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Ndege S, Washington S, Kaaria A, Prudhomme-O’Meara W, Were E, Nyambura M, Keter AK, Wachira J, Braitstein P. HIV Prevalence and Antenatal Care Attendance among Pregnant Women in a Large Home-Based HIV Counseling and Testing Program in Western Kenya. PLoS One 2016; 11:e0144618. [PMID: 26784957 PMCID: PMC4718704 DOI: 10.1371/journal.pone.0144618] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 10/19/2015] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To describe the uptake of and factors associated with HIV prevalence among pregnant women in a large-scale home-based HIV counseling and testing (HBCT) program in western Kenya. METHODS In 2007, the Academic Model Providing Access to Healthcare Program (AMPATH) initiated HBCT to all individuals aged ≥13 years and high-risk children <13 years. Included in this analysis were females aged 13-50 years, from 6 catchment areas (11/08-01/12). We used descriptive statistics and logistic regression to describe factors associated with HIV prevalence. RESULTS There were 119,678 women eligible for analysis; median age 25 (interquartile range, IQR: 18-34) years. Of these, 7,396 (6.2%) were pregnant at the time of HBCT; 4,599 (62%) had ever previously tested for HIV and 2,995 (40.5%) had not yet attended ANC for their current pregnancy. Testing uptake among pregnant women was high (97%). HBCT newly identified 241 (3.3%) pregnant HIV-positive women and overall HIV prevalence among all pregnant women was 6.9%. HIV prevalence among those who had attended ANC in this pregnancy was 5.4% compared to 9.0% among those who had not. Pregnant women were more likely to newly test HIV-positive in HBCT if they had not attended ANC in the current pregnancy (AOR: 6.85, 95% CI: 4.49-10.44). CONCLUSIONS Pregnant women who had never attended ANC were about 6 times more likely to newly test HIV-positive compared to those who had attended ANC, suggesting that the cascade of services for prevention of mother-to-child HIV transmission should optimally begin at the home and village level if elimination of perinatal HIV transmission is to be achieved.
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Affiliation(s)
- Samson Ndege
- Academic Model Providing Access to Healthcare (AMPATH) Program, Eldoret, Kenya
- Moi University, College of Health Sciences, School of Public Health, Eldoret, Kenya
| | - Sierra Washington
- Indiana University, School of Medicine, Indianapolis, Indiana, United States of America
| | - Alice Kaaria
- Academic Model Providing Access to Healthcare (AMPATH) Program, Eldoret, Kenya
- Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Wendy Prudhomme-O’Meara
- Academic Model Providing Access to Healthcare (AMPATH) Program, Eldoret, Kenya
- Moi University, College of Health Sciences, School of Public Health, Eldoret, Kenya
- Duke University, School of Medicine and Duke Global Health Institute, Durham, North Carolina, United States of America
| | - Edwin Were
- Academic Model Providing Access to Healthcare (AMPATH) Program, Eldoret, Kenya
- Moi University, College of Health Sciences, School of Medicine, Eldoret, Kenya
| | - Monica Nyambura
- Academic Model Providing Access to Healthcare (AMPATH) Program, Eldoret, Kenya
| | - Alfred K. Keter
- Academic Model Providing Access to Healthcare (AMPATH) Program, Eldoret, Kenya
| | - Juddy Wachira
- Academic Model Providing Access to Healthcare (AMPATH) Program, Eldoret, Kenya
- Moi University, College of Health Sciences, School of Medicine, Eldoret, Kenya
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH) Program, Eldoret, Kenya
- Moi University, College of Health Sciences, School of Medicine, Eldoret, Kenya
- University of Toronto, Dalla Lana School of Public Health, Toronto, Canada
- Indiana University, Fairbanks School of Public Health, Indianapolis, Indiana, United States of America
- Regenstrief Institute, Inc. Indianapolis, Indiana, United States of America
- * E-mail:
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Linnemayr S, Stecher C. Behavioral Economics Matters for HIV Research: The Impact of Behavioral Biases on Adherence to Antiretrovirals (ARVs). AIDS Behav 2015; 19:2069-75. [PMID: 25987190 DOI: 10.1007/s10461-015-1076-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Behavioral economics (BE) has been used to study a number of health behaviors such as smoking and drug use, but there is little knowledge of how these insights relate to HIV prevention and care. We present novel evidence on the prevalence of the common behavioral decision-making errors of present-bias, overoptimism, and information salience among 155 Ugandan HIV patients, and analyze their association with subsequent medication adherence. 36 % of study participants are classified as present-biased, 21 % as overoptimistic, and 34 % as having salient HIV information. Patients displaying present-bias were 13 % points (p = 0.006) less likely to have adherence rates above 90 %, overoptimistic clients were 9 % points (p = 0.04) less likely, and those not having salient HIV information were 17 % points (p < 0.001) less likely. These findings indicate that BE may be used to screen for future adherence problems and to better design and target interventions addressing these behavioral biases and the associated suboptimal adherence.
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Fairlie L, Karalius B, Patel K, van Dyke RB, Hazra R, Hernán MA, Siberry GK, Seage GR, Agwu A, Wiznia A. CD4+ and viral load outcomes of antiretroviral therapy switch strategies after virologic failure of combination antiretroviral therapy in perinatally HIV-infected youth in the United States. AIDS 2015; 29:2109-19. [PMID: 26182197 PMCID: PMC4612147 DOI: 10.1097/qad.0000000000000809] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 06/30/2015] [Accepted: 07/07/2015] [Indexed: 01/07/2023]
Abstract
OBJECTIVE This study compared 12-month CD4 and viral load outcomes in HIV-infected children and adolescents with virological failure, managed with four treatment switch strategies. DESIGN This observational study included perinatally HIV-infected (PHIV) children in the Pediatric HIV/AIDS Cohort Study (PHACS) and Pediatric AIDS Clinical Trials (PACTG) Protocol 219C. METHODS Treatment strategies among children with virologic failure were compared: continue failing combination antiretroviral therapy (cART); switch to new cART; switch to drug-sparing regimen; and discontinue all ART. Mean changes in CD4% and viral load from baseline (time of virologic failure) to 12 months follow-up in each group were evaluated using weighted linear regression models. RESULTS Virologic failure occurred in 939 out of 2373 (40%) children. At 12 months, children switching to new cART (16%) had a nonsignificant increase in CD4% from baseline, 0.59 percentage points [95% confidence interval (95% CI) -1.01 to 2.19], not different than those who continued failing cART (71%) (-0.64 percentage points, P = 0.15) or switched to a drug-sparing regimen (5%) (1.40 percentage points, P = 0.64). Children discontinuing all ART (7%) experienced significant CD4% decline -3.18 percentage points (95% CI -5.25 to -1.11) compared with those initiating new cART (P = 0.04). All treatment strategies except discontinuing ART yielded significant mean decreases in log10VL by 12 months, the new cART group having the largest drop (-1.15 log10VL). CONCLUSION In PHIV children with virologic failure, switching to new cART was associated with the best virological response, while stopping all ART resulted in the worst immunologic and virologic outcomes and should be avoided. Drug-sparing regimens and continuing failing regimens may be considered with careful monitoring.
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Affiliation(s)
- Lee Fairlie
- Wits Reproductive Health & HIV Institute (WRHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Brad Karalius
- Department of Epidemiology, Center for Biostatistics in AIDS Research (CBAR), Harvard School of Public Health, Boston, Massachusetts
| | - Kunjal Patel
- Department of Epidemiology, Center for Biostatistics in AIDS Research (CBAR), Harvard School of Public Health, Boston, Massachusetts
| | | | - Rohan Hazra
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, Maryland
| | - Miguel A. Hernán
- Department of Epidemiology, Center for Biostatistics in AIDS Research (CBAR), Harvard School of Public Health, Boston, Massachusetts
- Harvard-MIT Division of Health Sciences and Technology, Boston, Massachusetts
| | - George K. Siberry
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, Maryland
| | - George R. Seage
- Department of Epidemiology, Center for Biostatistics in AIDS Research (CBAR), Harvard School of Public Health, Boston, Massachusetts
| | - Allison Agwu
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrew Wiznia
- Jacobi Medical Center/Family Based Services, Albert Einstein College of Medicine, Bronx, New York, USA
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Factors Associated with Retention to Care in an HIV Clinic in Gabon, Central Africa. PLoS One 2015; 10:e0140746. [PMID: 26473965 PMCID: PMC4608719 DOI: 10.1371/journal.pone.0140746] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 09/30/2015] [Indexed: 01/30/2023] Open
Abstract
Background Retention to HIV care is vital for patients’ survival, to prevent onward transmission and emergence of drug resistance. Travelling to receive care might influence adherence. Data on the functioning of and retention to HIV care in the Central African region are limited. Methods This retrospective study reports outcomes and factors associated with retention to HIV care at a primary HIV clinic in Lambaréné, Gabon. Adult patients who presented to this clinic between January 2010 and January 2012 were included. Outcomes were retention in care (defined as documented show-up for clinical visits, regardless of delay) or LTFU (defined as a patient not retained in care; on ART or ART naïve, not returning to care during the study period with a patient delay for scheduled visits of more than 6 months), and mortality. Cox regression analysis was used to assess factors associated with respective outcomes. Qualitative data on reasons for LTFU were obtained from focus-group discussions. Results Of 223 patients included, 67.3% were female. The mean age was 40.5 (standard deviation 11.4) years and the median CD4 count 275 (interquartile range 100.5–449.5) cells/μL. In total, 34.1% were lost to follow up and 8.1% died. Documented tuberculosis was associated with increased risk of being LTFU (adjusted hazard ratio (aHR) 1.80, 95% confidence interval (95% CI) 1.05–3.11, P = 0.03), whereas early starting anti-retroviral therapy (ART) was associated with a decreased risk of LTFU (aHR 0.43, 95%CI 0.24–0.76, P = 0.004), as was confirmed by qualitative data. Conclusions Retention to HIV care in a primary clinic in Gabon is relatively poor and interventions to address this should be prioritized in the HIV program. Early initiation of ART might improve retention in care.
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Etyang AO, Munge K, Bunyasi EW, Matata L, Ndila C, Kapesa S, Owiti M, Khandwalla I, Brent AJ, Tsofa B, Kabibu P, Morpeth S, Bauni E, Otiende M, Ojal J, Ayieko P, Knoll MD, Smeeth L, Williams TN, Griffiths UK, Scott JAG. Burden of disease in adults admitted to hospital in a rural region of coastal Kenya: an analysis of data from linked clinical and demographic surveillance systems. LANCET GLOBAL HEALTH 2015; 2:e216-24. [PMID: 24782954 PMCID: PMC3986034 DOI: 10.1016/s2214-109x(14)70023-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Estimates of the burden of disease in adults in sub-Saharan Africa largely rely on models of sparse data. We aimed to measure the burden of disease in adults living in a rural area of coastal Kenya with use of linked clinical and demographic surveillance data. Methods We used data from 18 712 adults admitted to Kilifi District Hospital (Kilifi, Kenya) between Jan 1, 2007, and Dec 31, 2012, linked to 790 635 person-years of observation within the Kilifi Health and Demographic Surveillance System, to establish the rates and major causes of admission to hospital. These data were also used to model disease-specific disability-adjusted life-years lost in the population. We used geographical mapping software to calculate admission rates stratified by distance from the hospital. Findings The main causes of admission to hospital in women living within 5 km of the hospital were infectious and parasitic diseases (303 per 100 000 person-years of observation), pregnancy-related disorders (239 per 100 000 person-years of observation), and circulatory illnesses (105 per 100 000 person-years of observation). Leading causes of hospital admission in men living within 5 km of the hospital were infectious and parasitic diseases (169 per 100 000 person-years of observation), injuries (135 per 100 000 person-years of observation), and digestive system disorders (112 per 100 000 person-years of observation). HIV-related diseases were the leading cause of disability-adjusted life-years lost (2050 per 100 000 person-years of observation), followed by non-communicable diseases (741 per 100 000 person-years of observation). For every 5 km increase in distance from the hospital, all-cause admission rates decreased by 11% (95% CI 7–14) in men and 20% (17–23) in women. The magnitude of this decline was highest for endocrine disorders in women (35%; 95% CI 22–46) and neoplasms in men (30%; 9–45). Interpretation Adults in rural Kenya face a combined burden of infectious diseases, pregnancy-related disorders, cardiovascular illnesses, and injuries. Disease burden estimates based on hospital data are affected by distance from the hospital, and the amount of underestimation of disease burden differs by both disease and sex. Funding The Wellcome Trust, GAVI Alliance.
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Affiliation(s)
- Anthony O Etyang
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Kilifi District Hospital, Kilifi, Kenya
- Correspondence to: Dr Anthony O Etyang, KEMRI-Wellcome Trust Research Programme, PO Box 230-80108, Kilifi, Kenya
| | - Kenneth Munge
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Kilifi District Hospital, Kilifi, Kenya
| | - Erick W Bunyasi
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Kilifi District Hospital, Kilifi, Kenya
| | - Lena Matata
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Kilifi District Hospital, Kilifi, Kenya
| | | | - Sailoki Kapesa
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Kilifi District Hospital, Kilifi, Kenya
| | | | | | - Andrew J Brent
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Kilifi District Hospital, Kilifi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Imperial College, London, UK
| | - Benjamin Tsofa
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Kilifi District Hospital, Kilifi, Kenya
| | | | - Susan Morpeth
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Kilifi District Hospital, Kilifi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Evasius Bauni
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- INDEPTH Network, Accra, Ghana
| | - Mark Otiende
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - John Ojal
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Philip Ayieko
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Maria D Knoll
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Liam Smeeth
- London School of Hygiene & Tropical Medicine, London, UK
| | - Thomas N Williams
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Kilifi District Hospital, Kilifi, Kenya
- INDEPTH Network, Accra, Ghana
- Imperial College, London, UK
| | | | - J Anthony G Scott
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Kilifi District Hospital, Kilifi, Kenya
- London School of Hygiene & Tropical Medicine, London, UK
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- INDEPTH Network, Accra, Ghana
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Contemporary issues on the epidemiology and antiretroviral adherence of HIV-infected adolescents in sub-Saharan Africa: a narrative review. J Int AIDS Soc 2015; 18:20049. [PMID: 26385853 PMCID: PMC4575412 DOI: 10.7448/ias.18.1.20049] [Citation(s) in RCA: 150] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 07/10/2015] [Accepted: 08/12/2015] [Indexed: 12/25/2022] Open
Abstract
Introduction Adolescents are a unique and sometimes neglected group in the planning of healthcare services. This is the case in many parts of sub-Saharan Africa, where more than eight out of ten of the world's HIV-infected adolescents live. Although the last decade has seen a reduction in AIDS-related mortality worldwide, largely due to improved access to effective antiretroviral therapy (ART), AIDS remains a significant contributor to adolescent mortality in sub-Saharan Africa. Although inadequate access to ART in parts of the subcontinent may be implicated, research among youth with HIV elsewhere in the world suggests that suboptimal adherence to ART may play a significant role. In this article, we summarize the epidemiology of HIV among sub-Saharan African adolescents and review their adherence to ART, emphasizing the unique challenges and factors associated with adherence behaviour. Methods We conducted a comprehensive search of online databases for articles, relevant abstracts, and conference reports from meetings held between 2010 and 2014. Our search terms included “adherence,” “compliance,” “antiretroviral use” and “antiretroviral adherence,” in combination with “adolescents,” “youth,” “HIV,” “Africa,” “interventions” and the MeSH term “Africa South of the Sahara.” Of 19,537 articles and abstracts identified, 215 met inclusion criteria, and 148 were reviewed. Discussion Adolescents comprise a substantial portion of the population in many sub-Saharan African countries. They are at particular risk of HIV and may experience worse outcomes. Although demonstrated to have unique challenges, there is a dearth of comprehensive health services for adolescents, especially for those with HIV in sub-Saharan Africa. ART adherence is poorer among older adolescents than other age groups, and psychosocial, socio-economic, individual, and treatment-related factors influence adherence behaviour among adolescents in this region. With the exception of a few examples based on affective, cognitive, and behavioural strategies, most adherence interventions have been targeted at adults with HIV. Conclusions Although higher levels of ART adherence have been reported in sub-Saharan Africa than in other well-resourced settings, adolescents in the region may have poorer adherence patterns. There is substantial need for interventions to improve adherence in this unique population.
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Smillie K, Van Borek N, van der Kop ML, Lukhwaro A, Li N, Karanja S, Patel AR, Ojakaa D, Lester RT. Mobile health for early retention in HIV care: a qualitative study in Kenya (WelTel Retain). AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2015; 13:331-8. [PMID: 25555099 DOI: 10.2989/16085906.2014.961939] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Many people newly diagnosed with HIV are lost to follow-up before timely initiation of antiretroviral therapy (ART). A randomised controlled trial (RCT), WelTel Kenya1, demonstrated the effectiveness of the WelTel text messaging intervention to improve clinical outcomes among patients initiating ART. In preparation for WelTel Retain, an RCT that will evaluate the effect of the intervention to retain patients in care immediately following HIV diagnosis, we conducted an informative qualitative study with people living with HIV (n = 15) and healthcare providers (HCP) (n = 5) in October 2012. Study objectives included exploring the experiences of people living with HIV who have attempted to engage in HIV care, the use of cell phones in everyday life, and perceptions of communicating via text message with HCP. Participants were recruited through convenience sampling. Semi-structured, qualitative interviews were conducted and recorded, transcribed verbatim and analysed using NVivo software. Analysis was guided by the Theory of Reasoned Action and the Technology Acceptance Model. Results indicate that while individuals have many motivators for engaging in care after diagnosis, structural and individual barriers including poverty, depression and fear of stigma prevent them from doing so. All participants had access to a mobile phone, and most were comfortable communicating through text messages, or were willing to learn. Both people living with HIV and HCP felt that increased communication via the text messaging intervention has the potential to enable early identification of problems, leading to timely problem solving that may improve retention and engagement in care during the first year after diagnosis.
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Affiliation(s)
- Kirsten Smillie
- a British Columbia Centre for Disease Control , 655 West 12th Avenue, Vancouver , British Columbia , Canada , V5Z 4R4
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Ladner J, Besson MH, Rodrigues M, Saba J, Audureau E. Performance of HIV Prevention of Mother-To-Child Transmission Programs in Sub-Saharan Africa: Longitudinal Assessment of 64 Nevirapine-Based Programs Implemented in 25 Countries, 2000-2011. PLoS One 2015; 10:e0130103. [PMID: 26098311 PMCID: PMC4476579 DOI: 10.1371/journal.pone.0130103] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 05/15/2015] [Indexed: 11/19/2022] Open
Abstract
Background To evaluate the performance and to identify predictive factors of performance in prevention of mother-to-child HIV transmission programs (PMTCT) in sub-Saharan African countries. Methods From 2000 to 2011, PMTCT programs included in the Viramune Donation Programme (VDP) were prospectively followed. Each institution included in the VDP provided data on program implementation, type of management institution, number of PMTCT sites, key programs outputs (HIV counseling and testing, NVP regimens received by mothers and newborns). Nevirapine Coverage Ratio (NCR), defined as the number of women who should have received nevirapine (observed HIV prevalence x number of women in antenatal care), was used to measure performance. Included programs were followed every six months through progress reports. Results A total of 64 programs in 25 sub-Saharan African countries were included. The mean program follow-up was 48.0 months (SD = 24.5); 20,084,490 women attended in antenatal clinics were included. The overall mean NCR was 0.52 (SD = 0.25), with an increase from 0.37 to 0.57 between the first and last progress reports (p<.0001); NCR increased by 3.26% per year-program. Between the first and the last report, the number of women counseled and tested increased from 64.3% to 86.0% (p<.0001), the number of women post-counseled from 87.5% to 91.3% (p = 0.08). After mixed linear regression analysis, type of responsible institution, number of women attended in ANC, and program initiation in 2005-2006 were significant predictive factors associated with the NCR. The effect of the time period increased from earlier to later periods. Conclusion A longitudinal assessment of large PMTCT programs shows that scaling-up of programs was increased in sub-Saharan African countries. The PMTCT coverage increased throughout the study period, especially after 2006. Performance may be better for programs with a small or medium number of women attended in ANC. Identification of factors that predict PMTCT program performance may help in the development and expansion of additional large PMTCT services in sub-Saharan Africa.
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Affiliation(s)
- Joël Ladner
- Rouen University Hospital, Epidemiology and Public Health Department, Rouen, France
- * E-mail:
| | | | | | - Joseph Saba
- Axios International, 7 boulevard de la Madeleine, Paris, France
| | - Etienne Audureau
- Biostatistics and Epidemiology Unit, Paris Est University, hôpital Henri Mondor Hospital, Public Health, Assistance Publique Hôpitaux de Paris, Créteil, France
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Nelson A, Maritz J, Giddy J, Frigati L, Rabie H, van Cutsem G, Mutseyekwa T, Jange N, Bernheimer J, Cotton M, Cox V. HIV testing and antiretroviral therapy initiation at birth: Views from a primary care setting in Khayelitsha. South Afr J HIV Med 2015; 16:376. [PMID: 29568593 PMCID: PMC5842975 DOI: 10.4102/sajhivmed.v16i1.376] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 03/17/2015] [Indexed: 12/28/2022] Open
Affiliation(s)
- Aurélie Nelson
- Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa
| | - Jean Maritz
- Department of Medical Virology, National Health Laboratory Service, University of Stellenbosch, Tygerberg Campus, South Africa
| | - Janet Giddy
- Western Cape Department of Health, Khayelitsha and Eastern Substructure, Cape Town, South Africa
| | - Lisa Frigati
- Department of Paediatrics and Child Health, University of Stellenbosch, Tygerberg Campus, South Africa
| | - Helena Rabie
- Department of Paediatrics and Child Health, University of Stellenbosch, Tygerberg Campus, South Africa
| | - Gilles van Cutsem
- Médecins Sans Frontières, Cape Town, South Africa.,Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | | | - Nomfusi Jange
- Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa
| | | | - Mark Cotton
- Department of Paediatrics and Child Health, University of Stellenbosch, Tygerberg Campus, South Africa
| | - Vivian Cox
- Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa
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Vreeman RC, Nyandiko WM, Liu H, Tu W, Scanlon ML, Slaven JE, Ayaya SO, Inui TS. Comprehensive evaluation of caregiver-reported antiretroviral therapy adherence for HIV-infected children. AIDS Behav 2015; 19:626-34. [PMID: 25613594 DOI: 10.1007/s10461-015-0998-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
For HIV-infected children, adherence to antiretroviral therapy (ART) is often assessed by caregiver report but there are few data on their validity. We conducted prospective evaluations with 191 children ages 0-14 years and their caregivers over 6 months in western Kenya to identify questionnaire items that best predicted adherence to ART. Medication Event Monitoring Systems(®) (MEMS, MWV/AARDEX Ltd., Switzerland) electronic dose monitors were used as external criterion for adherence. We employed a novel variable selection tool using the LASSO technique with logistic regression to identify items best correlated with dichotomized MEMS adherence (≥90 or <90 % doses taken). Nine of 48 adherence items were identified as the best predictors of adherence, including missed or late doses in the past 7 days, problems giving the child medicines, and caregiver-level factors like not being present at medication taking. These items could be included in adherence assessment tools for pediatric patients.
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Olds PK, Kiwanuka JP, Ware NC, Tsai AC, Haberer JE. Explaining antiretroviral therapy adherence success among HIV-infected children in rural Uganda: a qualitative study. AIDS Behav 2015; 19:584-93. [PMID: 25323679 PMCID: PMC4393764 DOI: 10.1007/s10461-014-0924-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
High adherence is critical for achieving clinical benefits of HIV antiretroviral therapy (ART) and particularly challenging for children. We conducted 35 qualitative interviews with caregivers of HIV-infected Ugandan children who were followed in a longitudinal study of real-time ART adherence monitoring; 18 participants had undetectable HIV RNA, while 17 had detectable virus. Interviews blinded to viral suppression status elicited information on adherence experiences, barriers and facilitators to adherence, and social support. Using an inductive content analytic approach, we identified 'lack of resources,' 'Lazarus effect,' 'caregiver's sense of obligation and commitment,' and 'child's personal responsibility' as categories of influence on adherence, and defined types of caregiver social support. Among children with viral suppression, high hopes for the child's future and ready access to private instrumental support appeared particularly important. These findings suggest clinical counseling should explore caregivers' views of their children's futures and ability to access support in overcoming adherence barriers.
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Affiliation(s)
| | - Julius P. Kiwanuka
- Department of Paediatrics, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Norma C. Ware
- Department of Global Health and Social Medicine, Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Alexander C. Tsai
- Department of Psychiatry and Center for Global Health, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Jessica E. Haberer
- Department of Medicine, Harvard Medical School, Boston, MA, USA;Department of Medicine and Center for Global Health, MGH Center for Global Health, Massachusetts General Hospital, 100 Cambridge St., 15th Floor, Boston, MA 02114, USA
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L'Engle KL, Green K, Succop SM, Laar A, Wambugu S. Scaled-Up Mobile Phone Intervention for HIV Care and Treatment: Protocol for a Facility Randomized Controlled Trial. JMIR Res Protoc 2015; 4:e11. [PMID: 25650838 PMCID: PMC4319075 DOI: 10.2196/resprot.3659] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Accepted: 09/28/2014] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Adherence to prevention, care, and treatment recommendations among people living with HIV (PLHIV) is a critical challenge. Yet good clinical outcomes depend on consistent, high adherence to antiretroviral therapy (ART) regimens. Mobile phones offer a promising means to improve patient adherence and health outcomes. However, limited information exists on the impact that mobile phones for health (mHealth) programs have on ART adherence or the behavior change processes through which such interventions may improve patient health, particularly among ongoing clients enrolled in large public sector HIV service delivery programs and key populations such as men who have sex with men (MSM) and female sex workers (FSW). OBJECTIVE Our aim is to evaluate an mHealth intervention where text message reminders are used as supportive tools for health providers and as motivators and reminders for ART clients to adhere to treatment and remain linked to care in Ghana. Using an implementation science framework, we seek to: (1) evaluate mHealth intervention effects on patient adherence and health outcomes, (2) examine the delivery of the mHealth intervention for improving HIV care and treatment, and (3) assess the cost-effectiveness of the mHealth intervention. METHODS The 36-month study will use a facility cluster randomized controlled design (intervention vs standard of care) for evaluating the impact of mHealth on HIV care and treatment. Specifically, we will look at ART adherence, HIV viral load, retention in care, and condom use at 6 and 12-month follow-up. In addition, participant adoption and satisfaction with the program will be measured. This robust methodology will be complemented by qualitative interviews to obtain feedback on the motivational qualities of the program and benefits and challenges of delivery, especially for key populations. Cost-effectiveness will be assessed using incremental cost-effectiveness ratios, with health effects expressed in terms of viral load suppression and costs of resources used for the intervention. RESULTS This study and protocol was fully funded, but it was terminated prior to review from ethics boards and study implementation. CONCLUSIONS This cluster-RCT would have provided insights into the health effects, motivational qualities, and cost-effectiveness of mHealth interventions for PLHIV in public sector settings. We are seeking funding from alternate sources to implement the trial.
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Affiliation(s)
- Kelly L L'Engle
- FHI 360, Social and Behavioral Health Sciences, Durham, NC, United States.
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Tumusiime DK, Venter F, Musenge E, Stewart A. Prevalence of peripheral neuropathy and its associated demographic and health status characteristics, among people on antiretroviral therapy in Rwanda. BMC Public Health 2014; 14:1306. [PMID: 25526665 PMCID: PMC4320525 DOI: 10.1186/1471-2458-14-1306] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 12/16/2014] [Indexed: 11/13/2022] Open
Abstract
Background The introduction of antiretroviral therapy (ART) has dramatically reduced the mortality rate of people living with HIV (PLHIV). However, complications of both HIV and ART, such as peripheral neuropathy currently affect PLHIV. The purpose of this study was to establish the prevalence of peripheral neuropathy of the lower extremity and, its association with demographic and health status, characteristics among people on ART in Rwanda. Methods A cross sectional study was conducted among 507 women and men aged between 18 and 60 years, on ART, randomly selected from eight selected ART clinics in Rwanda. Brief Peripheral Neuropathy Screen was used to assess peripheral neuropathy. Results Peripheral neuropathy prevalence was 59% overall, mean age of the participants was 39.7 (±9.2) and a slightly older age was associated with peripheral neuropathy; [42(±9.2) vs 37 (±8.8) (p < 0.001)]. 78% of participants living in urban settings compared to 40% in rural settings reported peripheral neuropathy, 69% of participants with higher levels of education (secondary level and above) reported lower extremity neuropathy. The three factors were significantly associated with peripheral neuropathy in multivariable model analysis: older age [aOR = 1.1, 95% CI (1.0, 1.2), p < 0.001], primary education level [aOR = 0.6 95% Cl (0.3, 1.0), p = 0.04] and urban setting [aOR = 0.1, 95% CI (0.06, 0.3), p < 0.001], after adjusting for other factors. None of the health status characteristics namely; the level of CD4 cell count, duration of HIV infection and duration on ART, was independently associated with peripheral neuropathy. Conclusions The prevalence of peripheral neuropathy among PLHIV on ART in Rwanda is high. It is unclear why urban setting has an effect on PN levels in this cross sectional study, but does suggest that unidentified social and lifestyles factors may have a role in subjective symptoms and objective signs, of PN.
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Affiliation(s)
- David Kabagema Tumusiime
- Research Centre, College of Medicine and Health Sciences, University of Rwanda, Box 3286, Kigali, Rwanda.
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Oleribe OO, Oladipo O, Osita-Oleribe P, Nwachukwu C, Nkwopara F, Ekom E, Nwabuzor S, Iyalla G, Onyewuchi K, Olutola A, Nwanyanwu O, Nsubuga P. Commonization of HIV/AIDS services in Nigeria: the need, the processes and the prospects. Pan Afr Med J 2014; 19:329. [PMID: 25918569 PMCID: PMC4405065 DOI: 10.11604/pamj.2014.19.329.5138] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 11/17/2014] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION With the first case of Human Immunodeficiency Virus infection/Acquired Immunodeficiency Syndrome (HIV/AIDS) identified in 1986, the management of HIV/AIDS in Nigeria has evolved through the years. The emergency phase of the HIV/AIDS program, aimed at containing the HIV/AIDS epidemic within a short time frame, was carried out by international agencies that built structures separate from hospitals' programs. It is imperative that Nigeria shifts from the previous paradigm to the concept of Commonization of HIV to achieve sustainability. Commonization ensures that HIV/AIDS is seen as a health condition like others. It involves making HIV services available at all levels of healthcare. METHODS Excellence & Friends Management Consult (EFMC) undertook this process by conducting HIV tests in people's homes and work places, referring infected persons for treatment and follow up, establishing multiple HIV testing points and HIV services in private and public primary healthcare facilities. EFMC integrated HIV services within existing hospital care structures and trained all healthcare workers at all supported sites on HIV/AIDS prevention, care and treatment modalities. RESULTS Commonization has improved the uptake of HIV testing and counseling and enrolment into HIV care as more people are aware that HIV services are available. It has integrated HIV services into general hospital services and minimized the cost of HIV programming as the existing structures and personnel in healthcare facilities are utilized for HIV services. CONCLUSION Commonization of HIV services i.e. integrating HIV care into the existing fabric of the healthcare system, is highly recommended for a sustainable and efficient healthcare system as it makes HIV services acceptable by all.
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Affiliation(s)
| | - Olabisi Oladipo
- Excellence and Friends Management Care Centre (EFMC), Gwarimpa, Abuja, Nigeria
| | | | | | - Frank Nkwopara
- Excellence and Friends Management Care Centre (EFMC), Gwarimpa, Abuja, Nigeria
| | - Ekei Ekom
- Excellence and Friends Management Care Centre (EFMC), Gwarimpa, Abuja, Nigeria
| | - Solomon Nwabuzor
- Excellence and Friends Management Care Centre (EFMC), Gwarimpa, Abuja, Nigeria
| | - Grace Iyalla
- Excellence and Friends Management Care Centre (EFMC), Gwarimpa, Abuja, Nigeria
| | - Kenneth Onyewuchi
- Excellence and Friends Management Care Centre (EFMC), Gwarimpa, Abuja, Nigeria
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Measuring adherence to antiretroviral therapy in children and adolescents in western Kenya. J Int AIDS Soc 2014; 17:19227. [PMID: 25427633 PMCID: PMC4245448 DOI: 10.7448/ias.17.1.19227] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 09/19/2014] [Accepted: 10/16/2014] [Indexed: 01/04/2023] Open
Abstract
Introduction High levels of adherence to antiretroviral therapy (ART) are central to HIV management. The objective of this study was to compare multiple measures of adherence and investigate factors associated with adherence among HIV-infected children in western Kenya. Methods We evaluated ART adherence prospectively for six months among HIV-infected children aged ≤14 years attending a large outpatient HIV clinic in Kenya. Adherence was reported using caregiver report, plasma drug concentrations and Medication Event Monitoring Systems (MEMS®). Kappa statistics were used to compare adherence estimates with MEMS®. Logistic regression analyses were performed to assess the association between child, caregiver and household characteristics with dichotomized adherence (MEMS® adherence ≥90% vs. <90%) and MEMS® treatment interruptions of ≥48 hours. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated. Results Among 191 children, mean age at baseline was 8.2 years and 55% were female. Median adherence by MEMS® was 96.3% and improved over the course of follow-up (p<0.01), although 49.5% of children had at least one MEMS® treatment interruption of ≥48 hours. Adherence estimates were highest by caregiver report, and there was poor agreement between MEMS® and other adherence measures (Kappa statistics 0.04–0.37). In multivariable logistic regression, only caregiver-reported missed doses in the past 30 days (OR 1.25, 95% CI 1.14–1.39), late doses in the past seven days (OR 1.14, 95% CI 1.05–1.22) and caregiver-reported problems with getting the child to take ART (OR 1.10, 95% CI 1.01–1.20) were significantly associated with dichotomized MEMS® adherence. The caregivers reporting that ART made the child sick (OR 1.12, 95% CI 1.01–1.25) and reporting difficulties in the community that made giving ART more difficult (e.g. stigma) (OR 1.14, 95% CI 1.02–1.27) were significantly associated with MEMS® treatment interruptions in multivariable logistic regression. Conclusions Non-adherence in the form of missed and late doses, treatment interruptions of more than 48 hours and sub-therapeutic drug levels were common in this cohort. Adherence varied significantly by adherence measure, suggesting that additional validation of adherence measures is needed. Few factors were consistently associated with non-adherence or treatment interruptions.
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Mutwa PR, Boer KR, Asiimwe-Kateera B, Tuyishimire D, Muganga N, Lange JMA, van de Wijgert J, Asiimwe A, Reiss P, Geelen SPM. Safety and effectiveness of combination antiretroviral therapy during the first year of treatment in HIV-1 infected Rwandan children: a prospective study. PLoS One 2014; 9:e111948. [PMID: 25365302 PMCID: PMC4218827 DOI: 10.1371/journal.pone.0111948] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 10/08/2014] [Indexed: 11/19/2022] Open
Abstract
Background With increased availability of paediatric combination antiretroviral therapy (cART) in resource limited settings, cART outcomes and factors associated with outcomes should be assessed. Methods HIV-infected children <15 years of age, initiating cART in Kigali, Rwanda, were followed for 18 months. Prospective clinical and laboratory assessments included weight-for-age (WAZ) and height-for-age (HAZ) z-scores, complete blood cell count, liver transaminases, creatinine and lipid profiles, CD4 T-cell count/percent, and plasma HIV-1 RNA concentration. Clinical success was defined as WAZ and WAZ >−2, immunological success as CD4 cells ≥500/mm3 and ≥25% for respectively children over 5 years and under 5 years, and virological success as a plasma HIV-1 RNA concentration <40 copies/mL. Results Between March 2008 and December 2009, 123 HIV-infected children were included. The median (interquartile (IQR) age at cART initiation was 7.4 (3.2, 11.5) years; 40% were <5 years and 54% were female. Mean (95% confidence interval (95%CI)) HAZ and WAZ at baseline were −2.01 (−2.23, −1.80) and −1.73 (−1.95, −1.50) respectively and rose to −1.75 (−1.98, −1.51) and −1.17 (−1.38, −0.96) after 12 months of cART. The median (IQR) CD4 T-cell values for children <5 and ≥5 years of age were 20% (13, 28) and 337 (236, 484) cells/mm3respectively, and increased to 36% (28, 41) and 620 (375, 880) cells/mm3. After 12 months of cART, 24% of children had a detectable viral load, including 16% with virological failure (HIV-RNA>1000 c/mL). Older age at cART initiation, poor adherence, and exposure to antiretrovirals around birth were associated with virological failure. A third (33%) of children had side effects (by self-report or clinical assessment), but only 9% experienced a severe side effect requiring a cART regimen change. Conclusions cART in Rwandan HIV-infected children was successful but success might be improved further by initiating cART as early as possible, optimizing adherence and optimizing management of side effects.
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Affiliation(s)
- Philippe R. Mutwa
- Kigali University Teaching Hospital, Department of Pediatrics, Kigali, Rwanda
- Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Center, Amsterdam, The Netherlands
- * E-mail:
| | - Kimberly R. Boer
- Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Center, Amsterdam, The Netherlands
- Biomedical Research, Epidemiology Unit, Royal Tropical Institute, Amsterdam, The Netherlands
| | - Brenda Asiimwe-Kateera
- Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Center, Amsterdam, The Netherlands
| | - Diane Tuyishimire
- Outpatients Clinic, Treatment and Research on HIV/AIDS Centre, Kigali, Rwanda
| | - Narcisse Muganga
- Kigali University Teaching Hospital, Department of Pediatrics, Kigali, Rwanda
| | - Joep M. A. Lange
- Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Center, Amsterdam, The Netherlands
| | - Janneke van de Wijgert
- Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Center, Amsterdam, The Netherlands
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United of Kingdom
- Rinda Ubuzima, Kigali, Rwanda
| | | | - Peter Reiss
- Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Center, Amsterdam, The Netherlands
| | - Sibyl P. M. Geelen
- Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Center, Amsterdam, The Netherlands
- Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands
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Vermund SH, Blevins M, Moon TD, José E, Moiane L, Tique JA, Sidat M, Ciampa PJ, Shepherd BE, Vaz LME. Poor clinical outcomes for HIV infected children on antiretroviral therapy in rural Mozambique: need for program quality improvement and community engagement. PLoS One 2014; 9:e110116. [PMID: 25330113 PMCID: PMC4203761 DOI: 10.1371/journal.pone.0110116] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 09/16/2014] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Residents of Zambézia Province, Mozambique live from rural subsistence farming and fishing. The 2009 provincial HIV prevalence for adults 15-49 years was 12.6%, higher among women (15.3%) than men (8.9%). We reviewed clinical data to assess outcomes for HIV-infected children on combination antiretroviral therapy (cART) in a highly resource-limited setting. METHODS We studied rates of 2-year mortality and loss to follow-up (LTFU) for children <15 years of age initiating cART between June 2006-July 2011 in 10 rural districts. National guidelines define LTFU as >60 days following last-scheduled medication pickup. Kaplan-Meier estimates to compute mortality assumed non-informative censoring. Cumulative LTFU incidence calculations treated death as a competing risk. RESULTS Of 753 children, 29.0% (95% CI: 24.5, 33.2) were confirmed dead by 2 years and 39.0% (95% CI: 34.8, 42.9) were LTFU with unknown clinical outcomes. The cohort mortality rate was 8.4% (95% CI: 6.3, 10.4) after 90 days on cART and 19.2% (95% CI: 16.0, 22.3) after 365 days. Higher hemoglobin at cART initiation was associated with being alive and on cART at 2 years (alive: 9.3 g/dL vs. dead or LTFU: 8.3-8.4 g/dL, p<0.01). Cotrimoxazole use within 90 days of ART initiation was associated with improved 2-year outcomes Treatment was initiated late (WHO stage III/IV) among 48% of the children with WHO stage recorded in their records. Marked heterogeneity in outcomes by district was noted (p<0.001). CONCLUSIONS We found poor clinical and programmatic outcomes among children taking cART in rural Mozambique. Expanded testing, early infant diagnosis, counseling/support services, case finding, and outreach are insufficiently implemented. Our quality improvement efforts seek to better link pregnancy and HIV services, expand coverage and timeliness of infant diagnosis and treatment, and increase follow-up and adherence.
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Affiliation(s)
- Sten H. Vermund
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Meridith Blevins
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Troy D. Moon
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Eurico José
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Linda Moiane
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - José A. Tique
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Mohsin Sidat
- School of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Philip J. Ciampa
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Bryan E. Shepherd
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Lara M. E. Vaz
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Quelimane and Maputo, Mozambique
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Colvin CJ, Konopka S, Chalker JC, Jonas E, Albertini J, Amzel A, Fogg K. A systematic review of health system barriers and enablers for antiretroviral therapy (ART) for HIV-infected pregnant and postpartum women. PLoS One 2014; 9:e108150. [PMID: 25303241 PMCID: PMC4193745 DOI: 10.1371/journal.pone.0108150] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 08/25/2014] [Indexed: 11/29/2022] Open
Abstract
Background Despite global progress in the fight to reduce maternal mortality, HIV-related maternal deaths remain persistently high, particularly in much of Africa. Lifelong antiretroviral therapy (ART) appears to be the most effective way to prevent these deaths, but the rates of three key outcomes—ART initiation, retention in care, and long-term ART adherence—remain low. This systematic review synthesized evidence on health systems factors affecting these outcomes in pregnant and postpartum women living with HIV. Methods Searches were conducted for studies addressing the population of interest (HIV-infected pregnant and postpartum women), the intervention of interest (ART), and the outcomes of interest (initiation, adherence, and retention). Quantitative and qualitative studies published in English since January 2008 were included. A four-stage narrative synthesis design was used to analyze findings. Review findings from 42 included studies were categorized according to five themes: 1) models of care, 2) service delivery, 3) resource constraints and governance challenges, 4) patient-health system engagement, and 5) maternal ART interventions. Results Low prioritization of maternal ART and persistent dropout along the maternal ART cascade were key findings. Service delivery barriers included poor communication and coordination among health system actors, poor clinical practices, and gaps in provider training. The few studies that assessed maternal ART interventions demonstrated the importance of multi-pronged, multi-leveled interventions. Conclusions There has been a lack of emphasis on the experiences, needs and vulnerabilities particular to HIV-infected pregnant and postpartum women. Supporting these women to successfully traverse the maternal ART cascade requires carefully designed and targeted interventions throughout the steps. Careful design of integrated service delivery models is of critical importance in this effort. Key knowledge gaps and research priorities were also identified, including definitions and indicators of adherence rates, and the importance of cumulative measures of dropout along the maternal ART cascade.
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Affiliation(s)
- Christopher J. Colvin
- Centre for Infectious Disease Epidemiology and Research (CIDER), Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Medical School Campus, Cape Town, South Africa
- * E-mail:
| | - Sarah Konopka
- Center for Health Services, Management Sciences for Health, Arlington, Virginia, United States of America
| | - John C. Chalker
- Center for Pharmaceutical Management, Management Sciences for Health, Arlington, Virginia, United States of America
| | - Edna Jonas
- Center for Health Services, Management Sciences for Health, Arlington, Virginia, United States of America
| | - Jennifer Albertini
- United States Agency for International Development (USAID)/Africa Bureau, Washington, District of Columbia, United States of America
| | - Anouk Amzel
- USAID/Bureau for Global Health (BGH)/Office of HIV/AIDS, Washington, District of Columbia, United States of America
| | - Karen Fogg
- USAID/BGH/Office of Health, Infectious Diseases and Nutrition, Washington, District of Columbia, United States of America
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Friedman SR, Downing MJ, Smyrnov P, Nikolopoulos G, Schneider JA, Livak B, Magiorkinis G, Slobodianyk L, Vasylyeva TI, Paraskevis D, Psichogiou M, Sypsa V, Malliori MM, Hatzakis A. Socially-integrated transdisciplinary HIV prevention. AIDS Behav 2014; 18:1821-34. [PMID: 24165983 DOI: 10.1007/s10461-013-0643-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Current ideas about HIV prevention include a mixture of primarily biomedical interventions, socio-mechanical interventions such as sterile syringe and condom distribution, and behavioral interventions. This article presents a framework for socially-integrated transdisciplinary HIV prevention that may improve current prevention efforts. It first describes one socially-integrated transdisciplinary intervention project, the Transmission Reduction Intervention Project. We focus on how social aspects of the intervention integrate its component parts across disciplines and processes at different levels of analysis. We then present socially-integrated perspectives about how to improve combination antiretroviral treatment (cART) processes at the population level in order to solve the problems of the treatment cascade and make "treatment as prevention" more effective. Finally, we discuss some remaining problems and issues in such a social transdisciplinary intervention in the hope that other researchers and public health agents will develop additional socially-integrated interventions for HIV and other diseases.
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Affiliation(s)
- Samuel R Friedman
- Institute of Infectious Diseases Research, National Development and Research Institutes, Inc., 71 West 23rd Street, 8th Floor, New York, NY, 10010, USA,
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Kaufman MR, Cornish F, Zimmerman RS, Johnson BT. Health behavior change models for HIV prevention and AIDS care: practical recommendations for a multi-level approach. J Acquir Immune Defic Syndr 2014; 66 Suppl 3:S250-8. [PMID: 25007194 PMCID: PMC4536982 DOI: 10.1097/qai.0000000000000236] [Citation(s) in RCA: 164] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Despite increasing recent emphasis on the social and structural determinants of HIV-related behavior, empirical research and interventions lag behind, partly because of the complexity of social–structural approaches. This article provides a comprehensive and practical review of the diverse literature on multi-level approaches to HIV-related behavior change in the interest of contributing to the ongoing shift to more holistic theory, research, and practice. It has the following specific aims: (1) to provide a comprehensive list of relevant variables/factors related to behavior change at all points on the individual–structural spectrum, (2) to map out and compare the characteristics of important recent multi-level models, (3) to reflect on the challenges of operating with such complex theoretical tools, and (4) to identify next steps and make actionable recommendations. Using a multi-level approach implies incorporating increasing numbers of variables and increasingly context-specific mechanisms, overall producing greater intricacies. We conclude with recommendations on how best to respond to this complexity, which include: using formative research and interdisciplinary collaboration to select the most appropriate levels and variables in a given context; measuring social and institutional variables at the appropriate level to ensure meaningful assessments of multiple levels are made; and conceptualizing intervention and research with reference to theoretical models and mechanisms to facilitate transferability, sustainability, and scalability.
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Affiliation(s)
- Michelle R Kaufman
- *Johns Hopkins University Bloomberg School of Public Health, Center for Communication Programs, Baltimore, MD; †Department of Methodology, London School of Economics and Political Science, London, UK; ‡University of Missouri-St. Louis, College of Nursing; and §Department of Psychology, University of Connecticut and Center for Health, Intervention, and Prevention, Storrs CT
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The clinical and economic impact of point-of-care CD4 testing in mozambique and other resource-limited settings: a cost-effectiveness analysis. PLoS Med 2014; 11:e1001725. [PMID: 25225800 PMCID: PMC4165752 DOI: 10.1371/journal.pmed.1001725] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 07/30/2014] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Point-of-care CD4 tests at HIV diagnosis could improve linkage to care in resource-limited settings. Our objective is to evaluate the clinical and economic impact of point-of-care CD4 tests compared to laboratory-based tests in Mozambique. METHODS AND FINDINGS We use a validated model of HIV testing, linkage, and treatment (CEPAC-International) to examine two strategies of immunological staging in Mozambique: (1) laboratory-based CD4 testing (LAB-CD4) and (2) point-of-care CD4 testing (POC-CD4). Model outcomes include 5-y survival, life expectancy, lifetime costs, and incremental cost-effectiveness ratios (ICERs). Input parameters include linkage to care (LAB-CD4, 34%; POC-CD4, 61%), probability of correctly detecting antiretroviral therapy (ART) eligibility (sensitivity: LAB-CD4, 100%; POC-CD4, 90%) or ART ineligibility (specificity: LAB-CD4, 100%; POC-CD4, 85%), and test cost (LAB-CD4, US$10; POC-CD4, US$24). In sensitivity analyses, we vary POC-CD4-specific parameters, as well as cohort and setting parameters to reflect a range of scenarios in sub-Saharan Africa. We consider ICERs less than three times the per capita gross domestic product in Mozambique (US$570) to be cost-effective, and ICERs less than one times the per capita gross domestic product in Mozambique to be very cost-effective. Projected 5-y survival in HIV-infected persons with LAB-CD4 is 60.9% (95% CI, 60.9%-61.0%), increasing to 65.0% (95% CI, 64.9%-65.1%) with POC-CD4. Discounted life expectancy and per person lifetime costs with LAB-CD4 are 9.6 y (95% CI, 9.6-9.6 y) and US$2,440 (95% CI, US$2,440-US$2,450) and increase with POC-CD4 to 10.3 y (95% CI, 10.3-10.3 y) and US$2,800 (95% CI, US$2,790-US$2,800); the ICER of POC-CD4 compared to LAB-CD4 is US$500/year of life saved (YLS) (95% CI, US$480-US$520/YLS). POC-CD4 improves clinical outcomes and remains near the very cost-effective threshold in sensitivity analyses, even if point-of-care CD4 tests have lower sensitivity/specificity and higher cost than published values. In other resource-limited settings with fewer opportunities to access care, POC-CD4 has a greater impact on clinical outcomes and remains cost-effective compared to LAB-CD4. Limitations of the analysis include the uncertainty around input parameters, which is examined in sensitivity analyses. The potential added benefits due to decreased transmission are excluded; their inclusion would likely further increase the value of POC-CD4 compared to LAB-CD4. CONCLUSIONS POC-CD4 at the time of HIV diagnosis could improve survival and be cost-effective compared to LAB-CD4 in Mozambique, if it improves linkage to care. POC-CD4 could have the greatest impact on mortality in settings where resources for HIV testing and linkage are most limited. Please see later in the article for the Editors' Summary.
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Chan AK, Ford D, Namata H, Muzambi M, Nkhata MJ, Abongomera G, Mambule I, South A, Revill P, Grundy C, Mabugu T, Chiwaula L, Cataldo F, Hakim J, Seeley J, Kityo C, Reid A, Katabira E, Sodhi S, Gilks CF, Gibb DM. The Lablite project: a cross-sectional mapping survey of decentralized HIV service provision in Malawi, Uganda and Zimbabwe. BMC Health Serv Res 2014; 14:352. [PMID: 25138583 PMCID: PMC4148932 DOI: 10.1186/1472-6963-14-352] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Accepted: 07/29/2014] [Indexed: 12/05/2022] Open
Abstract
Background In sub-Saharan Africa antiretroviral therapy (ART) is being decentralized from tertiary/secondary care facilities to primary care. The Lablite project supports effective decentralization in 3 countries. It began with a cross-sectional survey to describe HIV and ART services. Methods 81 purposively sampled health facilities in Malawi, Uganda and Zimbabwe were surveyed. Results The lowest level primary health centres comprised 16/20, 21/39 and 16/22 facilities included in Malawi, Uganda and Zimbabwe respectively. In Malawi and Uganda most primary health facilities had at least 1 medical assistant/clinical officer, with average 2.5 and 4 nurses/midwives for median catchment populations of 29,275 and 9,000 respectively. Primary health facilities in Zimbabwe were run by nurses/midwives, with average 6 for a median catchment population of 8,616. All primary health facilities provided HIV testing and counselling, 50/53 (94%) cotrimoxazole preventive therapy (CPT), 52/53 (98%) prevention of mother-to-child transmission of HIV (PMTCT) and 30/53 (57%) ART management (1/30 post ART-initiation follow-up only). All secondary and tertiary-level facilities provided HIV and ART services. In total, 58/81 had ART provision. Stock-outs during the 3 months prior to survey occurred across facility levels for HIV test-kits in 55%, 26% and 9% facilities in Malawi, Uganda and Zimbabwe respectively; for CPT in 58%, 32% and 9% and for PMTCT drugs in 26%, 10% and 0% of facilities (excluding facilities where patients were referred out for either drug). Across all countries, in facilities with ART stored on-site, adult ART stock-outs were reported in 3/44 (7%) facilities compared with 10/43 (23%) facility stock-outs of paediatric ART. Laboratory services at primary health facilities were limited: CD4 was used for ART initiation in 4/9, 5/6 and 13/14 in Malawi, Uganda and Zimbabwe respectively, but frequently only in selected patients. Routine viral load monitoring was not used; 6/58 (10%) facilities with ART provision accessed centralised viral loads for selected patients. Conclusions Although coverage of HIV testing, PMTCT and cotrimoxazole prophylaxis was high in all countries, decentralization of ART services was variable and incomplete. Challenges of staffing and stock management were evident. Laboratory testing for toxicity and treatment effectiveness monitoring was not available in most primary level facilities. Electronic supplementary material The online version of this article (doi:10.1186/1472-6963-14-352) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Deborah Ford
- MRC Clinical Trials Unit at University College London, London, U,K.
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"I don't want financial support but verbal support." How do caregivers manage children's access to and retention in HIV care in urban Zimbabwe? J Int AIDS Soc 2014; 17:18839. [PMID: 24815595 PMCID: PMC4017591 DOI: 10.7448/ias.17.1.18839] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Revised: 03/21/2014] [Accepted: 04/07/2014] [Indexed: 11/08/2022] Open
Abstract
Introduction Children living with HIV experience particular challenges in accessing HIV care. Children usually rely on adult caregivers for access to care, including timely diagnosis, initiation of treatment and sustained engagement with HIV services. The aim of this study was to inform the design of a community-based intervention to support caregivers of HIV-positive children to increase children's retention in care as part of a programme introducing decentralized HIV care in primary health facilities. Methods Using an existing conceptual framework, we conducted formative research to identify key local contextual factors affecting children's linkages to HIV care in Harare, Zimbabwe. We conducted semi-structured interviews with 15 primary caregivers of HIV-positive children aged 6–15 years enrolled at a hospital clinic for at least six months, followed by interviews with nine key informants from five community-based organizations providing adherence support or related services. Results We identified a range of facilitators and barriers that caregivers experience. Distance to the hospital, cost of transportation, fear of disclosing HIV status to the child or others, unstable family structure and institutional factors such as drug stock-outs, healthcare worker absenteeism and unsympathetic school environments proved the most salient limiting factors. Facilitators included openness within the family, availability of practical assistance and psychosocial support from community members. Conclusions The proposed decentralization of HIV care will mitigate concerns about distance and transport costs but is likely to be insufficient to ensure children's sustained retention. Following this study, we developed a package of structured home visits by voluntary lay workers to proactively address other determinants such as disclosure within families, access to available services and support through caregivers’ social networks. A randomized controlled trial is underway to assess impact on children's retention in care over two years.
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Kranzer K, Meghji J, Bandason T, Dauya E, Mungofa S, Busza J, Hatzold K, Kidia K, Mujuru H, Ferrand RA. Barriers to provider-initiated testing and counselling for children in a high HIV prevalence setting: a mixed methods study. PLoS Med 2014; 11:e1001649. [PMID: 24866209 PMCID: PMC4035250 DOI: 10.1371/journal.pmed.1001649] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 04/16/2014] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND There is a substantial burden of HIV infection among older children in sub-Saharan Africa, the majority of whom are diagnosed after presentation with advanced disease. We investigated the provision and uptake of provider-initiated HIV testing and counselling (PITC) among children in primary health care facilities, and explored health care worker (HCW) perspectives on providing HIV testing to children. METHODS AND FINDINGS Children aged 6 to 15 y attending six primary care clinics in Harare, Zimbabwe, were offered PITC, with guardian consent and child assent. The reasons why testing did not occur in eligible children were recorded, and factors associated with HCWs offering and children/guardians refusing HIV testing were investigated using multivariable logistic regression. Semi-structured interviews were conducted with clinic nurses and counsellors to explore these factors. Among 2,831 eligible children, 2,151 (76%) were offered PITC, of whom 1,534 (54.2%) consented to HIV testing. The main reasons HCWs gave for not offering PITC were the perceived unsuitability of the accompanying guardian to provide consent for HIV testing on behalf of the child and lack of availability of staff or HIV testing kits. Children who were asymptomatic, older, or attending with a male or a younger guardian had significantly lower odds of being offered HIV testing. Male guardians were less likely to consent to their child being tested. 82 (5.3%) children tested HIV-positive, with 95% linking to care. Of the 940 guardians who tested with the child, 186 (19.8%) were HIV-positive. CONCLUSIONS The HIV prevalence among children tested was high, highlighting the need for PITC. For PITC to be successfully implemented, clear legislation about consent and guardianship needs to be developed, and structural issues addressed. HCWs require training on counselling children and guardians, particularly male guardians, who are less likely to engage with health care services. Increased awareness of the risk of HIV infection in asymptomatic older children is needed.
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Affiliation(s)
- Katharina Kranzer
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jamilah Meghji
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Tsitsi Bandason
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Ethel Dauya
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | | | - Joanna Busza
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Khameer Kidia
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Hilda Mujuru
- Department of Paediatrics, University of Zimbabwe, Harare, Zimbabwe
| | - Rashida A. Ferrand
- Biomedical Research and Training Institute, Harare, Zimbabwe
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
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75
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Zhao N, Pei SN, Parekh P, Salazar E, Zu Y. Blocking interaction of viral gp120 and CD4-expressing T cells by single-stranded DNA aptamers. Int J Biochem Cell Biol 2014; 51:10-8. [PMID: 24661998 DOI: 10.1016/j.biocel.2014.03.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 02/26/2014] [Accepted: 03/13/2014] [Indexed: 01/29/2023]
Abstract
To investigate the potential clinical application of aptamers to prevention of HIV infection, single-stranded DNA (ssDNA) aptamers specific for CD4 were developed using the systematic evolution of ligands by exponential enrichment approach and next generation sequencing. In contrast to RNA-based aptamers, the developed ssDNA aptamers were stable in human serum up to 12h. Cell binding assays revealed that the aptamers specifically targeted CD4-expressing cells with high binding affinity (Kd=1.59nM), a concentration within the range required for therapeutic application. Importantly, the aptamers selectively bound CD4 on human cells and disrupted the interaction of viral gp120 to CD4 receptors, which is a prerequisite step of HIV-1 infection. Functional studies showed that the aptamer polymers significantly blocked binding of viral gp120 to CD4-expressing cells by up to 70% inhibition. These findings provide a new approach to prevent HIV-1 transmission using oligonucleotide aptamers.
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Affiliation(s)
- Nianxi Zhao
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, and Cancer Pathology Laboratory, Houston Methodist Research Institute, 6565 Fannin Street, Houston, TX 77030, USA
| | - Sung-nan Pei
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, and Cancer Pathology Laboratory, Houston Methodist Research Institute, 6565 Fannin Street, Houston, TX 77030, USA
| | - Parag Parekh
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, and Cancer Pathology Laboratory, Houston Methodist Research Institute, 6565 Fannin Street, Houston, TX 77030, USA
| | - Eric Salazar
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, and Cancer Pathology Laboratory, Houston Methodist Research Institute, 6565 Fannin Street, Houston, TX 77030, USA
| | - Youli Zu
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, and Cancer Pathology Laboratory, Houston Methodist Research Institute, 6565 Fannin Street, Houston, TX 77030, USA.
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Olson KM, Godwin NC, Wilkins SA, Mugavero MJ, Moneyham LD, Slater LZ, Raper JL. A qualitative study of underutilization of the AIDS drug assistance program. J Assoc Nurses AIDS Care 2014; 25:392-404. [PMID: 24503498 DOI: 10.1016/j.jana.2013.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 11/11/2013] [Indexed: 10/25/2022]
Abstract
In our previous work, we demonstrated underutilization of the AIDS Drug Assistance Program (ADAP) at an HIV clinic in Alabama. In order to understand barriers and facilitators to utilization of ADAP, we conducted focus groups of ADAP enrollees. Focus groups were stratified by sex, race, and historical medication possession ratio as a measure of program utilization. We grouped factors according to the social-ecological model. We found that multiple levels of influence, including patient and clinic-related factors, influenced utilization of antiretroviral medications. Patients introduced issues that illustrated high-priority needs for ADAP policy and implementation, suggesting that in order to improve ADAP utilization, the following issues must be addressed: patient transportation, ADAP medication refill schedules and procedures, mailing of medications, and the ADAP recertification process. These findings can inform a strategy of approaches to improve ADAP utilization, which may have widespread implications for ADAP programs across the United States.
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Linkage, initiation and retention of children in the antiretroviral therapy cascade: an overview. AIDS 2013; 27 Suppl 2:S207-13. [PMID: 24361630 DOI: 10.1097/qad.0000000000000095] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
In 2012, there were an estimated 2 million children in need of antiretroviral therapy (ART) in the world, but ART is still reaching fewer than 3 in 10 children in need of treatment. [1, 7] As more HIV-infected children are identified early and universal treatment is initiated in children under 5 regardless of CD4, the success of pediatric HIV programs will depend on our ability to link children into care and treatment programs, and retain them in those services over time. In this review, we summarize key individual, institutional, and systems barriers to diagnosing children with HIV, linking them to care and treatment, and reducing loss to follow-up (LTFU). We also explore how linkage and retention can be optimally measured so as to maximize the impact of available pediatric HIV care and treatment services.
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Scheibe FJB, Waiswa P, Kadobera D, Müller O, Ekström AM, Sarker M, Neuhann HWF. Effective coverage for antiretroviral therapy in a Ugandan district with a decentralized model of care. PLoS One 2013; 8:e69433. [PMID: 23936015 PMCID: PMC3720624 DOI: 10.1371/journal.pone.0069433] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 06/07/2013] [Indexed: 12/04/2022] Open
Abstract
Introduction While increasing access to antiretroviral therapy (ART) is reported from many African countries, data on effective coverage particular from settings without external support or research remains scarce. We examined and report effective coverage data from a public ART program in rural Uganda. Methods We conducted a retrospective cohort study at all ART-providing governmental health facilities in Iganga District, Eastern Uganda. Based on all HIV patients registered between April 2004 and September 2009 (n = 4775), we assessed indicators of program performance and determined rates of retention and Cox proportional hazards for attrition. Effective ART coverage was calculated using projections (SPECTRUM software) adapted to the district demographic structure and number of people receiving ART. Results By September 2009, district public sector effective ART coverage was 10.3% for adults and 1.9% for children. After a median follow-up of 26.9 months, overall ART retention was 54.7%. The probability of retention was 0.72 (95% confidence interval (CI) 0.69–0.75) at 12 and 0.58 (CI 0.54–0.62) at 36 months after ART initiation. Individual health facilities differed considerably regarding performance indicators and retention. Overall, 198 (16.9%) individual files of 1171 registered ART patients were lost. Young adult age (15–24 years) had a higher risk of attrition (HR 2.1, CI 1.4–3.2) as well as WHO stage I (HR 4.8, CI 1.9–11.8) and WHO stage IV (HR 2.5, CI 1.3–4.7). An interval ≥6 weeks between HIV testing and ART initiation was associated with a reduced risk (HR 0.6, CI 0.47–0.78). Conclusion Compared to reported national data effective ART coverage in Iganga District was low. Intensified efforts to improve access, retention in care, and quality of documentation are urgently needed. Children and young adults require special attention in the program.
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Affiliation(s)
- Florian J. B. Scheibe
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
- Department of Cardiology/Pulmonology, Ortenau Klinikum, Offenburg, Germany
| | - Peter Waiswa
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda
- Division of Global Health, IHCAR, Karolinska Institutet, Stockholm, Sweden
- Iganga/Mayuge Health and Demographic Surveillance Site, Iganga, Uganda
| | - Daniel Kadobera
- Iganga/Mayuge Health and Demographic Surveillance Site, Iganga, Uganda
| | - Olaf Müller
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - Anna M. Ekström
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda
| | - Malabika Sarker
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
- James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh
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Feasibility and Acceptability of a Real-Time Adherence Device among HIV-Positive IDU Patients in China. AIDS Res Treat 2013; 2013:957862. [PMID: 23956851 PMCID: PMC3730150 DOI: 10.1155/2013/957862] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Accepted: 06/26/2013] [Indexed: 11/22/2022] Open
Abstract
We collected data on feasibility and acceptability of a real-time web-linked adherence monitoring container among HIV-positive injection drug users (IDU) in China. “Wisepill” uses wireless technology to track on-time medication dosing. Ten patients on antiretroviral therapy (ART) at the Guangxi CDC HIV clinic in Nanning, China, used Wisepill for one ART medication for one month. We monitored device use and adherence and explored acceptability of the device among patients. Mean adherence was 89.2% (SD 10.6%). Half of the subjects reported a positive overall experience with Wisepill. Seven said that it was inconvenient, supported by comments that it was large and conspicuous. Five worried about disclosure of HIV status due to the device; no disclosures were reported. Twelve signal lapses occurred (5.4% of prescribed doses), of which one was due to technical reasons, nine to behavioral reasons (both intentional and unintentional), and two to unclear reasons. Although the technical components must be monitored carefully, and acceptability to patients presents challenges which warrant further exploration, the Wisepill device has potential for adherence interventions that deliver rapid adherence-support behavioral feedback directly to patients, including IDU. The use of wireless technology appears uniquely promising for providing time-sensitive communication on patient behavior that can be harnessed to maximize the benefits of HIV treatment.
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Entry, Retention, and Virological Suppression in an HIV Cohort Study in India: Description of the Cascade of Care and Implications for Reducing HIV-Related Mortality in Low- and Middle-Income Countries. Interdiscip Perspect Infect Dis 2013; 2013:384805. [PMID: 23935613 PMCID: PMC3723357 DOI: 10.1155/2013/384805] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 06/16/2013] [Indexed: 11/25/2022] Open
Abstract
HIV treatment, care, and support programmes in low- and middle-income countries have traditionally focused more on patients remaining in care after the initiation of antiretroviral therapy (ART) than on earlier stages of care. This study describes the cumulative retention from HIV diagnosis to the achievement of virological suppression after ART initiation in an HIV cohort study in India. Of all patients diagnosed with HIV, 70% entered into care within three months. 65% of patients ineligible for ART at the first assessment were retained in pre-ART care. 67% of those eligible for ART initiated treatment within three months. 30% of patients who initiated ART died or were lost to followup, and 82% achieved virological suppression in the last viral load determination. Most attrition occurred the in pre-ART stages of care, and it was estimated that only 31% of patients diagnosed with HIV engaged in care and achieved virological suppression after ART initiation. The total mortality attributable to pre-ART attrition was considerably higher than the mortality for not achieving virological suppression. This study indicates that early entry into pre-ART care along with timely initiation of ART is more likely to reduce HIV-related mortality compared to achieving virological suppression.
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