System, Omaha, NE 68105, USA; (M.G.); (R.S.D.); (K.K.K.)
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Larisa Y. Poluektova
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA;
| | - Natalia A. Osna
- Department of Environmental Health, Occupational Health and Toxicology, University of Nebraska Medical Center, Omaha, NE 68198, USA
- Veteran Affairs Nebraska—Western Iowa Health Care System, Omaha, NE 68105, USA; (M.G.); (R.S.D.); (K.K.K.)
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68198, USA;
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Kleynhans J, Tempia S, Shioda K, von Gottberg A, Weinberger DM, Cohen C. Estimated impact of the pneumococcal conjugate vaccine on pneumonia mortality in South Africa, 1999 through 2016: An ecological modelling study. PLoS Med 2021; 18:e1003537. [PMID: 33591995 PMCID: PMC7924778 DOI: 10.1371/journal.pmed.1003537] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 03/02/2021] [Accepted: 01/12/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Data on the national-level impact of pneumococcal conjugate vaccine (PCV) introduction on mortality are lacking from Africa. PCV was introduced in South Africa in 2009. We estimated the impact of PCV introduction on all-cause pneumonia mortality in South Africa, while controlling for changes in mortality due to other interventions. METHODS AND FINDINGS We used national death registration data in South Africa from 1999 to 2016 to assess the impact of PCV introduction on all-cause pneumonia mortality in all ages, with the exclusion of infants aged <1 month. We created a composite (synthetic) control using Bayesian variable selection of nondiarrheal, nonpneumonia, and nonpneumococcal deaths to estimate the number of expected all-cause pneumonia deaths in the absence of PCV introduction post 2009. We compared all-cause pneumonia deaths from the death registry to the expected deaths in 2012 to 2016. We also estimated the number of prevented deaths during 2009 to 2016. Of the 9,324,638 deaths reported in South Africa from 1999 to 2016, 12·6% were pneumonia-related. Compared to number of deaths expected, we estimated a 33% (95% credible interval (CrI) 26% to 43%), 23% (95%CrI 17% to 29%), 25% (95%CrI 19% to 32%), and 23% (95%CrI 11% to 32%) reduction in pneumonia mortality in children aged 1 to 11 months, 1 to 4 years, 5 to 7 years, and 8 to 18 years in 2012 to 2016, respectively. In total, an estimated 18,422 (95%CrI 12,388 to 26,978) pneumonia-related deaths were prevented from 2009 to 2016 in children aged <19 years. No declines were estimated observed among adults following PCV introduction. This study was mainly limited by coding errors in original data that could have led to a lower impact estimate, and unmeasured factors could also have confounded estimates. CONCLUSIONS This study found that the introduction of PCV was associated with substantial reduction in all-cause pneumonia deaths in children aged 1 month to <19 years. The model predicted an effect of PCV in age groups who were eligible for vaccination (1 months to 4 years), and an indirect effect in those too old (8 to 18 years) to be vaccinated. These findings support sustaining pneumococcal vaccination to reduce pneumonia-related mortality in children.
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Affiliation(s)
- Jackie Kleynhans
- Centre for Respiratory Diseases and Meningitis (CRDM), National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Stefano Tempia
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kayoko Shioda
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Anne von Gottberg
- Centre for Respiratory Diseases and Meningitis (CRDM), National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Daniel M. Weinberger
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Cheryl Cohen
- Centre for Respiratory Diseases and Meningitis (CRDM), National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Sheik S, Willems B. Estimating qualification and factors associated with third-line antiretroviral therapy referral in the Western Cape. South Afr J HIV Med 2021; 22:1184. [PMID: 33824731 PMCID: PMC8008132 DOI: 10.4102/sajhivmed.v22i1.1184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 12/08/2020] [Indexed: 11/29/2022] Open
Abstract
Background South Africa’s antiretroviral therapy (ART) programme is the largest globally and the universal test-and-treat policy is expected to increase the numbers on ART. This may have implications for treatment failure rates implying a greater future need for third-line regimens. South Africa initiated a third-line programme in 2013. However, there is little evidence quantifying the third-line need in this setting and the programme itself has not been formally evaluated. Objectives The study evaluated the third-line ART referral process in the Western Cape. Method Routinely collected data were analysed to derive an estimate of patients meeting criteria for third-line referral and compared with patients who were referred. Factors associated with referral were identified. Results In the study period, 947 patients met criteria for third-line referral and 167 patients were referred. Comparison revealed a poor overlap of only 42 patients. In multivariate analysis, factors associated with referral included receiving care at a hospital rather than a primary healthcare facility (adjusted odd ratios [aOR] = 2.15, 95% confidence interval [CI] 1.1–4.2), a higher number of viral load [VLs] ≥ 1000 copies/mL whilst on a protease inhibitor (PI) (aOR = 1.2, 95% CI 1.01–1.42) and a greater number of years on a PI (aOR = 1.25, 95% CI 1.07–1.46). Patients with a 6-month gap in dispensing were less likely to be referred (aOR = 0.37, 95% CI 0.17–0.81). Conclusion This study adds to a limited body of knowledge regarding third-line ART programmes. The findings indicate missed opportunities for and inappropriate referral of patients. Factors associated with referral were largely health system related. Clinician awareness and compliance with referral remain unknown and may be contributory.
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Affiliation(s)
- Sadiyya Sheik
- Department of Global Health, Faculty of Health Systems and Public Health, Stellenbosch University, Cape Town, South Africa
| | - Bart Willems
- Department of Global Health, Faculty of Health Systems and Public Health, Stellenbosch University, Cape Town, South Africa
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Stone J, Mukandavire C, Boily M, Fraser H, Mishra S, Schwartz S, Rao A, Looker KJ, Quaife M, Terris‐Prestholt F, Marr A, Lane T, Coetzee J, Gray G, Otwombe K, Milovanovic M, Hausler H, Young K, Mcingana M, Ncedani M, Puren A, Hunt G, Kose Z, Phaswana‐Mafuya N, Baral S, Vickerman P. Estimating the contribution of key populations towards HIV transmission in South Africa. J Int AIDS Soc 2021; 24:e25650. [PMID: 33533115 PMCID: PMC7855076 DOI: 10.1002/jia2.25650] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 10/26/2020] [Accepted: 11/12/2020] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION In generalized epidemic settings, there is insufficient understanding of how the unmet HIV prevention and treatment needs of key populations (KPs), such as female sex workers (FSWs) and men who have sex with men (MSM), contribute to HIV transmission. In such settings, it is typically assumed that HIV transmission is driven by the general population. We estimated the contribution of commercial sex, sex between men, and other heterosexual partnerships to HIV transmission in South Africa (SA). METHODS We developed the "Key-Pop Model"; a dynamic transmission model of HIV among FSWs, their clients, MSM, and the broader population in SA. The model was parameterized and calibrated using demographic, behavioural and epidemiological data from national household surveys and KP surveys. We estimated the contribution of commercial sex, sex between men and sex among heterosexual partnerships of different sub-groups to HIV transmission over 2010 to 2019. We also estimated the efficiency (HIV infections averted per person-year of intervention) and prevented fraction (% IA) over 10-years from scaling-up ART (to 81% coverage) in different sub-populations from 2020. RESULTS Sex between FSWs and their paying clients, and between clients with their non-paying partners contributed 6.9% (95% credibility interval 4.5% to 9.3%) and 41.9% (35.1% to 53.2%) of new HIV infections in SA over 2010 to 2019 respectively. Sex between low-risk groups contributed 59.7% (47.6% to 68.5%), sex between men contributed 5.3% (2.3% to 14.1%) and sex between MSM and their female partners contributed 3.7% (1.6% to 9.8%). Going forward, the largest population-level impact on HIV transmission can be achieved from scaling up ART to clients of FSWs (% IA = 18.2% (14.0% to 24.4%) or low-risk individuals (% IA = 20.6% (14.7 to 27.5) over 2020 to 2030), with ART scale-up among KPs being most efficient. CONCLUSIONS Clients of FSWs play a fundamental role in HIV transmission in SA. Addressing the HIV prevention and treatment needs of KPs in generalized HIV epidemics is central to a comprehensive HIV response.
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Affiliation(s)
- Jack Stone
- Population Health SciencesUniversity of BristolBristolUnited Kingdom
| | - Christinah Mukandavire
- Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Marie‐Claude Boily
- Department of Infectious Disease EpidemiologyImperial CollegeLondonUnited Kingdom
| | - Hannah Fraser
- Population Health SciencesUniversity of BristolBristolUnited Kingdom
| | | | - Sheree Schwartz
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Amrita Rao
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | | | - Matthew Quaife
- London School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | | | - Alexander Marr
- University of California San FranciscoSan FranciscoCAUSA
| | - Tim Lane
- Equal InternationalWashingtonDCUSA
| | - Jenny Coetzee
- Perinatal HIV Research UnitFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- South African Medical Research CouncilCape TownSouth Africa
| | - Glenda Gray
- South African Medical Research CouncilCape TownSouth Africa
| | - Kennedy Otwombe
- Perinatal HIV Research UnitFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Minja Milovanovic
- Perinatal HIV Research UnitFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | | | | | | | | | - Adrian Puren
- National Institute of Communicable DiseasesJohannesburgSouth Africa
| | - Gillian Hunt
- National Institute of Communicable DiseasesJohannesburgSouth Africa
| | - Zamakayise Kose
- Research and Innovation OfficeNorth West UniversityPotchefstroomSouth Africa
| | | | - Stefan Baral
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Peter Vickerman
- Population Health SciencesUniversity of BristolBristolUnited Kingdom
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Mduzana L, Tiwari R, Lieketseng N, Chikte U. Exploring national human resource profile and trends of Prosthetists/Orthotists in South Africa from 2002 to 2018. Glob Health Action 2020; 13:1792192. [PMID: 32723026 PMCID: PMC7480577 DOI: 10.1080/16549716.2020.1792192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background The World Health Organization (WHO) in 2017 estimated that around 35–40 million people require prosthetic or orthotic services. The Framework and Strategy for Disability and Rehabilitation 2015–2030 for South Africa highlights a shortage of human resources for disability and rehabilitation services to manage the various risks and types of impairments faced by the population. Objective To describe the demographic trends of Prosthetists/Orthotists (P/O) registered with the Health Professions Council of South Africa (HPCSA) from 2002 to 2018. Methods The study was a retrospective record-based review of the Health Professions Council of South Africa (HPCSA) database from 2002 until 2018. The database of registered Prosthetists/Orthotists was obtained from the HPCSA. Results Data were analysed using the Statistical Package for the Social Sciences (SPSS version 22.0). In 2018, there were 544 P/Os registered with the HPCSA with a ratio of 0.09 P/Os per 10,000 population. There has been an average annual increase of 6% from 2002 to 2018. The majority (71.9%) of P/Os are located in the more densely populated and urbanized provinces, namely Gauteng, KwaZulu-Natal and Western Cape. The majority of registered P/Os identified as white (61%) followed by Black (22%), Indian (7%) and Coloured (2%). Most of registered P/Os are under the age of 40 years (54.2%) and males make up 73% of the registered P/Os. Conclusion This study highlights the unequal spatial distribution trends of P/Os which could be accounted for by South Africa’s apartheid history and the subsequent slow pace of transformation. Addressing the existing shortages is necessary to expand access to P/Os services and to ensure the motivation, planning and provision of adequate infrastructure to provide these services. The study presents a compelling case for the prioritization and strengthening of this workforce for the achievement of effective universal health coverage for persons with disabilities.
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Affiliation(s)
- Luphiwo Mduzana
- Department of Rehabilitation Medicine, Faculty of Health Sciences, Walter Sisulu University , Mthatha, South Africa
| | - Ritika Tiwari
- Division of Health Systems and Public Health, Department of Global Health, Stellenbosch University , Stellenbosch, South Africa
| | - Ned Lieketseng
- Centre for Rehabilitation Studies, Department of Global Health, Stellenbosch University , Stellenbosch, South Africa
| | - Usuf Chikte
- Division of Health Systems and Public Health, Department of Global Health, Stellenbosch University , Stellenbosch, South Africa
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Maphanga TG, Naicker SD, Gómez BL, Mhlanga M, Mpembe RS, Schwartz IS, Bamford C, Nel J, Govender NP. Cross-reactivity of a Histoplasma capsulatum antigen enzyme immunoassay in urine specimens from persons with emergomycosis in South Africa. Med Mycol 2020; 59:672-682. [PMID: 33330930 DOI: 10.1093/mmy/myaa100] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/26/2020] [Indexed: 01/20/2023] Open
Abstract
Histoplasma antigen detection in urine is a rapid diagnostic method for disseminated histoplasmosis, although cross-reactivity has been reported in specimens from patients with other thermally dimorphic fungal infections. We tested urine specimens, from persons with suspected invasive fungal infections, using a commercial monoclonal antibody Histoplasma enzyme immunoassay (EIA) at a South African national mycology reference laboratory from August 2014 through December 2018. Corresponding fungal culture and histopathology results were obtained from an electronic laboratory information system. In some cases, cultured fungal isolates were sent with the urine specimen for species-level identification by phenotypic and molecular methods. Cross-reactivity was confirmed using culture filtrates of several fungal pathogens. Of 212 referred cases, 41 (19%) were excluded since they had no recorded clinical history (n = 1), alternative diagnoses were confirmed (n = 2), or no fungal culture or histopathology results (n = 38). Eighty-seven of 212 (41%) had laboratory evidence of an invasive fungal disease, while 84 (40%) did not. Of the 87 cases, 37 (43%) were culture-confirmed mycoses: emergomycosis (n = 18), histoplasmosis (n = 8), sporotrichosis (n = 6), cryptococcosis (n = 2), talaromycosis (n = 1), and other fungi isolated (n = 2). The sensitivity and specificity of the EIA were calculated for two groups: culture-confirmed (n = 37) and histology-confirmed invasive fungal disease (n = 50). The sensitivity and specificity of the EIA for diagnosis of histoplasmosis compared to culture were 88% (7/8, 95%CI 47-100%) and 72% (21/29, 95%CI 53-87%), respectively, and for diagnosis of emergomycosis/histoplasmosis compared to histology was 83% (29/35, 95%CI 66-93%) and 93% (14/15, 95%CI 68-100%), respectively. Cross-reactions occurred in urine specimens of patients with Emergomyces africanus infection and in culture filtrates of E. africanus, T. marneffei and Blastomyces species. A commercial Histoplasma EIA had satisfactory accuracy for diagnosis of culture-confirmed histoplasmosis, but cross-reacted in urine specimens from patients with invasive disease caused by the closely-related pathogen, E. africanus and in culture filtrates of E. africanus and other related fungi. LAY SUMMARY Emergomyces africanus and Histoplasma capsulatum are fungi that cause a multi-system disease among HIV-seropositive persons with a low CD4 cell count. Handling live cultures of these fungi to confirm a diagnosis requires specialized laboratory equipment and infrastructure which is infrequently accessible in low-resource settings. The features of the two diseases (i.e., disseminated histoplasmosis and emergomycosis) may be indistinguishable when infected tissue is prepared, stained, and examined under a microscope. Enzyme immunoassays (EIA) have been developed as rapid diagnostic tools for the detection of a cell wall component of H. capsulatum in urine specimens, although cross-reactions have been reported in specimens from patients with other fungal infections. We evaluated the accuracy of a commercial Histoplasma EIA to diagnose histoplasmosis and to assess cross-reactions in urine specimens from persons with emergomycosis and in cultures of E. africanus and related fungi. We report a sensitivity and specificity of 88% (95%CI 47-100%) and 72% (95%CI 53-87%) for diagnosis of histoplasmosis compared to culture and 83% (95%CI 66-93%) and 93% (95%CI 68-100%) for diagnosis of either histoplasmosis/emergomycosis compared to a diagnosis made by microscopic examination of infected tissue. The assay cross-reacted in urine specimens from patients with emergomycosis and in culture filtrates of related fungi. Although the EIA cross-reacted with other related fungi, this test can decrease the time to diagnosis and facilitate early treatment of emergomycosis and histoplasmosis in South Africa.
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Affiliation(s)
- Tsidiso G Maphanga
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa.,Department of Medical Microbiology, University of the Free State, Bloemfontein, South Africa
| | - Serisha D Naicker
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa.,School of Pathology, University of the Witwatersrand, Johannesburg, South Africa
| | - Beatriz L Gómez
- School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
| | - Mabatho Mhlanga
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Ruth S Mpembe
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Ilan S Schwartz
- Department of Medicine, University of Alberta, Alberta, Canada
| | - Colleen Bamford
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa.,Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Jeremy Nel
- School of Pathology, University of the Witwatersrand, Johannesburg, South Africa
| | - Nelesh P Govender
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa.,School of Pathology, University of the Witwatersrand, Johannesburg, South Africa.,Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
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Hauser A, Kusejko K, Johnson LF, Günthard HF, Riou J, Wandeler G, Egger M, Kouyos RD. Impact of scaling up dolutegravir on antiretroviral resistance in South Africa: A modeling study. PLoS Med 2020; 17:e1003397. [PMID: 33315863 PMCID: PMC7735592 DOI: 10.1371/journal.pmed.1003397] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 11/10/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Rising resistance of HIV-1 to non-nucleoside reverse transcriptase inhibitors (NNRTIs) threatens the success of the global scale-up of antiretroviral therapy (ART). The switch to WHO-recommended dolutegravir (DTG)-based regimens could reduce this threat due to DTG's high genetic barrier to resistance. We used mathematical modeling to predict the impact of the scale-up of DTG-based ART on NNRTI pretreatment drug resistance (PDR) in South Africa, 2020 to 2040. METHODS AND FINDINGS We adapted the Modeling Antiretroviral drug Resistance In South Africa (MARISA) model, an epidemiological model of the transmission of NNRTI resistance in South Africa. We modeled the introduction of DTG in 2020 under 2 scenarios: DTG as first-line regimen for ART initiators, or DTG for all patients, including patients on suppressive NNRTI-based ART. Given the safety concerns related to DTG during pregnancy, we assessed the impact of prescribing DTG to all men and in addition to (1) women beyond reproductive age; (2) women beyond reproductive age or using contraception; and (3) all women. The model projections show that, compared to the continuation of NNRTI-based ART, introducing DTG would lead to a reduction in NNRTI PDR in all scenarios if ART initiators are started on a DTG-based regimen, and those on NNRTI-based regimens are rapidly switched to DTG. NNRTI PDR would continue to increase if DTG-based ART was restricted to men. When given to all men and women, DTG-based ART could reduce the level of NNRTI PDR from 52.4% (without DTG) to 10.4% (with universal DTG) in 2040. If only men and women beyond reproductive age or on contraception are started on or switched to DTG-based ART, NNRTI PDR would reach 25.9% in 2040. Limitations include substantial uncertainty due to the long-term predictions and the current scarcity of knowledge about DTG efficacy in South Africa. CONCLUSIONS Our model shows the potential benefit of scaling up DTG-based regimens for halting the rise of NNRTI resistance. Starting or switching all men and women to DTG would lead to a sustained decline in resistance levels, whereas using DTG-based ART in all men, or in men and women beyond childbearing age, would only slow down the increase in levels of NNRTI PDR.
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Affiliation(s)
- Anthony Hauser
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Katharina Kusejko
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Leigh F. Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - Huldrych F. Günthard
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Julien Riou
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Gilles Wandeler
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- * E-mail: (ME); (RDK)
| | - Roger D. Kouyos
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
- * E-mail: (ME); (RDK)
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Challenges in estimating HIV prevalence trends and geographical variation in HIV prevalence using antenatal data: Insights from mathematical modelling. PLoS One 2020; 15:e0242595. [PMID: 33216793 PMCID: PMC7679018 DOI: 10.1371/journal.pone.0242595] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 11/05/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND HIV prevalence data among pregnant women have been critical to estimating HIV trends and geographical patterns of HIV in many African countries. Although antenatal HIV prevalence data are known to be biased representations of HIV prevalence in the general population, mathematical models have made various adjustments to control for known sources of bias, including the effect of HIV on fertility, the age profile of pregnant women and sexual experience. METHODS AND FINDINGS We assessed whether assumptions about antenatal bias affect conclusions about trends and geographical variation in HIV prevalence, using simulated datasets generated by an agent-based model of HIV and fertility in South Africa. Results suggest that even when controlling for age and other previously-considered sources of bias, antenatal bias in South Africa has not been constant over time, and trends in bias differ substantially by age. Differences in the average duration of infection explain much of this variation. We propose an HIV duration-adjusted measure of antenatal bias that is more stable, which yields higher estimates of HIV incidence in recent years and at older ages. Simpler measures of antenatal bias, which are not age-adjusted, yield estimates of HIV prevalence and incidence that are too high in the early stages of the HIV epidemic, and that are less precise. Antenatal bias in South Africa is substantially greater in urban areas than in rural areas. CONCLUSIONS Age-standardized approaches to defining antenatal bias are likely to improve precision in model-based estimates, and further recency adjustments increase estimates of HIV incidence in recent years and at older ages. Incompletely adjusting for changing antenatal bias may explain why previous model estimates overstated the early HIV burden in South Africa. New assays to estimate the fraction of HIV-positive pregnant women who are recently infected could play an important role in better estimating antenatal bias.
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Haas AD, Radin E, Hakim AJ, Jahn A, Philip NM, Jonnalagadda S, Saito S, Low A, Patel H, Schwitters AM, Rogers JH, Frederix K, Kim E, Bello G, Williams DB, Parekh B, Sachathep K, Barradas DT, Kalua T, Birhanu S, Musuka G, Mugurungi O, Tippett Barr BA, Sleeman K, Mulenga LB, Thin K, Ao TT, Brown K, Voetsch AC, Justman JE. Prevalence of nonsuppressed viral load and associated factors among HIV-positive adults receiving antiretroviral therapy in Eswatini, Lesotho, Malawi, Zambia and Zimbabwe (2015 to 2017): results from population-based nationally representative surveys. J Int AIDS Soc 2020; 23:e25631. [PMID: 33225559 PMCID: PMC7680921 DOI: 10.1002/jia2.25631] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 09/28/2020] [Accepted: 10/02/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION The global target for 2020 is that ≥90% of people living with HIV (PLHIV) receiving antiretroviral therapy (ART) will achieve viral load suppression (VLS). We examined VLS and its determinants among adults receiving ART for at least four months. METHODS We analysed data from the population-based HIV impact assessment (PHIA) surveys in Eswatini, Lesotho, Malawi, Zambia and Zimbabwe (2015 to 2017). PHIA surveys are nationally representative, cross-sectional household surveys. Data collection included structured interviews, home-based HIV testing and laboratory testing. Blood samples from PLHIV were analysed for HIV RNA, CD4 counts and recent exposure to antiretroviral drugs (ARVs). We calculated representative estimates for the prevalence of VLS (viral load <1000 copies/mL), nonsuppressed viral load (NVL; viral load ≥1000 copies/mL), virologic failure (VF; ARVs present and viral load ≥1000 copies/mL), interrupted ART (ARVs absent and viral load ≥1000 copies/mL) and rates of switching to second-line ART (protease inhibitors present) among PLHIV aged 15 to 59 years who participated in the PHIA surveys in Eswatini, Lesotho, Malawi, Zambia and Zimbabwe, initiated ART at least four months before the survey and were receiving ART at the time of the survey (according to self-report or ARV testing). We calculated odds ratios and incidence rate ratios for factors associated with NVL, VF, interrupted ART, and switching to second-line ART. RESULTS We included 9200 adults receiving ART of whom 88.8% had VLS and 11.2% had NVL including 8.2% who experienced VF and 3.0% who interrupted ART. Younger age, male sex, less education, suboptimal adherence, receiving nevirapine, HIV non-disclosure, never having married and residing in Zimbabwe, Lesotho or Zambia were associated with higher odds of NVL. Among people with NVL, marriage, female sex, shorter ART duration, higher CD4 count and alcohol use were associated with lower odds for VF and higher odds for interrupted ART. Many people with VF (44.8%) had CD4 counts <200 cells/µL, but few (0.31% per year) switched to second-line ART. CONCLUSIONS Countries are approaching global VLS targets for adults. Treatment support, in particular for younger adults, and people with higher CD4 counts, and switching of people to protease inhibitor- or integrase inhibitor-based regimens may further reduce NVL prevalence.
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Affiliation(s)
- Andreas D Haas
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Elizabeth Radin
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Avi J Hakim
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA, USA
| | | | - Neena M Philip
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Sasi Jonnalagadda
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA, USA
| | - Suzue Saito
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Andrea Low
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Hetal Patel
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA, USA
| | - Amee M Schwitters
- Division of Global HIV and TB, Center for Global Health, CDC Lesotho, Maseru, Lesotho
| | - John H Rogers
- Division of Global HIV and TB, Center for Global Health, CDC Zimbabwe, Harare, Zimbabwe
| | - Koen Frederix
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Evelyn Kim
- Division of Global HIV and TB, Center for Global Health, CDC Malawi, Lilongwe, Malawi
| | | | - Daniel B Williams
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA, USA
| | - Bharat Parekh
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA, USA
| | - Karampreet Sachathep
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Danielle T Barradas
- Division of Global HIV and TB, Center for Global Health, CDC Zambia, Lusaka, Zambia
| | | | - Sehin Birhanu
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA, USA
| | - Godfrey Musuka
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
| | | | - Beth A Tippett Barr
- Division of Global HIV and TB, Center for Global Health, CDC Zimbabwe, Harare, Zimbabwe
| | - Katrina Sleeman
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA, USA
| | | | - Kyaw Thin
- Research Coordination Unit, Ministry of Health, Maseru, Lesotho
| | - Trong T Ao
- Division of Global HIV and TB, Center for Global Health, CDC Eswatini, Mbabane, Swaziland
| | - Kristin Brown
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA, USA
| | - Andrew C Voetsch
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA, USA
| | - Jessica E Justman
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
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Hodgkinson LM, Abwalaba RA, Arudo J, Barry M. Ten-year survival with analysis of gender difference, risk factors, and causes of death during 13 years of public antiretroviral therapy in rural Kenya. Medicine (Baltimore) 2020; 99:e20328. [PMID: 32481319 PMCID: PMC7249944 DOI: 10.1097/md.0000000000020328] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 04/15/2020] [Accepted: 04/18/2020] [Indexed: 12/26/2022] Open
Abstract
Evidence for why antiretroviral therapy (ART) outcomes differ by gender in developing countries has been inconclusive. In this first study to assess 10-year survival on ART in Kenya, our objective was to compare gender differences in survival for those who began ART as adults and as children. Kakamega County Referral Hospital (KCRH) is a tertiary rural hospital that has provided public ART to Kenyans since 2004. All patients enrolled in ART at KCRH who died between July 2004 and March 2017 and a sample of living patients were included in a survival analysis that bootstrapped sampled data. Case-cohort regressions identified adjusted hazard ratios. In total, 1360 patients were included in the study. Ten-year survival was 77% (95% confidence band [CB] 73-81%), significantly different for men (65%; 95% CB: 45-74%) and women (83%; 95% CB: 78-86%) who began therapy as adults. Ten-year survival was intermediate with no significant gender difference (76%; 95% CB: 69-81%) for patients who began therapy as children. Hazard of death was increased for men (hazard ratio [HR] 1.56; 95% confidence interval [CI] 1.13-2.17), infants (HR 2.87; 95% CI 1.44-5.74), patients with consistently poor clinic attendance (HR 3.94; 95% CI 3.19-4.86), and divorced patients (HR 2.25; 95% CI 1.19-4.25). Tuberculosis, diarrheal illnesses, human immunodeficiency virus (HIV) wasting syndrome, and malaria were leading causes of death. Survival was significantly lower for men than for women in all time periods, but only for patients who began therapy as adults, indicating against biological etiologies for the gender mortality difference.
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Affiliation(s)
- Luqman Mushila Hodgkinson
- Center for Innovation in Global Health
- Stanford University School of Medicine, Stanford University, Stanford, USA
- Masinde Muliro University of Science and Technology School of Medicine
| | - Roselyne Asiko Abwalaba
- Department of Clinical Nursing and Health Informatics, Masinde Muliro University of Science and Technology
- Kakamega County Referral Hospital, Kakamega, Kenya
| | - John Arudo
- Department of Clinical Nursing and Health Informatics, Masinde Muliro University of Science and Technology
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Kerkhoff AD, Sikombe K, Eshun-Wilson I, Sikazwe I, Glidden DV, Pry JM, Somwe P, Beres LK, Simbeza S, Mwamba C, Bukankala C, Hantuba C, Moore CB, Holmes CB, Padian N, Geng EH. Mortality estimates by age and sex among persons living with HIV after ART initiation in Zambia using electronic medical records supplemented with tracing a sample of lost patients: A cohort study. PLoS Med 2020; 17:e1003107. [PMID: 32401797 PMCID: PMC7219718 DOI: 10.1371/journal.pmed.1003107] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 04/10/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Men in sub-Saharan Africa have lower engagement and retention in HIV services compared to women, which may result in differential survival. However, the true magnitude of difference in HIV-related mortality between men and women receiving antiretroviral therapy (ART) is incompletely characterized. METHODS AND FINDINGS We evaluated HIV-positive adults ≥18 years old newly initiating ART in 4 Zambian provinces (Eastern, Lusaka, Southern, and Western). In addition to mortality data obtained from routine electronic medical records, we intensively traced a random sample of patients lost to follow-up (LTFU) and incorporated tracing outcomes through inverse probability weights. Sex-specific mortality rates and rate differences were determined using Poisson regression. Parametric g-computation was used to estimate adjusted mortality rates by sex and age. The study included 49,129 adults newly initiated on ART between August 2013 and July 2015; overall, the median age among patients was 35 years, the median baseline CD4 count was 262 cells/μl, and 37.2% were men. Men comprised a smaller proportion of individuals starting ART (37.2% versus 62.8%), tended to be older (median age 37 versus 33 years), and tended to have lower CD4 counts (median 220 versus 289 cells/μl) at the time of ART initiation compared to women. The overall rate of mortality among men was 10.3 (95% CI 8.2-12.4) deaths/100 person-years (PYs), compared to 5.5 (95% CI 4.3-6.8) deaths/100 PYs among women (difference +4.7 [95% CI 2.3-7.2] deaths/100 PYs; p < 0.001). Compared to women in the same age groups, men's mortality rates were particularly elevated among those <30 years old (+6.7 deaths/100 PYs difference), those attending rural health centers (+9.4 deaths/100 PYs difference), those who had an initial CD4 count < 100 cells/μl (+9.2 deaths/100 PYs difference), and those who were unmarried (+8.0 deaths/100 PYs difference). After adjustment for potential confounders and mediators including CD4 count, a substantially higher mortality rate was predicted among men <30 years old compared to women of the same age, while women ≥50 years old had a mortality rate similar to that of age-matched men, but considerably higher than that predicted among young women (<30 years old). No clinically significant differences were evident with respect to rates of facility transfer or care disengagement between men and women. The main study limitations were the inability to successfully ascertain outcomes in all patients selected for tracing and missing clinical and laboratory data due to the use of medical records. CONCLUSIONS In this study, we found that among HIV-positive adults newly initiating ART, mortality among men exceeded mortality among women; disparities were most pronounced among young patients. Older women, however, also experienced high mortality. Specific interventions for men and older women at highest mortality risk are needed to improve HIV treatment outcomes.
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Affiliation(s)
- Andrew D. Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, United States of America
| | | | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Department of Medicine, Washington University, St. Louis, Missouri, United States of America
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - David V. Glidden
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, United States of America
| | - Jake M. Pry
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, Department of Medicine, Washington University, St. Louis, Missouri, United States of America
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
| | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Laura K. Beres
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Chama Bukankala
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Cardinal Hantuba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Charles B. Holmes
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
- Georgetown University, Washington, District of Columbia, United States of America
| | - Nancy Padian
- University of California, Berkeley, Berkeley, California, United States of America
| | - Elvin H. Geng
- Division of Infectious Diseases, Department of Medicine, Washington University, St. Louis, Missouri, United States of America
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
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Kehoe K, Boulle A, Tsondai PR, Euvrard J, Davies MA, Cornell M. Long-term virologic responses to antiretroviral therapy among HIV-positive patients entering adherence clubs in Khayelitsha, Cape Town, South Africa: a longitudinal analysis. J Int AIDS Soc 2020; 23:e25476. [PMID: 32406983 PMCID: PMC7224308 DOI: 10.1002/jia2.25476] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 02/06/2020] [Accepted: 02/20/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION In South Africa, an estimated 4.6 million people were accessing antiretroviral therapy (ART) in 2018. As universal Test and Treat is implemented, these numbers will continue to increase. Given the need for lifelong care for millions of individuals, differentiated service delivery models for ART services such as adherence clubs (ACs) for stable patients are required. In this study, we describe long-term virologic outcomes of patients who have ever entered ACs in Khayelitsha, Cape Town. METHODS We included adult patients enrolled in ACs in Khayelitsha between January 2011 and December 2016 with a recorded viral load (VL) before enrolment. Risk factors for an elevated VL (VL >1000 copies/mL) and confirmed virologic failure (two consecutive VLs >1000 copies/mL one year apart) were estimated using Cox proportional hazards models. VL completeness over time was assessed. RESULTS Overall, 8058 patients were included in the analysis, contributing 16,047 person-years of follow-up from AC entry (median follow-up time 1.7 years, interquartile range [IQR]:0.9 to 2.9). At AC entry, 74% were female, 46% were aged between 35 and 44 years, and the median duration on ART was 4.8 years (IQR: 3.0 to 7.2). Among patients virologically suppressed at AC entry (n = 8058), 7136 (89%) had a subsequent VL test, of which 441 (6%) experienced an elevated VL (median time from AC entry 363 days, IQR: 170 to 728). Older age (adjusted hazard ratio [aHR] 0.64, 95% confidence interval [CI] 0.46 to 0.88), more recent year of AC entry (aHR 0.76, 95% CI 0.68 to 0.84) and higher CD4 count (aHR 0.67, 95% CI 0.54 to 0.84) were protective against experiencing an elevated VL. Among patients with an elevated VL, 52% (150/291) with a repeat VL test subsequently experienced confirmed virologic failure in a median time of 112 days (IQR: 56 to 168). Frequency of VL testing was constant over time (82 to 85%), with over 90% of patients remaining virologically suppressed. CONCLUSIONS This study demonstrates low prevalence of elevated VLs and confirmed virologic failure among patients who entered ACs. Although ACs were expanded rapidly, most patients were well monitored and remained stable, supporting the continued rollout of this model.
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Affiliation(s)
- Kathleen Kehoe
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Khayelitsha ART Programme and Médecins Sans FrontièresCape TownSouth Africa
- Health Impact Assessment Provincial Government of the Western CapeCape TownSouth Africa
| | - Priscilla R Tsondai
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Khayelitsha ART Programme and Médecins Sans FrontièresCape TownSouth Africa
| | - Mary Ann Davies
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Health Impact Assessment Provincial Government of the Western CapeCape TownSouth Africa
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
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Lentoor AG. Clinico-Immunological Status and Neurocognitive Function of Perinatally Acquired HIV-Positive Children on cART: A Cross-Sectional Correlational Study in South Africa. Front Neurol 2020; 11:243. [PMID: 32362864 PMCID: PMC7180221 DOI: 10.3389/fneur.2020.00243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 03/13/2020] [Indexed: 12/23/2022] Open
Abstract
Despite the undisputed benefits of combination antiretroviral therapy (cART), perinatally acquired human immunodeficiency virus (PHIV) children on treatment often present with a spectrum of neurological deficits known as HIV-associated neurocognitive impairment. Even higher CD4 cell count does not seem to prevent the development of neurocognitive impairment in children with PHIV. While CD4 cell count has shown to have the greatest prognostic value, its association with neurocognitive abilities remains to be clarified. This study aimed at determining the correlation between plasma CD4+ lymphocyte and neurocognitive function in children with PHIV on cART. In total, 152 purposively recruited hospital-based sample of children with PHIV on cART, aged 3 years to 7 years 6 months (mean age, 63.13 months), underwent neurocognitive assessment using the Wechsler Preschool and Primary Scale of Intelligence, Third Edition. Immunological status of each child was based on the plasma CD4+ lymphocyte levels. The mean CD4+ lymphocyte cell count at the time of neurocognitive assessment was 1,259.85 cells/mm3 (mean range, 139-2,717 cells/mm3), with significant age difference on CD4+ lymphocyte count levels [F (2, 149) = 13.58, p = 0.000]. CD4+ lymphocyte counts was significantly correlated with subdomains of neurocognitive function scores of task that measures working memory, processing speed, and perceptual reasoning. Global cognitive ability (Full Scale Intellectual Quotient) had no significant association with immunological status of the children. The findings support an association between immunological status of PHIV infection and executive function task. These neurocognitive faculties are critical for learning, school readiness and success in early childhood, and ultimately treatment adherence in adolescence. The need for early identification of neurodevelopment deficits in children, even when on cART, is crucial because early psychosocial and neurorehabilitative interventions can lead to better outcome for children with PHIV.
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Affiliation(s)
- Antonio G. Lentoor
- Department of Clinical Psychology, School of Medicine, Sefako Makgatho Health Sciences University, Pretoria, South Africa
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75
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Gibbs A, Reddy T, Dunkle K, Jewkes R. HIV-Prevalence in South Africa by settlement type: A repeat population-based cross-sectional analysis of men and women. PLoS One 2020; 15:e0230105. [PMID: 32182255 PMCID: PMC7077822 DOI: 10.1371/journal.pone.0230105] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 02/21/2020] [Indexed: 01/08/2023] Open
Abstract
To assess i) whether there is an independent association between HIV-prevalence and settlement types (urban formal, urban informal, rural formal, rural informal), and, ii) whether this changes over time, in South Africa. We draw on four (2002; 2005; 2008; 2012) cross-sectional South African household surveys. Data is analysed by sex (male/female), and for women by age categories (15-49; and 15-24; 25-49) at all-time points, for men in 2012 data is analysed by age categories (15-24; 25-49). By settlement type and sex/age combinations, we descriptively assess the association between socio-demographic and HIV-risk factors; HIV-prevalence; and trends in HIV-prevalence by time. Relative risk ratios assess unadjusted and adjusted risk for HIV-prevalence by settlement type. All estimates are weighted, and account for survey design. In all survey years, and combinations of sex/age categorisations, HIV-prevalence is highest in urban informal settlements. For men (15-49) an increasing HIV-prevalence over time in rural informal settlements was seen (p = 0.001). For women (15-49) HIV-prevalence increases over time for urban informal, rural informal, rural formal, and women (15-24) decreases in urban formal and urban informal, and women (25-49) increases urban informal and rural informal settlements. In analyses adjusting for potential socio-demographic and risk factors, compared to urban formal settlements, urban informal settlements had consistently higher relative risk of HIV for women, in all age categorisations, for instance in 2012 this was RR1.89 (1.50, 2.40) for all women (15-49), for 15-24 (RR1.79, 1.17-2.73), and women 25-49 (RR1.91, 1.47-2.48). For men, in the overall age categorization, urban informal settlements had a higher relative risk for HIV in all years. In 2012, when this was disaggregated by age, for men 15-24 rural informal (IRR2.69, 1.28-5.67), and rural formal (RR3.59, 1.49-8.64), and for men 25-49 it was urban informal settlements with the highest (RR1.68, 1.11-2.54). In 2012, rural informal settlements also had higher adjusted relative risk for HIV-prevalence for men (15-49) and women (15-49; 15-24; 25-49). In South Africa, HIV-prevalence is patterned geographically, with urban informal settlements having a particularly high burden. Geographical targeting of responses is critical for the HIV-response.
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Affiliation(s)
- Andrew Gibbs
- Gender and Health Research Unit, South African Medical Research Council, Pretoria, South Africa
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Tarylee Reddy
- Biostatistics Unit, South African Medical Research Council, Durban, South Africa
| | - Kristin Dunkle
- Gender and Health Research Unit, South African Medical Research Council, Pretoria, South Africa
| | - Rachel Jewkes
- Gender and Health Research Unit, South African Medical Research Council, Pretoria, South Africa
- Office of the Executive Scientist, South African Medical Research Council, Pretoria, South Africa
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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76
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Hirasen K, Fox MP, Hendrickson CJ, Sineke T, Onoya D. HIV Treatment Outcomes Among Patients Initiated on Antiretroviral Therapy Pre and Post-Universal Test and Treat Guidelines in South Africa. Ther Clin Risk Manag 2020; 16:169-180. [PMID: 32184609 PMCID: PMC7061415 DOI: 10.2147/tcrm.s227290] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 12/06/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction Officially rolled out on 01 September 2016, South Africa’s Universal Test and Treat (UTT) policy calls for first-line antiretroviral treatment (ART) initiation among all known HIV-positive patients, irrespective of CD4 cell count. We evaluate treatment outcomes of patients initiated on first-line ART directly before and after the implementation of UTT. Methods We analysed prospectively collected clinical cohort data among ART-naïve adult patients within two HIV clinics in Johannesburg, South Africa. We compare two groups: 1) an unexposed pre-UTT group initiating treatment from 01 December 2014 to 31 May 2015; and 2) an exposed UTT group initiating treatment from 01 December 2016 to 31 May 2017. Primary treatment outcomes included lost to follow-up (LTFU) (>90 days late for the last scheduled visit with no subsequent clinical visit). Cox proportional hazards models were used to estimate the association between pre-UTT vs UTT initiation on LTFU by 12 months. Results We included 2410 patients. A total of 1267 (52.6%) patients initiated ART before UTT implementation and 1143 (47.4%) after the change in policy. LTFU (adjusted Hazard Ratio (aHR): 1.51; 95% Confidence Interval (CI): 1.16–1.98) between groups and specifically among those initiating with a CD4 cell count ≤500 cells/mm3 (aHR: 1.59; 95% CI: 1.21–2.10) was higher among patients initiating ART under UTT. Conclusion LTFU under UTT proved higher than that of previous periods. Patients initiating first-line therapy under the treat-all policy may often start treatment in better health, subsequently not perceiving a direct benefit to treatment which may deter patients from consistent engagement in HIV treatment programmes.
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Affiliation(s)
- Kamban Hirasen
- 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
| | - 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
| | - Cheryl J Hendrickson
- 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
| | - Tembeka Sineke
- 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
| | - Dorina Onoya
- 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
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77
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Hermans LE, Carmona S, Nijhuis M, Tempelman HA, Richman DD, Moorhouse M, Grobbee DE, Venter WDF, Wensing AMJ. Virological suppression and clinical management in response to viremia in South African HIV treatment program: A multicenter cohort study. PLoS Med 2020; 17:e1003037. [PMID: 32097428 PMCID: PMC7041795 DOI: 10.1371/journal.pmed.1003037] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/24/2020] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Uptake of antiretroviral treatment (ART) is expanding rapidly in low- and middle-income countries (LMIC). Monitoring of virological suppression is recommended at 6 months of treatment and annually thereafter. In case of confirmed virological failure, a switch to second-line ART is indicated. There is a paucity of data on virological suppression and clinical management of patients experiencing viremia in clinical practice in LMIC. We report a large-scale multicenter assessment of virological suppression over time and management of viremia under programmatic conditions. METHODS AND FINDINGS Linked medical record and laboratory source data from adult patients on first-line ART at 52 South African centers between 1 January 2007 and 1 May 2018 were studied. Virological suppression, switch to second-line ART, death, and loss to follow-up were analyzed. Multistate models and Cox proportional hazard models were used to assess suppression over time and predictors of treatment outcomes. A total of 104,719 patients were included. Patients were predominantly female (67.6%). Median age was 35.7 years (interquartile range [IQR]: 29.9-43.0). In on-treatment analysis, suppression below 1,000 copies/mL was 89.0% at month 12 and 90.4% at month 72. Suppression below 50 copies/mL was 73.1% at month 12 and 77.5% at month 72. Intention-to-treat suppression was 75.0% and 64.3% below 1,000 and 50 copies/mL at month 72, respectively. Viremia occurred in 19.8% (20,766/104,719) of patients during a median follow-up of 152 (IQR: 61-265) weeks. Being male and below 35 years of age and having a CD4 count below 200 cells/μL prior to start of ART were risk factors for viremia. After detection of viremia, confirmatory testing took 29 weeks (IQR: 16-54). Viral resuppression to below 1,000 copies/mL without switch of ART occurred frequently (45.6%; 6,030/13,210) but was associated with renewed viral rebound and switch. Of patients with confirmed failure who remained in care, only 41.5% (1,872/4,510) were switched. The median time to switch was 68 weeks (IQR: 35-127), resulting in 12,325 person-years spent with a viral load above 1,000 copies/mL. Limitations of this study include potential missing data, which is in part addressed by the use of cross-matched laboratory source data, and the possibility of unmeasured confounding. CONCLUSIONS In this study, 90% virological suppression below the threshold of 1,000 copies/mL was observed in on-treatment analysis. However, this target was not met at the 50-copies/mL threshold or in intention-to-treat analysis. Clinical management in response to viremia was profoundly delayed, prolonging the duration of viremia and potential for transmission. Diagnostic tools to establish the cause of viremia are urgently needed to accelerate clinical decision-making.
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Affiliation(s)
- Lucas E. Hermans
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
- Ndlovu Research Consortium, Elandsdoorn, South Africa
| | - Sergio Carmona
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Service (NHLS), Johannesburg, South Africa
| | - Monique Nijhuis
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Ndlovu Research Consortium, Elandsdoorn, South Africa
- University of the Witwatersrand, Johannesburg, South Africa
| | - Hugo A. Tempelman
- Ndlovu Research Consortium, Elandsdoorn, South Africa
- University of the Witwatersrand, Johannesburg, South Africa
| | - Douglas D. Richman
- Center for AIDS Research, University of California San Diego, United States of America
- VA San Diego Healthcare System, California, United States of America
| | - Michelle Moorhouse
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Diederick E. Grobbee
- Ndlovu Research Consortium, Elandsdoorn, South Africa
- Clinical Epidemiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands
| | - Willem D. F. Venter
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
- Ndlovu Research Consortium, Elandsdoorn, South Africa
| | - Annemarie M. J. Wensing
- Virology, Department of Medical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
- Ndlovu Research Consortium, Elandsdoorn, South Africa
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Global variations in mortality in adults after initiating antiretroviral treatment: an updated analysis of the International epidemiology Databases to Evaluate AIDS cohort collaboration. AIDS 2019; 33 Suppl 3:S283-S294. [PMID: 31800405 PMCID: PMC6919233 DOI: 10.1097/qad.0000000000002358] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND UNAIDS models use data from the International epidemiology Databases to Evaluate AIDS (IeDEA) collaboration in setting assumptions about mortality rates after antiretroviral treatment (ART) initiation. This study aims to update these assumptions with new data, to quantify the extent of regional variation in ART mortality and to assess trends in ART mortality. METHODS Adult ART patients from Africa, Asia and the Americas were included if they had a known date of ART initiation during 2001-2017 and a baseline CD4 cell count. In cohorts that relied only on passive follow-up (no patient tracing or linkage to vital registration systems), mortality outcomes were imputed in patients lost to follow-up based on a meta-analysis of tracing study data. Poisson regression models were fitted to the mortality data. RESULTS 464 048 ART patients were included. In multivariable analysis, mortality rates were lowest in Asia and highest in Africa, with no significant differences between African regions. Adjusted mortality rates varied significantly between programmes within regions. Mortality rates in the first 12 months after ART initiation were significantly higher during 2001-2006 than during 2010-2014, although the difference was more substantial in Asia and the Americas [adjusted incidence rate ratio (aIRR) 1.43, 95% CI: 1.22-1.66] than in Africa (aIRR 1.07, 95% CI: 1.04-1.11). CONCLUSION There is substantial variation in ART mortality between and within regions, even after controlling for differences in mortality by age, sex, baseline CD4 category and calendar period. ART mortality rates have declined substantially over time, although declines have been slower in Africa.
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79
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Global, regional and country-level 90-90-90 estimates for 2018: assessing progress towards the 2020 target. AIDS 2019; 33 Suppl 3:S213-S226. [PMID: 31490781 PMCID: PMC6919229 DOI: 10.1097/qad.0000000000002355] [Citation(s) in RCA: 113] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Supplemental Digital Content is available in the text Background: In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and partners set the 90–90–90 target for the year 2020: diagnose 90% of all people living with HIV (PLHIV); treat 90% of people who know their status; and suppress the virus in 90% of people on treatment. In 2015, countries began reporting to UNAIDS on progress against 90–90–90 using standard definitions and methods. Methods: We used data submitted to UNAIDS from 170 countries to assess country-specific progress towards 90–90–90 through 2018. To assess global and regional progress, overall and by sex for adults aged 15 years and older, we combined country-reported data with estimates generated with a Bayesian hierarchical model. Results: A total of 60 countries reported on all three 90s in 2018, up from 23 in 2015. Among all PLHIV worldwide, 79% (67–92%) knew their HIV status. Of these, 78% (69–82%) were accessing treatment and 86% (72–92%) of people accessing treatment had suppressed viral loads. Of the 37.9 million (32.7–44.0 million) PLHIV worldwide, 53% (43–63%) had suppressed viral loads. The gap to fully achieving 73% of PLHIV with suppressed viral load was 7.7 million; 15 countries had already achieved this target by 2018. Conclusion: Increased data availability has led to improved measures of country and global progress towards the 90–90–90 target. Although gains in access to testing and treatment continue, many countries and regions are unlikely to reach the 90–90–90 target by 2020.
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Biggerstaff M, Cohen C, Reed C, Tempia S, McMorrow ML, Walaza S, Moyes J, Treurnicht FK, Cohen AL, Hutchinson P, Stoecker C, Steinberg J. A cost-effectiveness analysis of antenatal influenza vaccination among HIV-infected and HIV-uninfected pregnant women in South Africa. Vaccine 2019; 37:6874-6884. [PMID: 31575494 PMCID: PMC8939109 DOI: 10.1016/j.vaccine.2019.09.059] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 09/16/2019] [Accepted: 09/18/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Pregnant women and infants are at increased risk of severe disease from influenza. Antenatal influenza vaccination is safe and can reduce the risk of illness for women and their infants. We evaluated for South Africa the health effects of antenatal influenza vaccination among pregnant women and their infants aged <6 months old and assessed its cost-effectiveness. METHODS We constructed a decision tree model to simulate the population of pregnant women and infants aged <6 months in South Africa using TreeAge Pro Suite 2015. The model evaluated the change in societal costs and outcomes associated with a vaccination campaign that prioritized HIV-infected over HIV-uninfected pregnant women compared with no vaccination. We also examined the impacts of a campaign without prioritization. Upper and lower 90% uncertainty intervals (90% UI) were generated using probabilistic sensitivity analysis on 10000 Monte Carlo simulations. The cost-effectiveness threshold was set to the 2015 per capita gross domestic product of South Africa, US$5724. RESULTS Antenatal vaccination with prioritization averted 9070 (90% UI: 7407-11217) total cases of influenza among pregnant women and infants, including 411 (90% UI: 305-546) hospitalizations and 30 (90% UI: 22-40) deaths. This corresponds to an averted fraction of 13.5% (90% UI: 9.0-20.5%). Vaccinating without prioritization averted 7801 (90% UI: 6465-9527) cases of influenza, including 335 (90% UI: 254-440) hospitalizations and 24 (90% UI: 18-31) deaths. This corresponds to an averted fraction of 11.6% (90% UI: 7.8-17.4%). Vaccinating the cohort of pregnant women with prioritization had societal cost of $4689 (90% UI: $3128-$7294) per Quality Adjusted Life Year (QALY) gained while vaccinating without prioritization had a cost of $5924 (90% UI: $3992-$9056) per QALY. CONCLUSIONS Antenatal influenza vaccination campaigns in South Africa would reduce the impact of influenza and could be cost-effective.
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Affiliation(s)
- Matthew Biggerstaff
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Cheryl Cohen
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Carrie Reed
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Stefano Tempia
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, USA; Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa; Influenza Program, Centers for Disease Control and Prevention, Pretoria, South Africa; MassGenics, Duluth, GA, USA
| | - Meredith L McMorrow
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, USA; Influenza Program, Centers for Disease Control and Prevention, Pretoria, South Africa; US Public Health Service, Rockville, MD, USA
| | - Sibongile Walaza
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jocelyn Moyes
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Florette K Treurnicht
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa; School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Adam L Cohen
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, USA; Influenza Program, Centers for Disease Control and Prevention, Pretoria, South Africa; US Public Health Service, Rockville, MD, USA; Expanded Programme on Immunization, Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
| | - Paul Hutchinson
- Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Charles Stoecker
- Department of Health Policy and Management, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Joni Steinberg
- Department of Health Policy and Management, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
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Wilkinson L, Grimsrud A, Cassidy T, Orrell C, Voget J, Hayes H, Keene C, Steele SJ, Gerstenhaber R. A cluster randomized controlled trial of extending ART refill intervals to six-monthly for anti-retroviral adherence clubs. BMC Infect Dis 2019; 19:674. [PMID: 31362715 PMCID: PMC6664572 DOI: 10.1186/s12879-019-4287-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 07/15/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The antiretroviral therapy (ART) adherence club (AC) differentiated service delivery model, where clinically stable ART patients receive their ART refills and psychosocial support in groups has supported clinically stable patients' retention and viral suppression. Patients and health systems could benefit further by reducing visit frequency and increasing ART refills. We designed a cluster-randomized control trial comparing standard of care (SoC) ACs and six-month ART refill (Intervention) ACs in a large primary care facility in Khayelitsha, South Africa. METHODS Existing ACs were randomized to either the control (SOC ACs) or intervention (Intervention ACs) arm. SoC ACs meet five times annually, receiving two-month ART refills with a four-month ART refill over year-end. Blood is drawn at the AC visit ahead of the clinical assessment visit. Intervention ACs meet twice annually receiving six-month ART refills, with a third individual visit for routine blood collection anytime two-four weeks before the annual clinical assessment AC visit. Primary outcomes will be retention in care, annual viral load assessment completion and viral load suppression. (<400copies/mL) after 2 years. Ethics approval has been granted by the University of Cape Town (HREC 652/2016) and the Medecins Sans Frontieres (MSF) Ethics Review Board (#1639). Results will be published in peer-reviewed journals and made widely available through presentations and briefing documents. DISCUSSION Evaluation of an extended ART refill interval in adherence clubs will provide evidence towards novel model adaptions that can be made to further improve convenience for patients and leverage health system efficiencies. TRIAL REGISTRATION Registered with the Pan African Clinical Trial Registry: PACTR201810631281009. Registered 11 September 2018.
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Affiliation(s)
- Lynne Wilkinson
- Center for Infectious Disease and Epidemiological Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Tali Cassidy
- Medécins Sans Frontières, Cape Town, South Africa. .,Division of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Isivivana Centre, 8 Mzala Street, Khayelitsha, Cape Town, South Africa.
| | - Catherine Orrell
- Department of Medicine, Faculty of Health Sciences, Cape Town, South Africa.,The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Jacqueline Voget
- Western Cape Government Department of Health, Cape Town, South Africa
| | - Helen Hayes
- Western Cape Government Department of Health, Cape Town, South Africa
| | - Claire Keene
- Medécins Sans Frontières, Cape Town, South Africa
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Hauser A, Kusejko K, Johnson LF, Wandeler G, Riou J, Goldstein F, Egger M, Kouyos RD. Bridging the gap between HIV epidemiology and antiretroviral resistance evolution: Modelling the spread of resistance in South Africa. PLoS Comput Biol 2019; 15:e1007083. [PMID: 31233494 PMCID: PMC6611642 DOI: 10.1371/journal.pcbi.1007083] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 07/05/2019] [Accepted: 05/06/2019] [Indexed: 11/19/2022] Open
Abstract
The scale-up of antiretroviral therapy (ART) in South Africa substantially reduced AIDS-related deaths and new HIV infections. However, its success is threatened by the emergence of resistance to non-nucleoside reverse-transcriptase inhibitors (NNRTI). The MARISA (Modelling Antiretroviral drug Resistance In South Africa) model presented here aims at investigating the time trends and factors driving NNRTI resistance in South Africa. MARISA is a compartmental model that includes the key aspects of the local HIV epidemic: continuum of care, disease progression, and gender. The dynamics of NNRTI resistance emergence and transmission are then added to this framework. Model parameters are informed using data from HIV cohorts participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) and literature estimates, or fitted to UNAIDS estimates. Using this novel approach of triangulating clinical and resistance data from various sources, MARISA reproduces the time trends of HIV in South Africa in 2005–2016, with a decrease in new infections, undiagnosed individuals, and AIDS-related deaths. MARISA captures the dynamics of the spread of NNRTI resistance: high levels of acquired drug resistance (ADR, in 83% of first-line treatment failures in 2016), and increasing transmitted drug resistance (TDR, in 8.1% of ART initiators in 2016). Simulation of counter-factual scenarios reflecting alternative public health policies shows that increasing treatment coverage would have resulted in fewer new infections and deaths, at the cost of higher TDR (11.6% in 2016 for doubling the treatment rate). Conversely, improving switching to second-line treatment would have led to lower TDR (6.5% in 2016 for doubling the switching rate) and fewer new infections and deaths. Implementing drug resistance testing would have had little impact. The rapid ART scale-up and inadequate switching to second-line treatment were the key drivers of the spread of NNRTI resistance in South Africa. However, even though some interventions could have substantially reduced the level of NNRTI resistance, no policy including NNRTI-based first line regimens could have prevented this spread. Thus, by combining epidemiological data on HIV in South Africa with biological data on resistance evolution, our modelling approach identified key factors driving NNRTI resistance, highlighting the need of alternative first-line regimens. Resistance to non-nucleoside reverse transcriptase inhibitors (NNRTI) threatens the long-term success of antiretroviral therapy (ART) roll-out in South Africa. We developed a compartmental model integrating the local HIV epidemiology with biological mechanisms of drug resistance. A first dimension of the model accounts for the continuum of care: infection, diagnosis, first-line treatment with suppression or failure, and second-line treatment. Other dimensions include: disease progression (CD4 counts), gender, and acquisition and transmission of NNRTI resistance. Whenever possible, we informed the parameters using the data available from local cohorts. Other parameters were informed using literature or UNAIDS estimates. The model captured the rise of NNRTI resistance during the period. We assessed the impact of counter-factual scenarios reflecting alternative countrywide policies during the period 2005 to 2016, considering either increasing ART coverage, improving management of treatment failure, broadening ART eligibility, or implementing drug resistance testing before ART initiation. We identified key drivers of the NNRTI resistance epidemic: large-scale ART roll-out and insufficient monitoring of first-line treatment failure. The model also suggested that no policy including NNRTI-based first line regimens could have prevented the spread of NNRTI resistance.
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Affiliation(s)
- Anthony Hauser
- Institute of Social and Preventive Medicine, University of Bern, Switzerland
| | - Katharina Kusejko
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Leigh F. Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - Gilles Wandeler
- Institute of Social and Preventive Medicine, University of Bern, Switzerland
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Julien Riou
- Institute of Social and Preventive Medicine, University of Bern, Switzerland
| | - Fardo Goldstein
- Institute of Social and Preventive Medicine, University of Bern, Switzerland
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Switzerland
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - Roger D. Kouyos
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
- * E-mail:
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83
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Demitto FO, Schmaltz CAS, Sant'Anna FM, Arriaga MB, Andrade BB, Rolla VC. Predictors of early mortality and effectiveness of antiretroviral therapy in TB-HIV patients from Brazil. PLoS One 2019; 14:e0217014. [PMID: 31170171 PMCID: PMC6553696 DOI: 10.1371/journal.pone.0217014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 05/02/2019] [Indexed: 01/03/2023] Open
Abstract
Background The implementation of antiretroviral (ARV) therapy caused a significant decrease in HIV-associated mortality worldwide. Nevertheless, mortality is still high among people living with HIV/AIDS and tuberculosis (TB). ARV-naïve HIV patients coinfected with tuberculosis (TB) have more options to treat both diseases concomitantly. Nevertheless, some TB-HIV patients undertaking ARVs (ARV-experienced) are already failing the first line efavirenz-based regimen and seem to display different response to second line ARV therapy and exhibit other predictors of mortality. Methods We performed a retrospective cohort study including 273 patients diagnosed with TB-HIV and treated at a referral center in Rio de Janeiro, Brazil, between 2008 and 2016. Multivariate analysis and Cox regression models were used to evaluate the effectiveness of ARV therapy regimens (viral load [VL] <80 copies from the 4th to 10th months after TB therapy introduction) and to identify predictors of early mortality (100 days after TB therapy initiation) considering ARV-naïve and ARV-experienced patients adjusting for sociodemographic, clinical and therapeutic covariates. Findings Survival analysis included 273 patients, out of whom 154 (56.4%) were ARV-naïve and 119 (43.6%) were ARV-experienced. Seven deaths occurred within 6 months of anti-TB treatment, 4 in ARV-naïve and 3 in ARV-experienced patients. Multivariate analysis revealed that in ARV-naïve patients, the chance of death was substantially higher in patients who developed immune reconstitution inflammatory syndrome during the study follow up (HR = 40.6, p<0.01). For ARV-experienced patients, similar analyses failed to identify factors significantly associated with mortality. Variables independently associated with treatment failure for the ARV-naïve group were previous TB (adjusted OR [aOR] = 6.1 p = 0.03) and alcohol abuse (aOR = 3.7 p = 0.01). For ARV-experienced patients, a ritonavir boosted. Protease Inhibitor-based regimen resulted in a 2.6 times higher risk of treatment failure compared to the use of efavirenz based ARV regimens (p = 0.03) and High baseline HIV VL (p = 0.03) were predictors of treatment failure. Conclusions Risk factors for mortality and ARV failure were different for ARV-naïve and ARV-experienced patients. The latter patient group should be targeted for trials with less toxic and rifampicin-compatible drugs to improve TB-HIV treatment outcomes and prevent death.
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Affiliation(s)
- Fernanda O Demitto
- Programa de Pós-Graduação em Pesquisa Clínica em Doenças Infecciosas, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Carolina A S Schmaltz
- Laboratório de Pesquisa Clínica em Micobacterioses (LAPCLIN-TB), Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Flávia M Sant'Anna
- Laboratório de Pesquisa Clínica em Micobacterioses (LAPCLIN-TB), Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - María B Arriaga
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
| | - Bruno B Andrade
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, Brazil.,Universidade Salvador (UNIFACS), Laureate Universities, Salvador, Brazil.,Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, Republic of South Africa.,Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Valeria C Rolla
- Programa de Pós-Graduação em Pesquisa Clínica em Doenças Infecciosas, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.,Laboratório de Pesquisa Clínica em Micobacterioses (LAPCLIN-TB), Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
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84
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Dwyer-Lindgren L, Cork MA, Sligar A, Steuben KM, Wilson KF, Provost NR, Mayala BK, VanderHeide JD, Collison ML, Hall JB, Biehl MH, Carter A, Frank T, Douwes-Schultz D, Burstein R, Casey DC, Deshpande A, Earl L, El Bcheraoui C, Farag TH, Henry NJ, Kinyoki D, Marczak LB, Nixon MR, Osgood-Zimmerman A, Pigott D, Reiner RC, Ross JM, Schaeffer LE, Smith DL, Davis Weaver N, Wiens KE, Eaton JW, Justman JE, Opio A, Sartorius B, Tanser F, Wabiri N, Piot P, Murray CJL, Hay SI. Mapping HIV prevalence in sub-Saharan Africa between 2000 and 2017. Nature 2019; 570:189-193. [PMID: 31092927 PMCID: PMC6601349 DOI: 10.1038/s41586-019-1200-9] [Citation(s) in RCA: 272] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 04/10/2019] [Indexed: 12/16/2022]
Abstract
HIV/AIDS is a leading cause of disease burden in sub-Saharan Africa. Existing evidence has demonstrated that there is substantial local variation in the prevalence of HIV; however, subnational variation has not been investigated at a high spatial resolution across the continent. Here we explore within-country variation at a 5 × 5-km resolution in sub-Saharan Africa by estimating the prevalence of HIV among adults (aged 15-49 years) and the corresponding number of people living with HIV from 2000 to 2017. Our analysis reveals substantial within-country variation in the prevalence of HIV throughout sub-Saharan Africa and local differences in both the direction and rate of change in HIV prevalence between 2000 and 2017, highlighting the degree to which important local differences are masked when examining trends at the country level. These fine-scale estimates of HIV prevalence across space and time provide an important tool for precisely targeting the interventions that are necessary to bringing HIV infections under control in sub-Saharan Africa.
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Affiliation(s)
- Laura Dwyer-Lindgren
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Michael A Cork
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Amber Sligar
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Krista M Steuben
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Kate F Wilson
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Naomi R Provost
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | | | - John D VanderHeide
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Michael L Collison
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Jason B Hall
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Molly H Biehl
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Austin Carter
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Tahvi Frank
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Dirk Douwes-Schultz
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Roy Burstein
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Daniel C Casey
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Aniruddha Deshpande
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Lucas Earl
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Charbel El Bcheraoui
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Tamer H Farag
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Nathaniel J Henry
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Damaris Kinyoki
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Laurie B Marczak
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Molly R Nixon
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | | | - David Pigott
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Robert C Reiner
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Jennifer M Ross
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Lauren E Schaeffer
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - David L Smith
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Nicole Davis Weaver
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Kirsten E Wiens
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Jeffrey W Eaton
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Jessica E Justman
- ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Alex Opio
- Medireal Investment Uganda, Entebbe, Uganda
| | - Benn Sartorius
- Public Health Medicine, School of Nursing and Public Health, College of Health Sciences, 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, KwaZulu-Natal, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
- Research Department of Infection & Population Health, University College London, London, UK
| | - Njeri Wabiri
- HIV/AIDS, STIs & TB Research Programme, Human Sciences Research Council, Pretoria, South Africa
| | - Peter Piot
- London School of Hygiene & Tropical Medicine, London, UK
| | | | - Simon I Hay
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
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Mgwaba T, Maharaj P. Unpacking the practice of ukujola in contemporary South Africa: understanding informal/casual sexual relations of young African adults in the context of HIV and AIDS. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2019; 17:341-351. [PMID: 30560730 DOI: 10.2989/16085906.2018.1544573] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
HIV and AIDS continue to pose a global health and development challenge, particularly in sub-Saharan Africa. South Africa has the largest number of people living with HIV (PLHIV) in the world. In spite of the accelerated efforts to combat the HIV and AIDS epidemic, there still remains an unabated challenge, i.e. continuing new infections, particularly among young African adults. HIV is largely transmitted through unprotected vaginal and anal sexual intercourse. This study sought to unpack the meaning of ukujola (casual or informal sexual relationships) as socially constructed by Zulu people, and to identify underlying socio-economic factors for ukujola. This study uses a generic qualitative study approach in which 32 qualitative interviews (4 focus groups, 20 in-depth interviews and 8 key-informant interviews) were conducted with isiZulu-speaking participants (aged 21-34) from Umgungundlovu district, KwaZulu-Natal province. The study found that ukujola relationships are a relatively new phenomenon in Zulu society. Ukujola relationships encompass all "illegitimate" relationships, i.e. in which there has never been involvement of the families. The involvement of families in negotiating ilobolo (bride wealth) is a pre-requisite for legitimate relationships, particularly marriage. Multiple concurrent sexual partnerships typically exist in ukujola relationships, and unprotected sex is common. There is a need for a national dialogue on ilobolo in the context of HIV and AIDS.
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Affiliation(s)
- Themba Mgwaba
- a School of Built Environment and Development Studies , University of KwaZulu-Natal , Durban , South Africa
| | - Pranitha Maharaj
- b DST/NRF SARChI Chair in Economic Development, School of Built Environment and Development Studies , University of KwaZulu-Natal , Durban , South Africa
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Yang F, Zheng G, Fu T, Li X, Tu G, Li YH, Yao X, Xue W, Zhu F. Prediction of the binding mode and resistance profile for a dual-target pyrrolyl diketo acid scaffold against HIV-1 integrase and reverse-transcriptase-associated ribonuclease H. Phys Chem Chem Phys 2019; 20:23873-23884. [PMID: 29947629 DOI: 10.1039/c8cp01843j] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The rapid emergence of drug-resistant variants is one of the most common causes of highly active antiretroviral therapeutic (HAART) failure in patients infected with HIV-1. Compared with the existing HAART, the recently developed pyrrolyl diketo acid scaffold targeting both HIV-1 integrase (IN) and reverse transcriptase-associated ribonuclease H (RNase H) is an efficient approach to counteract the failure of anti-HIV treatment due to drug resistance. However, the binding mode and potential resistance profile of these inhibitors with important mechanistic principles remain poorly understood. To address this issue, an integrated computational method was employed to investigate the binding mode of inhibitor JMC6F with HIV-1 IN and RNase H. By using per-residue binding free energy decomposition analysis, the following residues: Asp64, Thr66, Leu68, Asp116, Tyr143, Gln148 and Glu152 in IN, Asp443, Glu478, Trp536, Lys541 and Asp549 in RNase H were identified as key residues for JMC6F binding. And then computational alanine scanning was carried to further verify the key residues. Moreover, the resistance profile of the currently known major mutations in HIV-1 IN and 2 mutations in RNase H against JMC6F was predicted by in silico mutagenesis studies. The results demonstrated that only three mutations in HIV-1 IN (Y143C, Q148R and N155H) and two mutations in HIV-1 RNase H (Y501R and Y501W) resulted in a reduction of JMC6F potency, thus indicating their potential role in providing resistance to JMC6F. These data provided important insights into the binding mode and resistance profile of the inhibitors with a pyrrolyl diketo acid scaffold in HIV-1 IN and RNase H, which would be helpful for the development of more effective dual HIV-1 IN and RNase H inhibitors.
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Affiliation(s)
- Fengyuan Yang
- Innovative Drug Research and Bioinformatics Group, School of Pharmaceutical Sciences and Collaborative Innovation Center for Brain Science, Chongqing University, Chongqing 401331, China.
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Nut and Bolt Microfluidics with Helical Minichannel for Counting CD4+ T-Cells. Bioengineering (Basel) 2019; 6:bioengineering6010024. [PMID: 30875995 PMCID: PMC6466421 DOI: 10.3390/bioengineering6010024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/07/2019] [Accepted: 03/12/2019] [Indexed: 01/01/2023] Open
Abstract
In this study, we developed the prototype of an optical imaging-based point-of-care (POC) device for monitoring human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) progression that can detect CD4+ T-lymphocytes in human blood. The proposed portable cell-counting system, Helios CD4 Analyzer (Helios), can acquire sample images and analyze the cells automatically using a simple fluorescence imaging module and sample cartridge with a three-dimensional (3D) helical minichannel. The helical minichannel formed on the cylindrical surface enables the sample cartridge to hold a cell suspension present in a fixed sample volume for absolute counting of the cells. With a given total channel length, the helical minichannel-based sample cartridge is smaller than the conventional sample cartridge with a planar microchannel. The implemented nut and bolt mechanism allows the scanning of a relatively large volume of the sample along the helical minichannel by just rotating the cylindrical chamber coupled with a single DC motor rather than using a two-axis motorized translation stage, which considerably simplifies the associated electromechanical parts. It has distinct advantages over the existing devices because of its small size and simple scanning mechanism. We optimized various imaging parameters to enhance the fluorescence detection efficiency of the prototype. Performance evaluations using human blood samples demonstrated good agreement for low CD4 count between the Helios and the PIMATM, one of the most widely used POC CD4+ analyzers.
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Abstract
Implementation science uses methods to promote the scaling up and use of evidence-based practices by health systems to improve quality and outcomes. Its use is vital to maximise the efficiency of limited resources for health care in tropical settings. HIV and tuberculosis (TB) are two of the major causes of morbidity and mortality in sub-Saharan Africa, and globally. Although effective treatments are widely available, lack of diagnosis remains a large barrier to accessing treatment, particularly in resource-limited settings. We explore HIV and TB diagnostics that can be used at point-of-care in any settings, and outline some important principles and applications of implementation science to aid their application and use. Despite robust evidence of diagnostic accuracy and efficacy in improving patient-centred outcomes, such interventions cannot be fully utilised without addressing operational barriers and knowledge gaps.
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Affiliation(s)
- Ankur Gupta-Wright
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
- Department of Infection, St Thomas' Hospital, London, UK
| | - Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine Johns Hopkins School of Medicine, Baltimore, USA
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89
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Ghys PD, Williams BG, Over M, Hallett TB, Godfrey-Faussett P. Epidemiological metrics and benchmarks for a transition in the HIV epidemic. PLoS Med 2018; 15:e1002678. [PMID: 30359372 PMCID: PMC6201869 DOI: 10.1371/journal.pmed.1002678] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Peter Godfrey-Faussett and colleagues present six epidemiological metrics for tracking progress in reducing the public health threat of HIV.
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Affiliation(s)
- Peter D. Ghys
- Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
| | - Brian G. Williams
- South Africa Centre for Epidemiological Modelling and Analysis, Stellenbosch, South Africa
| | - Mead Over
- Center for Global Development, Washington, DC, United States of America
| | - Timothy B. Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
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Grebe E, Welte A, Johnson LF, van Cutsem G, Puren A, Ellman T, Etard JF, Huerga H. Population-level HIV incidence estimates using a combination of synthetic cohort and recency biomarker approaches in KwaZulu-Natal, South Africa. PLoS One 2018; 13:e0203638. [PMID: 30212513 PMCID: PMC6136757 DOI: 10.1371/journal.pone.0203638] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 08/26/2018] [Indexed: 11/30/2022] Open
Abstract
Introduction There is a notable absence of consensus on how to generate estimates of population-level incidence. Incidence is a considerably more sensitive indicator of epidemiological trends than prevalence, but is harder to estimate. We used a novel hybrid method to estimate HIV incidence by age and sex in a rural district of KwaZulu-Natal, South Africa. Methods Our novel method uses an ‘optimal weighting’ of estimates based on an implementation of a particular ‘synthetic cohort’ approach (interpreting the age/time structure of prevalence, in conjunction with estimates of excess mortality) and biomarkers of ‘recent infection’ (combining Lag-Avidity, Bio-Rad Avidity and viral load results to define recent infection, and adapting the method for age-specific incidence estimation). Data were obtained from a population-based cross-sectional HIV survey conducted in Mbongolwane and Eshowe health service areas in 2013. Results Using the combined method, we find that age-specific HIV incidence in females rose rapidly during adolescence, from 1.33 cases/100 person-years (95% CI: 0.98,1.67) at age 15 to a peak of 5.01/100PY (4.14,5.87) at age 23. In males, incidence was lower, 0.34/100PY (0.00-0.74) at age 15, and rose later, peaking at 3.86/100PY (2.52-5.20) at age 30. Susceptible population-weighted average incidence in females aged 15-29 was estimated at 3.84/100PY (3.36-4.40), in males aged 15-29 at 1.28/100PY (0.68-1.50) and in all individuals aged 15-29 at 2.55/100PY (2.09-2.76). Using the conventional recency biomarker approach, we estimated HIV incidence among females aged 15-29 at 2.99/100PY (1.79-4.36), among males aged 15-29 at 0.87/100PY (0.22-1.60) and among all individuals aged 15-59 at 1.66/100PY (1.13-2.27). Discussion HIV incidence was very high in women aged 15-30, peaking in the early 20s. Men had lower incidence, which peaked at age 30. The estimates obtained from the hybrid method are more informative than those produced by conventional analysis of biomarker data, and represents a more optimal use of available data than either the age-continuous biomarker or synthetic cohort methods alone. The method is mainly useful at younger ages, where excess mortality is low and uncertainty in the synthetic cohort estimates is reasonably small. Conclusion Application of this method to large-scale population-based HIV prevalence surveys is likely to result in improved incidence surveillance over methods currently in wide use. Reasonably accurate and precise age-specific estimates of incidence are important to target better prevention, diagnosis and care strategies.
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Affiliation(s)
- Eduard Grebe
- DST-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- * E-mail:
| | - Alex Welte
- DST-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Leigh F. Johnson
- Centre for Infectious Diseases Epidemiology and Research (CIDER), University of Cape Town, Cape Town, South Africa
| | - Gilles van Cutsem
- Centre for Infectious Diseases Epidemiology and Research (CIDER), University of Cape Town, Cape Town, South Africa
- Médecins Sans Frontières, Cape Town, South Africa
| | - Adrian Puren
- National Institute for Communicable Diseases (NICD), National Health Laboratory Service, Johannesburg, South Africa
| | - Tom Ellman
- Médecins Sans Frontières, Cape Town, South Africa
| | - Jean-François Etard
- TransVIHMI, Institut de Recherche pour le Développement (IRD), Institut National de la Santé et de la Recherche Médicale (INSERM), Montpellier University, Montpellier, France
- Epicentre, Paris, France
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Bekker LG, Alleyne G, Baral S, Cepeda J, Daskalakis D, Dowdy D, Dybul M, Eholie S, Esom K, Garnett G, Grimsrud A, Hakim J, Havlir D, Isbell MT, Johnson L, Kamarulzaman A, Kasaie P, Kazatchkine M, Kilonzo N, Klag M, Klein M, Lewin SR, Luo C, Makofane K, Martin NK, Mayer K, Millett G, Ntusi N, Pace L, Pike C, Piot P, Pozniak A, Quinn TC, Rockstroh J, Ratevosian J, Ryan O, Sippel S, Spire B, Soucat A, Starrs A, Strathdee SA, Thomson N, Vella S, Schechter M, Vickerman P, Weir B, Beyrer C. Advancing global health and strengthening the HIV response in the era of the Sustainable Development Goals: the International AIDS Society-Lancet Commission. Lancet 2018; 392:312-358. [PMID: 30032975 PMCID: PMC6323648 DOI: 10.1016/s0140-6736(18)31070-5] [Citation(s) in RCA: 212] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/25/2018] [Accepted: 05/04/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Linda-Gail Bekker
- International AIDS Society, Geneva, Switzerland; Desmond Tutu HIV Centre, University of Cape Town, South Africa.
| | - George Alleyne
- NCD Alliance, Office of the Director, Pan American Health Organization, Washington, DC, USA
| | - Stefan Baral
- Centre for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Javier Cepeda
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California-San Diego, San Diego, CA, USA
| | | | - David Dowdy
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Mark Dybul
- Centre for Global Health and Quality, Georgetown University School of Medicine, Washington, DC, USA
| | - Serge Eholie
- Department of Dermatology and Infectious Diseases, Medical School, Felix Houphouet Boigny Universty Abidjan, Cote d'Ivoire
| | - Kene Esom
- HIV, Health and Development Group, United Nations Development Programme, New York, NY, USA
| | - Geoff Garnett
- HIV Delivery, Bill & Melinda Gates Foundation, Washington, DC, USA
| | | | - James Hakim
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Diane Havlir
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California-San Francisco, San Fransisco, CA, USA
| | | | - Leigh Johnson
- School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Parastu Kasaie
- Department of Health, Behaviour and Society, Johns Hopkins University, Baltimore, MD, USA
| | - Michel Kazatchkine
- UNAIDS and Global Health Center, Graduate Institute, Geneva, Switzerland
| | - Nduku Kilonzo
- National AIDS Control Council for Kenya, Nairobi, Kenya
| | - Michael Klag
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA; Department of Health Policy and Management, Johns Hopkins University, Baltimore, MD, USA
| | - Marina Klein
- Division of Infectious Diseases, Faculty of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Sharon R Lewin
- The Peter Doherty Institute for Infection and Immunity, The University of Melbourne and Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Chewe Luo
- HIV/AIDS Section, United Nations Children's Fund, New York City, NY, USA
| | - Keletso Makofane
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Natasha K Martin
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California-San Diego, San Diego, CA, USA
| | - Kenneth Mayer
- The Fenway Institute, Harvard Medical School, Boston, MA, USA
| | | | - Ntobeko Ntusi
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Loyce Pace
- Global Health Council, Washington, DC, USA
| | - Carey Pike
- Desmond Tutu HIV Centre, University of Cape Town, South Africa
| | - Peter Piot
- London School of Hygiene and Tropical Medicine, London, UK
| | - Anton Pozniak
- HIV Services, Chelsea and Westminster NHS Foundation Trust Hospital, London, UK
| | - Thomas C Quinn
- Centre for Global Health, Johns Hopkins University, Baltimore, MD, USA; International AIDS Society-National Institute for Drug Abuse, Johns Hopkins University, Baltimore, MD, USA; Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institute of Health, MD, USA
| | - Jurgen Rockstroh
- HIV Clinic, Department of Medicine, University Hospital Bonn, Bonn, Germany
| | - Jirair Ratevosian
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Owen Ryan
- International AIDS Society, Geneva, Switzerland
| | - Serra Sippel
- Center for Health and Gender Equity, Washington DC, USA
| | - Bruno Spire
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France
| | - Agnes Soucat
- Health Systems, Governance and Financing, World Health Organisation, Geneva, Switzerland
| | | | - Steffanie A Strathdee
- Global Health Sciences, Department of Medicine, University of California-San Diego, San Diego, CA, USA
| | - Nicholas Thomson
- Centre for Public Health and Human Rights, Johns Hopkins University, Baltimore, MD, USA; Nossal Institute for Global Health, University of Melbourne, VIC, Australia
| | - Stefano Vella
- Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Mauro Schechter
- Department of Preventative Medicine, Universidade Federal do Rio de Janeiro, Rio de Janerio, Brazil
| | - Peter Vickerman
- School of Social and Community Medicine, Bristol Medical School, University of Bristol, Bristol, UK
| | - Brian Weir
- Department of Health, Behaviour and Society, Johns Hopkins University, Baltimore, MD, USA
| | - Chris Beyrer
- International AIDS Society, Geneva, Switzerland; Centre for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
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Abstract
In a Perspective, Amitabh Suthar and Till Bärnighausen discuss progress made so far in reducing HIV-related mortality in South Africa and keys towards further population mortality reductions going forward.
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Affiliation(s)
- Amitabh B. Suthar
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- * E-mail:
| | - Till Bärnighausen
- Africa Health Research Institute, Mtubatuba, South Africa
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Heidelberg Institute of Public Health, Heidelberg, Germany
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